Type of study- The present study was a retrospective and cohort study.

Sampling method- The present study was conducted on 50 cases of breast carcinoma received during June 2017 to May 2018 (one year study) in the Department of Pathology, Karnataka Institute of Medical Sciences, as per the inclusion and exclusion criteria.

Sample size- All cases of breast carcinoma meeting the inclusion and exclusion criteria, received in the Department of Pathology, Karnataka Institute of Medical Sciences, during June 2017 to May 2018 (one year study) were included in the study.

Inclusion criteria

1. Lumpectomy specimens
2. Mastectomy specimens

Exclusion criteria

1. Trucut biopsy specimens
2. Reference slides received from outside
3. Blocks received from outside

Data collection- Patients clinical data were collected from histopathological requests and hospital records. This was a retrospective study, all the histopathological slides were retrieved and representative slides were evaluated for typing and grading of the tumour. The representative blocks were selected and sent to a standard laboratory for ER, PR, Her2neu and Ki67 in batches. Positive and negative controls were included for each batch. Correlation of ER, PR, Her2neu and Ki67 with various prognostic factors was done.

Scoring system- The Nottingham modification of the Bloom Richardson grading system (grade I, II and III) was used for histopathological grading of the breast carcinoma (Table 1).[5]

Table-1: The Nottingham modification of the Bloom Richardson grading system.

Abbreviation: hpf, high power fields.

Grade I = 3- 5 score

Grade II = 6, 7 score

patients) and the mean age of breast carcinoma (BC) patients being 49.52 (±11.2SD) years. In this study group, 27 patients (54%) were belonging to postmenopausal status and 23 patients (46%) were belonging to premenopausal status. The tumour size varied from 1.5 to 12.0 cm in size with 94% cases with size >2cm. The various histologic types were 46 cases (92%) of Infiltrating ductal carcinomanot otherwise specified (IDC NOS), one case (2%) of Medullary carcinoma and three cases (6%) of Colloid carcinoma.

Grade II tumours were maximum, consisting of 66% (33/50) followed by Grade III tumours which were 26% (13/50) (Figure 1) and Grade I tumours accounted to 8% (04/50).According to the Mitotic index, 20% of the cases had Mitotic index 1, 38% had Mitotic index 2 and 42% had Mitotic index 3. Lymph nodes were recovered in 43 cases out of which metastasis was seen in 27 cases (Figure 2). Lymphovascular invasions were seen in 18 cases (36%) and were absent in 32 cases (64%) (Figure 3).

ER, positivity was observed in 46% of cases (23/50) and PR positivity was observed in 30% of cases (15/50). In all of these cases, Her2neu was negative. Amongst the 50 cases, only five cases came out to be positive for Her2neu, seven cases were equivocal with 2+ score and 38cases were negative. The equivocal cases were not subjected to Fluorescent in situ Hybridisation and hence it was taken as negative in the present study. (Table 4, Figure 4 to 6).

Table-4: Percentage of ER/PR and Her2neu positive and negative cases.

ER and PR positivity were observed in 65.2% of cases (15/50). ER positivity alone without PR positivity was observed in 34.8% cases (08/50) (Table 5). There were no cases of PR alone positivity with ER negativity.

Table-5: Correlation between ER and PR status.

41 cases (82%) (Figure 7 and 8).

ER and PR positivity were higher in postmenopausal patients (65.2% and 73.3% respectively). The ‘p’ value for both ER and PR (0.142 and 0.137 ) did not correlate with the menopausal state. Her2neu showed no correlation with the age of the patient as only five cases were positive in the study. Ki67 expression was high in premenopausal patients (53.7%) but it was statistically insignificant (0.051) (Table 7).

Six out of seven ER-negative cases were seen in tumour size of T3 category, while T2 was equally distributed with 20 out of 40 cases and T1 was one out of three cases (T3>T2>T1). Similarly, six out of seven PR negative cases were in the T3 category, T2 had 27 out of 40 cases, and T1 had two out of three cases (T3>T2>T1). Her2neu showed no correlation with the size of the tumour as five cases were only positive in this study. Low Ki67 expression was seen in nine out of 31 cases in the T2 category while resting all other cases of T1, remaining T2 and all T3 category showed high Ki67 expression (Table 8).

Fig-3: Lymphovascular invasion (40x, H and E stain).

Fig-4: ER-positive- nuclear stain (40x, IHC).

Fig-7: Low Ki67 expression - <15%- nuclear stain (40x, IHC).

Fig-8: High Ki67 expression- ≥ 15%- nuclear stain (40x, IHC).

Discussion

Breast cancer is most common among women worldwide, its incidence is expected to increase by 26% by 2020 in developing countries[9]. Similar to the Indian and Western population studies, the mean age of BC is 49.52 (±11.2SD) years and also the incidence of BC is high in postmenopausal patients (54.0%)[10].

Our present study showed estrogen receptor positivity in 23 cases comprising 46% of the total cases, which was almost similar with various Indian studies conducted by Kaur et al (36%), Rashmi K et al (34.5%)and Desai SB et al(as 32.6 %) [9,11,12].

However, the incidence was higher in western authors when compared to black and Asians, which might be due to inherent biology and low incidence in Indian population may be due to decreased Hormone Replacement Therapy[13].

In the present study, 30% was positive for PR which was closely similar to Kaur et al(36%), Rashmi K et al (36.4%) and Haroon S et al (38.1 %). However, Desai SB et al (46.1%) and Ghosh J et al (51.2%) had more number of cases of PR positivity [9,11,12,14,15].

In the present study, 46% of cases showed ER positivity and 30 % of cases showed PR positivity. The possible reason which can be explained could be a technical reason like antigen retrieval or prolonged cold ischemic time causing low

tumour and ER and PR negativity was observed by Thiygarajan M et al, Juneja S et al, Azizun- Nisa et al, Antoniades K et al, Shet T et al and Fatima et al [10,16,23,26,27,28].

Her2neu expression had no correlation with tumour grade in the current study which was similar to the studies done by Thiygarajan M et al,Almari et al and Barrios GRM et al [10,17,24]. However equivocal cases which were seven out of 50 were not confirmed by Florescent In situ Hybridisation test as our patients were unaffordable.

All these seven cases were considered as negative in this study. Hence only IHC Her2neu positive cases were considered for this study. High Ki67 proliferation index was significantly correlated with a higher grade of the tumour in the present study similar to the studies done by Haroon S et al, Inwald EC et al, Peng Y, Han JS et aland Rhee J et al [14,18,29,30,31].

ER/PR receptor status had not much of a correlation with nodal status in the current study similar to the observation in studies like Thiygarajan M et al, Azizun- Nisa et al and Fatima et al [10,23,28].

In the current study, there was not much of a correlation between the nodal status and Her2neu status, in contrast, to study done by Thiygarajan M et al, Azizun- Nisa et al and Naqvi et al where a significant correlation was found between Her2neu overexpression and lymph node status [10,23,32].

High Ki67 expression was seen in lymph node metastasis positive cases similar to the studies done by Peng Y, Han JS et al and Rhee J et al [29,30,31].

Most number of patients presented with absent lymphovascular invasion (64%) in the present study similar to study done by Thiygarajan M et al (60%)[10].There was no significant correlation noted between the receptor status and the lymphovascular invasion similar to the study done by Thiygarajan M et al [10].

ER negativity and PR negativity significantly increased with increase in Mitotic index similar to the study done by Thiygarajan M et al [10].

Her2neu and Mitotic Index had no significant correlation similar toThiygarajan M et al and Barrios GRM et al [10,20]. High Ki67 index (≥ 15%) significantly correlated with the high mitotic count, which was in agreement with the results of Soliman et al, Nishimura et al and Yerushalmi et al [33,34,35].

Dr.Mithraa Devi S: Helped with data collection, analysis, manuscript construction and involved in the submission of the final report.

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