الفهرس 
TNM staging for breast cancer-7th Edition AJCC Cancer Staging Manual.Only 14 pages are availabe for public view
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Abstract
Breast cancer is the most common cancer diagnosed among women worldwide accounting for 29% of the total new cancer cases. It is also the second leading cause of cancer death among women after lung cancer, accounting for 15% of the total cancer deaths (Siegel et al., 2014). In United States of America (U.S.A), excluding skin cancers, breast cancer is the most common cancer diagnosed among women in the United States, accounting for nearly 1 in 3 cancers (Desantis et al., 2013). The profile of breast carcinoma in Egyptian patients has specific features of its own. It is the first of top ten cancers. It accounts 18.3% of estimated incidence with 37.3 age-standardized rate (ASR) per 100,000. Also breast cancer ranks as the first malignancy affecting females, contributing 30% of all female cancers. It affects 1 in 14 women during their life time (El Bolkainy et al., 2013a). Breast cancers have been classified according to the histopathological type, grade and stage (Chlebowski and Geller, 2006). During the last decade, five molecular subtypes of breast carcinoma (BC) (luminal A, luminal B, HER2/neu-positive, basal-like, and normal breast-like) have been characterized and intensively studied based on molecular classification (Bertucc et al., 2006). Classifications may help in prognostication and targeting of treatment to those most likely to benefit (Blows et al., 2010). However, current classification systems are descriptive, based on morphological entities and immunohistochemistry (IHC) findings that have been shown to have prognostic implications (Geyer et al., 2009). For the success of targeted therapies and individualized medicine, a predictive rather than purely prognostic classification system is required (Geyer et al., 2009). Moreover, despite the advances in treatment modalities, up to 40% of breast cancers are usually resistant to both radiotherapy and chemotherapy, and this is could be attributed to poor tissue oxygenation (Nordsmark et al., 2005). Hypoxia is associated with malignant progression and increased risk of metastasis. It also adversely affects treatment outcome because hypoxic tumors are usually resistant to radiotherapy and chemotherapy (Nordsmark et al., 2005). Hypoxia upregulates the activity of number of genes through hypoxia-inducible factor 1 (HIF-1α) including two carbonic anhydrases (CA IX and CA XII) (Lendahl et al., 2009). Carbonic anhydrases (CAs) are a large family of Zn metalloenzymes that catalyze the reversible hydration of carbon dioxide, of which at least five distinct CA families (α, β, γ, δ and ε) have been characterized (Hilvo et al., 2005). CA IX belongs to α family and is encoded by the CA IX gene (Potter and Harris, 2004), and catalyzes reversible hydration of carbon dioxide (Co2) resulting in a net extrusion of H+ increasing the intracellular pH (pHi). So, it plays an important role in maintaining the pH of several tumor types. Furthermore, different studies have directly and indirectly validated the use of CA IX as an intrinsic surrogate marker of tumor hypoxia (Loncaster et al., 2001). Therefore, CA IX expression has prompted researches to develop potent and selective CA IX inhibitors over the recent years to enhance response to standard therapies in radio-resistant and chemo-resistant tumors (Potter and Harris, 2004). The aim of the current study was to evaluate IHC expression of CA IX in BC of Egyptian patients and to investigate the impact of CA IX on standard clinico-pathologic features, IHC subtyping of BC and overall survival (OS). This retrospective study was carried out on 56 archival specimens; representative of 56 patients with invasive BC. Cases were diagnosed in Pathology Department, Faculty of Medicine, Menoufiya University, spanning the period between January 2008 and December 2010. Revision of all submitted BC cases in this period was done. The selection of the studied cases was done meticulously according to inclusion and exclusion criteria. The patients’ ages ranged from 30 to 81 years, with a mean of 47.85 ± 11years. The material were: Invasive carcinoma of no special type (IC, NST) represented 49 out of 56 cases (87.5%), while invasive lobular carcinoma (ILC) was observed in 3 out of 56 cases (5.4%), the remaining 4 cases (7.1%) were medullary carcinomas. Thirty five cases (62.5%) were of grade 2, while grade 3 was observed in 21cases (37.5%). Histologic type, tumor grade, tumor stage, Nottingham Prognostic Index (NPI), stroma, lymphovascular invasion (LVI), spontaneous tumor necrosis, mitotic and apoptotic counts were assessed in H&E stained sections. Moreover, IHC stained slides for estrogen receptor (ER), progesterone receptor (PR), HER2/neu statuses and Ki 67 labeling index (LI) were re-assessed. The studied BC cases subtyped into the followings; 22 (39.3%) were luminal A, 11 (16.9%) were luminal B, 16 (28.6%) were HER2/neu positive and 7 (12.5%) were triple negative (TN). We assessed the adjacent non tumerous breast tissues. They were detected in 31 (55.4 %) out of 56 BC cases. Twenty two BC cases had adjacent normal breast tissues with unremarkable changes, 3 BC cases had adjacent fibrocystic disease and 6 BC cases had adjacent ductal carcinoma in situ (DCIS). Assessment of IHC expression of CA IX was done in adjacent non tumerous breast tissue, malignant epithelial tissues and cancer associated stroma. The adjacent non tumerous breast tissue displayed negative IHC expression of CA IX in 22 normal breast tissues and 3 fibrocystic disease and positive immunoreactivity in 3 cases (50%) out of 6 DCIS cases. One of them showed strong expression and 2 cases showed moderate immunoreactivity. As regards to CA IX IHC expression; 51 out of 56 (91.1%) showed positive immunoreactivity, while five cases (8.9%) showed negative expression. All studied BC cases showed cytoplasmic expression. CA IX showed variable degree of expression ranging from mild, moderate, to strong. The CA IX score ranged from 0 to 28 with x ± SD of 135.45 ± 79.58 and a median 140. For practical and reproducibility purposes, CA IX H score was dichotomized into two groups by using the median H score (140) as a cutoff point. Therefore, thirty two cases (57.1%) belonged to negative/low positive CA IX group, while 24 cases (42.9%) belonged to high positive score group. None of BC cases showed stromal positive immunoreactivity in the studied BC. There were significant association between positive CA IX expression and advanced stage (P=0.03) and desmoplastic stromal response (P=0.002). However, there was no significant relationship between CA IX status (positive/negative) and any of the clinico–demographic characteristics, hormone receptor status, HER2/neu status, Ki 67 LI, or IHC molecular subtype of BC cases. Also, there was no significant correlation between H score of CA IX and age, tumor size, necrotic percentage, mitotic and apoptotic counts. There were significant association between high positive CA IX H scores and advanced stage (P=0.03) and necrosis (P=0.02). However there was no significant association between CA IX H score grouping and the demographic and clinical parameters, hormonal status, HER2/neu status, Ki 67-LI and BC molecular subtypes. Assessment of necrosis revealed 30 cases out of 56 cases (53.57%) showing necrosis. For each case exhibiting necrosis, we evaluated the expression of CA IX in perinecrotic tumor area and in tumor tissue distant from necrosis separately. Positive expression of CA IX in perinecrotic area was noted in 2 out of 30 cases (83 33 ) and all of them displayed cytoplasmic localization CA IX showed variable expression ranging from mild to strong CA IX score ranged from 30 to 2 with x ± SD of 139.23 ± 70.18 and a median of 135. While, positive expression of CA IX in tumor tissue distant from necrotic area was noted in 23/30 (76.7%) cases and all of them displayed cytoplasmic localization. CA IX showed variable expression ranging from mild to strong CA IX score ranged from 20 to 2 0 with x ± SD of 101.30 ± 64.19 and a median 80. There was a high significant direct correlation between H score of CA IX in tumor tissue distant from necrosis and perinecrotic area (r=0.79 & P=0.000). There was no significant association between perinecrotic CA IX H score and the clinico-demographic parameters. However, there was a trend towards significant association between high perinecrotic CA IX H score and tumors located at lower inner quadrant (LIQ) (P=0.05), desmoplastic stromal reaction (P=0.06) and positive lymph node (LN) status of tumor (P=0.08). Also correlation between perinecrotic H score of CA IX had no significant values with some demographic, clinical, histopathologic parameters. There was no significant association between CA IX H score in tumor tissue distant from necrosis and the clinico-demographic profiles of BC cases and the histopathological parameters. However, its worth mentioning that CA IX H score in tumor tissue distant from necrosis showed a trend towards significant association with positive LN status of tumor (P=0.08). Similarly there was no significant association between CA IX H score in tumor tissue distant from necrosis and hormone receptor status, HER2/neu status, Ki 67-LI and BC IHC molecular subtype. There was no significant correlation between H score of CA IX in tumor tissue distant from necrosis and some demographic, clinical, histopathologic parameters The overall survival (OS) was traced up to December 2013. The survival time was calculated from the date of diagnosis to the date of last follow up or patient’s death. The survival time ranged from 11-55 months with mean± SD of 33.6±9.9 months and a median 31 months. In the univariate Kaplan-Meier survival analysis, left side (P=0.01), tumor stage I (P=0.000), low proliferative Ki 67-LI (P=0.001) and low CA IX H-score grouping (P= 0.02) had significant association with improved overall patients’ survival . Multivariate Cox regression analysis was performed using OS time in months and the co-variates which showed significant association with OS. Cox regression analysis revealed that CA IX H score grouping and Ki 67-LI were independent prognostic factors affecting patients’ OS.