title: Receptor conversion in distant breast cancer metastases.
abstract: BACKGROUND
  When breast cancer patients develop distant metastases, the choice of systemic treatment is usually based on tissue characteristics of the primary tumor as determined by immunohistochemistry (IHC) and/or molecular analysis. Several previous studies have shown that the immunophenotype of distant breast cancer metastases may be different from that of the primary tumor ("receptor conversion"), leading to inappropriate choice of systemic treatment. The studies published so far are however small and/or methodologically suboptimal. Therefore, definite conclusions that may change clinical practice could not yet be drawn. We therefore aimed to study receptor conversion for estrogen receptor alpha (ERα), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) in a large group of distant (non-bone) breast cancer metastases by re-staining all primary tumors and metastases with current optimal immunohistochemical and in situ hybridization methods on full sections.
  
  
  METHODS
  233 distant breast cancer metastases from different sites (76 skin, 63 liver, 43 lung, 44 brain and 7 gastro-intestinal) were IHC stained for ERα, PR and HER2, and expression was compared to that of the primary tumor. HER2 in situ hybridization (ISH) was done in cases of IHC conversion or when primary tumors or metastases showed an IHC 2+ result.
  
  
  RESULTS
  Using a 10% threshold, receptor conversion by IHC for ERα, PR occurred in 10.3%, 30.0% of patients, respectively. In 10.7% of patients, conversion from "ER+ or PR+" to ER-/PR- and in 3.4% from ER-/PR- to "ER+ or PR+" was found. Using a 1% threshold, ERα and PR conversion rates were 15.1% and 32.6%. In 12.4% of patients conversion from "ER+ or PR+" to ER-/PR-, and 8.2% from ER-/PR- to "ER+ or PR+" occurred. HER2 conversion occurred in 5.2%. Of the 12 cases that showed HER2 conversion by IHC, 5 showed also conversion by ISH. One further case showed conversion by ISH, but not by IHC. Conversion was mainly from positive in the primary tumor to negative in the metastases for ERα and PR, while HER2 conversion occurred equally both ways. PR conversion occurred significantly more often in liver, brain and gastro-intestinal metastases.
  
  
  CONCLUSIONS
  Receptor conversion by immunohistochemistry in (non-bone) distant breast cancer metastases does occur, is relatively uncommon for ERα and HER2, and more frequent for PR, especially in brain, liver and gastro-intestinal metastases.
authors.affiliation: Department of Pathology, University Medical Center Utrecht, The Netherlands.
authors.forename: Laurien D C
authors.initials: LD
authors.lastname: Hoefnagel
authors.forename: Marc J
authors.initials: MJ
authors.lastname: van de Vijver
authors.forename: Henk-Jan
authors.initials: HJ
authors.lastname: van Slooten
authors.forename: Pieter
authors.initials: P
authors.lastname: Wesseling
authors.forename: Jelle
authors.initials: J
authors.lastname: Wesseling
authors.forename: Pieter J
authors.initials: PJ
authors.lastname: Westenend
authors.forename: Joost
authors.initials: J
authors.lastname: Bart
authors.forename: Cornelis A
authors.initials: CA
authors.lastname: Seldenrijk
authors.forename: Iris D
authors.initials: ID
authors.lastname: Nagtegaal
authors.forename: Joost
authors.initials: J
authors.lastname: Oudejans
authors.forename: Paul
authors.initials: P
authors.lastname: van der Valk
authors.forename: Petra
authors.initials: P
authors.lastname: van der Groep
authors.forename: Elisabeth G E
authors.initials: EG
authors.lastname: de Vries
authors.forename: Elsken
authors.initials: E
authors.lastname: van der Wall
authors.forename: Paul J
authors.initials: PJ
authors.lastname: van Diest
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D014408:Biomarkers, Tumor / Q000235:genetics / Q000378:metabolism; D001932:Brain Neoplasms / Q000378:metabolism / Q000556:secondary; D001943:Breast Neoplasms / Q000378:metabolism* / Q000473:pathology; D047628:Estrogen Receptor alpha / Q000378:metabolism*; D005260:Female; D005770:Gastrointestinal Neoplasms / Q000378:metabolism / Q000556:secondary; D015972:Gene Expression Regulation, Neoplastic; D006801:Humans; D007150:Immunohistochemistry; D008113:Liver Neoplasms / Q000378:metabolism / Q000556:secondary; D008175:Lung Neoplasms / Q000378:metabolism / Q000556:secondary; D008875:Middle Aged; D009362:Neoplasm Metastasis; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000378:metabolism*; D011980:Receptors, Progesterone / Q000378:metabolism*; D012878:Skin Neoplasms / Q000378:metabolism / Q000556:secondary
chemical_list: D014408:Biomarkers, Tumor; D047628:Estrogen Receptor alpha; D018719:Erb-b2 Receptor Tyrosine Kinases; D011980:Receptors, Progesterone; C508053:ERBB2 protein, human