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Year : 2018  |  Volume : 55  |  Issue : 3  |  Page : 210--213

Clinicopathological profile of breast cancer: An institutional experience

Ajay Gogia1, S VS Deo2, NK Shukla2, Sandeep Mathur3, DN Sharma4, Akash Tiwari1,  
1 Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi, India
2 Department of Surgical Oncology, All India Institute of Medical Sciences, New Delhi, India
3 Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
4 Department of Radiation Oncology, All India Institute of Medical Sciences, New Delhi, India

Correspondence Address:
Dr. Ajay Gogia
Department of Medical Oncology, All India Institute of Medical Sciences, New Delhi
India

Abstract

INTRODUCTION: This study was undertaken to evaluate the clinicopathological characteristics of patients with breast cancer at our institute, a tertiary-care cancer center in northern India. MATERIALS AND METHODS: This retrospective study included all patients with breast cancer registered at our institute from January 1st, 2014 to December 31st, 2016. We retrieved data (demographic, baseline clinical characteristics, pathology, and treatment details) from prospectively maintained clinical case records. Patients with incomplete case records or missing baseline information were excluded. RESULTS: We included 550 patients with breast cancer. The median age was 48 years (23–85). The median clinical tumor size was 5.0 cm. The TNM (AJCC-7th edition) stage distribution was stage I, 22 (4%); stage II, 182 (33%); stage III, 247 (44.9%); and stage IV, 99 (18%). Locally advanced breast cancer constituted 40% of the cases. Bone (48 [48.5%]) was the most common site for metastasis followed by lung. Infiltrating ductal carcinoma (528 [96%]) was the most common histologic subtype. Majority of patients, 325 (59%), were positive for estrogen receptor/progesterone receptor whereas 160 (29%) patients were HER2/neu positive. Triple negative breast cancer (TNBC) constituted 28% (154) of patients. In the nonmetastatic subgroup, 343 (76%) patients underwent modified radical mastectomy. Neoadjuvant chemotherapy (NACT) was given in 120 (26.6%) patients, of these 23 (19%) achieved pathological complete remission. Sequential anthracyline and taxane were used as NACT/adjuvant chemotherapy in most cases. Of the eligible patients, 48 (30%) received anti-HER2/neu therapy. CONCLUSION: This is one of the largest comprehensive data from a single center in India. Majority of our patients are younger in age and have advanced disease. TNBC and HER2/neu positive breast cancer are more common in our population.



How to cite this article:
Gogia A, Deo S V, Shukla N K, Mathur S, Sharma D N, Tiwari A. Clinicopathological profile of breast cancer: An institutional experience.Indian J Cancer 2018;55:210-213


How to cite this URL:
Gogia A, Deo S V, Shukla N K, Mathur S, Sharma D N, Tiwari A. Clinicopathological profile of breast cancer: An institutional experience. Indian J Cancer [serial online] 2018 [cited 2019 Feb 22 ];55:210-213
Available from: http://www.indianjcancer.com/text.asp?2018/55/3/210/250902


Full Text



 Introduction



Breast carcinoma is the most common malignant tumor among women worldwide. According to Globocan 2012, the annual age-standardized incidence rate of breast cancer worldwide was 43.1/100,000. The incidence of breast cancer has increased globally over the last several decades including Asian countries. Because of the rising incidence and awareness, breast cancer is the most common cancer in urban Indian females including Delhi, and it accounts for 30% of all cancers among females.[1] Breast cancer is a heterogeneous disease with varied clinical and pathologic features. These features, such as age, tumor size, involvement of axillary nodes, histologic grade, hormonal receptor status, and human epidermal growth factor receptor 2 (HER2)/neu amplification, guide the choice of therapy and help in determining the prognosis of the patient. Data regarding these characteristics of patients with breast cancer in our population are scarce and heterogeneous. This study was undertaken to document the clinicopathological characteristics of breast cancer at our institute.

 Materials and Methods



All patients diagnosed with breast cancer and registered at our center between January 1st, 2014 and December 31st, 2016 were included in this study. The data regarding demographics, baseline clinical characteristics, pathology, treatment received, and complete pathologic response were collected from our computer database and prospectively maintained clinical case records obtained from our medical records section using ICD code 50. The patients with incomplete records (missing information on stage, HER2/neu or hormone receptor status) were excluded. Immunohistochemical testing to determine estrogen receptor/progesterone receptor (ER/PR) and HER2/neu receptor status was performed using the standard procedures on 4 μm sections of paraffin embedded tissue specimens stained with the monoclonal antibodies (1:400; Thermo, USA), (1:400; Spring, USA), and (1:100; Thermo, USA) for ER, PR, and HER2/neu, respectively. Nuclear staining greater than 1% of tumor cell was considered as positive for ER/PR. Patients were considered HER2/neu-positive if they had immunohistochemistry (IHC) 3 + or fluorescence in situ hybridization (FISH) was amplified (more than six copies of HER2/neu gene or HER2/neu: CEP17 ratio of more than 2) by DAKO Hercep Test. The patients with HER2/neu IHC 2+ underwent FISH to confirm HER2/neu amplification. Chemotherapy regimens were used as combination (DEC, docetaxel 75 mg/m2, epirubicin 75 mg/m2, and cyclophosphamide 500 mg/m2 with growth factor support, 3 weekly) or sequentially (four cycles of FEC, 5-FU 600 mg/m2, epirubicin 75 mg/m2, cyclophosphamide 600 mg/m2 followed by four cycles of docetaxel 85 mg/m2, 3 weekly) or with targeted therapy TCH regimen (trastuzumab [8 mg/kg loading followed by 6 mg/kg], carboplatin [AUC = 6], and docetaxel [75 mg/m2] q 21 days for six cycles). The patients receiving neoadjuvant chemotherapy were evaluated clinically at the end of two cycles for response. The patients who progressed were referred for surgery, and the remaining patients completed 6–8 cycles of scheduled chemotherapy. The pathological complete response (pCR) was defined as the absence of residual invasive or in situ cancer in breast or axilla. Locally advanced breast cancer (LABC) was defined as: large breast tumors (>5 cm) associated with either skin/chest wall involvement or with fixed axillary lymph nodes or spread to ipsilateral internal mammary or supraclavicular nodes. This study was ethically approved by the institutional ethics committee.

 Results



A total of 697 patients with a diagnosis of invasive breast cancer were registered between January 2014 and December 2016 at our center. The patients for whom baseline clinical details or information regarding ER, PR, and HER2/neu status (including FISH for IHC 2+) were not available were excluded from study. We excluded seven patients with male breast and eight patients with synchronous bilateral breast cancer. The remaining 550 patients were included in this study. The common descriptive characteristics of patients are presented in [Table 1]. The median age at diagnosis was 48 (23–85) years. Fifty-six percent cases were postmenopausal. Young breast cancer (age <35 years) and elderly breast cancer (age >65 years) constitute 10% and 11% of our study population, respectively. Most of the females were multiparous (408 (80%). The common symptoms were breast lump 490 (89%) followed by nipple retraction, ulcer, pain, and rarely bleeding. Infiltrating ductal carcinoma was seen in 528 (96%) cases whereas lobular carcinoma along with other histologies was present in 22 (4%) of cases. In our cohort 325 (59%) patients were ER/PR positive and 160 (29%) patients were HER2/neu positive. Triple negative breast cancer (TNBC) constituted 28% (154) of the study population. Of the patients with HER2/neu positive breast cancer 87 (54.3%) were ER/PR positive. Ninety-nine patients (18%) had metastatic disease (stage IV) at presentation, 22 (4%) patients had stage I, 182 (33%) patients had stage II, and the remaining 247 patients (45%) had stage III disease. Overall, 180 (40%) patients had LABC. The median clinical tumor size was 5 cm among patients with nonmetastatic breast cancer, 343 (76%) patients underwent modified radical mastectomy (MRM) and 108 (24%) patients had breast conservation surgery (BCS). Baseline disease and treatment characteristics are given in [Table 1] and [Table 2]. One hundred twenty patients received NACT and, of these, complete pathological response (CPR) was observed in 23 (19%) patients. Ninety percent of patients (nonmetastatic) received chemotherapy in form of NACT or adjuvant therapy. Seventy-five percent of them received four sequential cycles of FEC followed by four cycles of docetaxel and 18% received TCH regimen and in remaining 7% of cases other regimens (FEC, DEC, DC, CMF) were used. Seventy percent of metastatic disease received chemotherapy; single agent taxane (either paclitaxal or docetaxel) was the most commonly used chemotherapy agent for palliative treatment. Hormone treatment and radiotherapy were advised whenever indicated. Bone was the most common site for metastasis followed by lung and liver. More than one site of metastases was present in 59 (59.5%) patients. Details of metastatic sites are given in [Table 3].{Table 1}{Table 2}{Table 3}

 Discussion



The median age was 48 years in our series, approximately one decade earlier than western population, likely due to a different age distribution pattern in India.[2],[3] Male breast cancer were excluded from the study (which comprises 1% of total breast cancer at our institute) due to their different clinical and biological behavior.[4] Young breast cancer (<35 years) constitute 10% of our cases, that is, slightly higher than published Indian literature.[5] The most common histological type of breast cancer in our series is infiltrating ductal carcinoma similar to that found that in other series.[6],[7] At presentation, the patients in our population had larger tumor size, more nodal involvement and hence a large majority of patients had advanced disease as compared to those in developed countries of western hemisphere where majority of patients present with early breast cancer.[8] In our study, 18% patients had metastatic disease at presentation which is also higher than the percentage of patients presenting with metastatic disease in other series published from more developed countries (5–10%).[9] This difference could be multifactorial. A major reason for this discrepancy in stage distribution is a lack of robust screening program in our population. It is also noteworthy that most of our patients are young with larger proportion of patients with TNBC or HER2/neu positive tumors. Therefore, they may have a more aggressive biology compared to their counterparts. It is also likely that lack of awareness regarding symptoms and delay in referral chain may have contributed to this stage shift in our population apart from the lack of screening and aggressive biology. Lastly, our patients with LABC were upstaged using PET-CT scan. One of our institutional studies has shown that PET-CT is LABC lead to stage migration from stage III to stage IV in 17% of patients as compared to staging with CT scan and bone scan.[10],[11] In our cohort 59% patients had ER/PR positive breast cancer that is lower than western populations.[11] The proportion of patients with HER2/neu positive breast cancer and TNBC was higher in our population as compared to earlier studies in patients from developed world.[12] The overall receptor expression pattern in our patients suggests a lower fraction of hormone receptor-positive and higher fraction of triple negative and HER2/neu-positive disease. The description of major Indian studies is tabulated in [Table 4]. The prevalence of TNBC has gradually increased at our center as evidenced from a previous study from our center, which reported that 23% of the cohort had TNBC.[13] The other study from Tata Memorial Hospital has shown the same frequency of TNBC in their cohort.[14] In our study 29% patients had HER2/neu positive breast cancer that is higher than published Indian literature.[15],[16] The reason might be a referral bias or the fact that we have performed FISH for nearly all patients who had IHC for HER2/neu as 2+.{Table 4}

The pathological complete response rate in our study is low, but it is comparable to previous published literature.[17],[18],[19] It is important to note that though we have reported a higher pathologic complete response rate in patients treated with TCH protocol, as NACT.[18] Only 30% of patients received trastuzumab, who were eligible for anti-HER2/neu therapy. The major reason for this was cost of therapy and financial constraints. Our study has a few limitations. It is a retrospective study and therefore due to nonavailability of certain records we could not include sequential patients. The pathological grade was not available for all patients.

 Conclusion



In conclusion, the patients with breast cancer presenting to our institute are young and have higher proportion of LABC and metastatic breast cancer at presentation. In keeping with the young age and advanced disease a higher proportion of our patients have HER2/neu positive and TNBC whereas the proportion of patients with hormone receptor positive breast cancer is lower.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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