Introduction
Immunohistochemistry has a very important role in the assessment of prognostic and predictive factors in invasive breast cancer (IBC) today. Prognostic factors are defined as clinical, pathological & biological features associated with the innate aggressiveness of untreated invasive breast cancer and if adverse, usually result in the use of additional therapies following surgery.1 Although a large number of potentially useful factors have been identified, only 3 are currently use in the clinical practice and their assessment is mandatory. These include estrogen receptor-α (ER-α), the Progesterone receptor (PgR) & the HER-2/neu oncogene/onco protein. There is also a close correlation in breast carcinomas between the Ki-67 growth fraction and histopathological grades.2
It is a histological grading system for invasive duct carcinoma breast.3 Percentage of tubule formation, nuclear pleomorphism and mitotic rate is each assigned 1, 2 or 3 points and scores added to grade tumor in grade I(score 3-5 well differentiated), grade II(6-7 moderately differentiated) and grade III (8-9 poorly differentiated).
HER-2/neu over expression is associated with poor prognosis and high grade of tumor, nodal metastasis and ER, PR negativity. The reduced hormone receptor expression might be one of the mechanisms by which HER-2/neu positive tumor show a decreased response to hormonal agents.4
Materials and Methods
The present study entitled “To Study ductal carcinoma breast with histopathological grades of Nottingham score” was conducted in Dept. of Pathology, at SRMSIMS, Bareilly.
This case study was prospective and retrospective. Prospective cases were selected from the patients admitted for surgery of invasive ductal carcinoma breast in Medical College Hospital. As regards retrospective cases, they were obtained from the histopathological records obtained from Pathology department of SRMS-IMS, Bareilly.
Biopsies and mastectomy specimens were fixed in 10% formalin.
Detailed history about age, family history, clinical diagnosis and chief complaints was enquired.
Tissue was fixed in buffered formalin for about 6 hour after adequate slicing.
Gross appearance of mastectomy specimen/biopsy was noted.
Paraffin blocks after thorough tissue processing were prepared.
Sections were cut 3-4 micron thick and subjected to following:
Routine haematoxylin and eosin staining was done for histological typing and grading of all cases.
Immunohistochemistry was done using labelled antibodies for hormone receptor status (Oestrogen receptor & Progesterone status), Her2/neu & proliferative index Ki-67.
Invasive ductal carcinomas and all other invasive tumours were graded based on an assessment of tubule/gland formations, nuclear pleomorphism, and mitotic counts as per criteria of Nottingham’s grading.
Results
Table 1
Distribution of cases according to gross
|
Gross |
Number of cases |
Percentage |
|
MRM |
02 |
3.57% |
|
Radical MRM |
52 |
92.85% |
|
Core Biopsy |
02 |
3.57% |
Out of 56 cases, 52 cases (92.85%) had undergone modified radical mastectomy under which whole breast tissue including axillary tail, nipple, surrounding skin were excised. In 2 cases (3.57%) radical mastectomy was done under which besides pectoralis muscles was also excised. In 2 cases (3.57%) core biopsies from breast were taken.
Table 2
Distribution according to metastatic lymph nodes
|
Metastasis |
No. of cases (N=54) |
Percentage |
|
LYMPH node positive |
54 |
100% |
|
LYMPH node negative |
- |
- |
As evident from study of 54 cases of MRM and Radical MRM all were positive for lymph node metastasis and in 2 cases of core biopsy no lymph node.
Table 3
Distribution of cases according to quick score
The quick scoring of ER & PR is combination of proportion and intensity scoring. Out of 56 cases, 24 cases (42.85%) were ER negative & 22 cases (39.28%) were PR negative while both were negative in 18 cases (32.14%).
Discussion
Grading of ductal carcinoma is an estimate of differentiation
Histologic grading describe the microscopic growth pattern of invasive ductal carcinoma. The most widely used histologic grading systems are based on criteria established by Bloom & Richardson5 & Elston & Ellis.6 The parameters measured are:
Each of the three elements is assigned a score on a scale of 1 to 3& the final grade is determined from the sums of score.
Histological grade is traditionally expressed in three categories: score 3 to 5, well differentiated (grade 1): scores 6 to 7, intermediate (Grade II) & scores 8 to 9 poorly differentiated (grade III).
Mitotic rate was reported to be the most important feature of Bloom Richardson grading system. The original Bloom Richardson grading system considered hyperchromatic nuclei to be mitotic, but Nottingham histologic grade excludes hyperchromatic nuclei when this is the only mitosis-related feature.7
Several variants of Bloom Richardson grading have been described. The system of Schauer & Weiss sub divided Bloom Richardson grade III in to two sub categories used by in total of four grades. 8 The modification of Bloom Richardson grading with more rigorous criteria for most parameters resulted in new staging i.e Nottingham grading.
Nottingham grading
Tubule formation
