Estrogen and Progesterone Receptors (ER and PR) Status of Breast Cancer Cases in Kurdistan and Their Correlation with Pathologic Prognostic Variables

Mayada I. Yalda
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Keywords : Immunohistochemistry, ER, PR, Breast, Cancer, Prognosis
Medical Journal of Babylon  10:1 , 2014 doi:1812-156X-10-1
Published :2013


Background: breast cancer shows different clinico-pathological features according to geographic and ethnic groups variation. The ER and PR positive status is an indication that the patient is a good candidate for hormone therapy. Furthermore, the high percentage and intensity of ER and PR positive cells are important predictive markers for this cancer. Aim To assess breast cancer-specific features for patients diagnosed in the north of Iraq and to assess the hormone receptors status and their relation to other pathological prognostic factors. Patients and Methods: This study included 324 breast cancer cases diagnosed and reviewed by histopathology in the central lab of Duhok/ Iraq, from May 2007 to March 2012. Immunohistochemical markers were used to identify the ER and PR status and scoring according to Allred scoring guideline. Results: About 68.2% of the patients included in this study were younger than 50 years. Most of them presented at stage II and III. Negative stain for ER was seen in more than half of the patients. The score proportion was decreasing with the increase in the stage, but the correlation was statistically insignificant; on contrary the correlation of ER and PR scoring with lymph node involvement was statistically highly significant Conclusion: The young onset of breast cancer among Kurdish patients, the high stage at first presentation and the relatively high percentages of hormone insensitive cancers in both young and old patients could be attributed to the genetic predisposition modified by the revolution in life style and required additional study and analysis.


Breast cancer, the most terrifying cancer for females, is the commonest malignancy and the second leading cause of cancer death in women. [1] Since the discovery of the ER and PR in 1950s, the ER, and to a lesser extent PR, have become important prognostic and predictive markers for breast cancer. [2] They act as DNA-binding transcription factors and regulate the activity of different genes mediating breast cell proliferation and DNA replication leading to mutations. [3, 4] Survival and response to hormonal therapy such as tamoxifen or aromatase inhibitors are most favorable among patients with hormone sensitive cancers. [5] The advance in the production of monoclonal antibodies and in antigen retrieval methods has greatly improved the detection of ER/PR in sections from formalin-fixed paraffin imbedded tissue.[6] Many investigators shed light upon the importance of using one of the semiquantitative immunohistochemistry (IHC) methods (Allred-score, Q-score, or an H-score like method) [7] because large amount of information is lost when one labels a tumor as a mere ER positive one. Although IHC scoring of ER and PR is recommended by the American Society of Clinical Oncology to guide breast cancer treatment, [8] unfortunately, inter-laboratory variability and diversity in IHC assessment are relatively high in clinical practice. Rhodes et al showed that in hormone sensitive cancers about 73% of laboratories demonstrate mere ER positivity, and only 27% demonstrate the ER low-expressing tumors. [9, 10] Epidemiologic studies have shown that the hormone sensitive cancers are associated with other indicators of favorable prognosis include; low-grade, negative nodes, [11] low S-phase fraction, normal complement of DNA and low proliferative index, [7] in addition to other variables like older age, white (vs. black) race, and nulliparity. [12] According to our knowledge this is the first wide research on breast cancer cases and hormone status in Kurdistan.

Materials and methods

This study was conducted from the first of May 2007 to the first of March 2012 and included 324 patients diagnosed and reviewed in the central lab of Dohuk as patients having breast cancer. Cases were referred from Dohuk, Arbil and Sulaymani for diagnosis and to assess the hormonal status of cancer. The breast cancer was classified histologically according to the World Health Organization classification, [13] graded using the Bloom-Richardson grading system [14] and staged according to American Joint Committee on Cancer Staging. [15]

The paraffin embedded blokes (PEBs), containing representative breast cancer tissue, were used to perform immunohistochemical analysis for ER and PR according to the Avidin Bioin Complex (ABC) detection system.[16] Sections of 4 microns thickness, obtained from the PEBs, placed on positively charged slides, together with adjacent parallel control sections, were processed with each set of staining for the IHC. Primary and secondary antibody kits were used, provided by the DAKO Company detected with the Envision+ system that employs peroxidase-labeled polymer conjugated to anti-mouse immunoglobulin antibodies. Immune complexes were identified by using a peroxidase reaction with DAB+ as chromogen.

The IHC scoring was assessed by examining 100 malignant cells (at X 40 objective) according to Allred scoring guideline by assessing the proportion score (PS) and intensity score (IS) as follow.
PS 0--------------- 1----------------- 2----------------- 3------------------ 4------------------ 5
0 > 0 to 1/100 > 1/100 to 1/10 > 1/10 to 1/3 > 1/3 to 2/3 > 2/3 to 1
IS 0 1 2 3
Negative weak intermediate strong
A total score (TS) = sum of PS and IS (0 or 2 – 8). A positive result is defined as TS = or > 3 which was validated in numerous studies. [17, 18]


In this study only 8 out of the 324 breast cancer cases were males (2.5%), all the rest cases were females (97.5%). The age ranged from 19 to 72 years, with a mean age of 46.8 years. About 68.2% of the patients were younger than 50 years (table1). Histopathological analysis revealed that non invasive carcinoma was found only in 2.5% of the patients, representing stage 0, while infiltrating carcinoma were reported in the majority of patients (97.5%); among them infiltrating ductal carcinoma comprises the commonest type (89.5%), followed by infiltrating lobular carcinoma (5.9%). Other types including mixed infiltrating ductal and lobular carcinoma, medullary carcinoma, papillary, mucinous and tubular carcinoma reported in lower percentages. The results of tumor grading showed that 25.9% of cases were in grade I, 38.3% were in grade II and 35.8% were in grade III (table2). The TNM staging revealed that stage 0 formed only 2.5% and most of the patients included in this study (83.9) presented at stage II and III (table4). Axillary lymph-node could not be assessed (Nx) in the 64 cases. In 260 cases the lymph node involved in 37.1% of patients (table5). The association of the ER score with the age is seen in table 1. Negative stain for ER (which is also considered as score 0) was seen in more than half of our patients (51.9), and in 44.4% for PR stain. Among the negative ER cases, 67.3% were younger than 50 years. A similar interpretation can be given for PR results with slight ineffective differences form ER results. Regarding the grading; positive hormonal receptors status were significantly high in grade I only (Table 2). For scoring of ER and PR there were increase in percentages of patients in grade I with strong staining, (Table 3) but unlike the results in(table 2) there was no statistical significant for the score in this observation. Table 4 analyzes the association of ER and PR scoring with the stage of the tumor. The percentage of total score proportion is decreasing with the increase in the stage. The decrease is more obvious in strong staining (44.4% - 39.5% – 8.4%). To a lesser extent, the PR scoring had a slight decrease with the increase in the stage. But these figures were statistically insignificant for both ER and PR. The correlation of ER scoring with the lymph node involvement was statistically highly significant in most of the scoring (p<0.005). Negative ER staining was seen in 80 out of 120 cases with positive lymph node and only 8 patients with positive lymph node show strong ER score. The same association was seen in PR hormonal receptor scoring and lymph-node involvement (Table 5)


The relatively low mean age of breast cancer patients reported in this study (46.8) is close to that reported by other authors in Baghdad (46.5 years), [19] Egypt (46 years), [20] Kingdom of Saudi Arabia (45 years). [21] Slightly higher mean ages reported in Morocco, Algeria, Tunisia and Libya (48 years) with 55 % of breast cancer cases being younger than 50 years [22]. Higher mean ages reported in Palestinian Arab kindred and Jewish population (51.5 and 55.9 years respectively). [23] The median age of onset of our patients is more than ten years younger than that reported in Europe and USA (excluding the African-Americans). While numerous theories have been proposed to explain this difference, including age at menarche, time of first delivery, parity, socio-demographic factors and genetic difference, none are completely satisfactory and more researches are needed in this area. [24, 25, 26, 27] About 51.9% of our patients had negative ER staining. Nearly 29.6% of the ER positive cases had strong positive stain (score 7-8). In Baghdad higher occurrences of these receptors reported in malignant breast tissues (61.9% for ER and 52% for PR). [28] Even higher figures recorded in Western studies. [7, 29] Unexpectedly the ER negative cases in this study were higher than the positive cases for both before and after 50 years. Opposite results reported in several studies, which suggested that low ER values in premenopausal women might represent a true lack of the receptor protein, [30] or the tumors among elderly women tend to be better differentiated and hence have higher receptor content [31] After these debatable findings of hormonal status, we may say that the young onset of breast cancer among patients in the north of Iraq and the relatively high percentages of hormonally insensitive cancer in young and old patients could be attributed to the genetic predisposition Most of patients included in this study (83.9) presented for the first time at stage II and III. Detection at early stages of the cancer formed only 7.4% (for stage 0 and stage1). The positive hormonal receptors status was significantly high in grade I and in negative lymph node. It was mentioned in the 1st World Conference on breast cancer that in Iraq breast cancer incidence is increasing and the diagnosis is mostly at late stage. Furthermore it has been pointed to a high rate of malignant breast tumors in Iraq with poorly differentiated cells (aneuploid). [28] A tumor in which 15% of cells exhibiting weak ER staining is biologically different from a tumor demonstrating strong intensity staining in 90% of cells. This fact has been demonstrated not only by IHC and ligand binding assay, but also by quantitative RT-PCR assays. [32, 33] Moreover, the greater benefit from tamoxifen is seen in patients with stronger ER expression. A similar interpretation can be given for PR results with slight ineffective differences form ER results. [34] The correlation of ER scoring with the lymph node involvement was statistically highly significant in most of the scoring. Similar results have been documented by many authors. [6, 35, 36] Simpson, PT 2005 hypothesized that low and high-grade breast cancers may represent separate pathways of oncogenesis, thus the absence of low grade tumors the advance in the stage is not explained by delay in diagnosis allowing progression to a higher grade. [11] This may explain the few cases in our study with positive hormone receptors and strong total score in stage IV and in metastatic lymph nodes.


The criteria of patients with breast cancer at first presentation including; the low age, the excess of high-grade, the advanced stage, and the substantially low hormone receptor status, may suggest a role of genetic predisposition in addition to environmental risk factors in developing the cancer in this population. These criteria are closer to that of eastern than the western world. The relatively low hormone sensitive cancers could be attributed to the overall low age at presentation, but the particular low ER in patients older than 50 years required additional analysis. The ER and PR positive status and scoring correlate significantly with the negative lymph node involvement and there were decreasing in strong staining with the increase in the stage.


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