Breast cancer represents a spectrum of heterogeneous diseases with different clinical behaviour and response to specific systemic therapy. Invasive lobular carcinoma (ILC) is the second most frequent subtype of breast cancer, representing around 10% of all breast cancer cases.1
It has been demonstrated that ILC is a special disease entity that differs from the more common invasive breast carcinomas such as invasive ductal carcinoma (IDC). These differences include risk factors, histological and clinical characteristics, transcriptional signatures and genomic profiles.2,3,4 ILCs usually arise in postmenopausal women, are larger in size at the time of diagnosis due to insidious nature of its growth, but are typically of lower histological grade. The majority of ILC tumors express hormone receptors such as estrogen receptors (ER), progesterone receptors (PR) but they less commonly exhibit human epidermal growth factor receptor-2 (HER-2) overexpression or amplification.5 Data about prognosis of ILC vary substantially; studies have demonstrated better6,7, the same8, and worse long-term overall survival (OS) in comparison to unselected invasive breast cancers.9
Additionally, it has been reported that ILC is less responsive to chemotherapy (ChT).10,11,12 However, these tumors respond well to endocrine therapy (ET) given their biological profile.13 Results of an important retrospective study clearly showed an OS benefit of adjuvant ET for patients with ILC.14
Desmedt
Investigators of the BIG 1–98 study which compared letrozole monotherapy and letrozole switching strategy to tamoxifen (TAM) monotherapy reported that postmenopausal patient population with ILC may derive greater benefit from letrozole (AIs) than patients with IBC, NOS (invasive breast carcinoma, no otherwise specified).17 Furthermore, additional post-hoc analysis of the BIG 1–98 study showed that irrespective of the histological subtype of breast cancer tumors with
In this study, we aimed to evaluate the independent prognostic role of
After obtaining approval from the institutional review committee and ethical approval of the Ministry of Health of the Slovenian Republic (#0120-323/2019), we performed a retrospective analysis of a cohort of patients with early-stage ILC identified from a pathology database at the Institute of Oncology Ljubljana. Eligible patients were treated between January 1st 2003 and December 31st 2008, thereby allowing at least 10 years of follow-up at the time of data analysis.
Formalin-fixed and paraffin embedded (FFPE) and hematoxylin and eosin stained tumor slides of all included patients were reviewed by an experienced breast pathologist (BGK) to ensure that the diagnosis of ILC and its subtype(s) were correct. We collected the following clinicopathological parameters from each patient's from the existing pathology reports: age at diagnosis, subtype of ILC, tumor size, nodal status, grade, mitotic count, ER and PR expression, HER-2 overexpression or amplification, lymphovascular invasion (LVI) and perineural invasion (PNVI). Ki-67 labeling index and tumor infiltrating lymphocytes (TILs) were additionally determined retrospectively by a single breast cancer pathologist as these biomarkers were not assessed routinely in years of the cohort inception. Tumor grading was classified according to the Bloom-Richardson-Elston classification.19 ER and PR expression and HER-2 status were determined using the American Society of Clinical Oncology/College of American Pathologists guidelines.20,21 Proliferation index Ki-67 was estimated with DAKO, Glostrup antibody MIB1 according to recommendations from the International Ki-67 in Breast Cancer Working Group.22 For the evaluation of TILs the recommendations of the 2014 International TILs Working Group were followed.23
We collected all data about systemic therapy for each patient included into the study such as whether the patient received ChT, ET and HER-2-targeted therapy. We also collected data about the type of ChT (cyclophosphamide – metotrexate-5-fluorouracil regimen (CMF), anthracycline-based chemotherapy, anthracyclines and taxanes, taxanes without anthracyclines), type of ET (tamoxifen monotherapy, AI monotherapy or a switching approach [TAM-AI]) and duration of ET (up to 5 years or more than 5 years).
The outcomes of interest were distant metastasis-free survival (DMFS) and overall survival (OS) defined as time from diagnosis (date of surgery) to distant relapse or death (whichever occurred first) and as time from diagnosis to death from any cause, respectively. The last date of a follow-up was October 31st 2021. Data were analyzed using R version 4.1.2 (Vienna, Austria). Descriptive statistics were used to describe patient characteristics. Age and duration of therapy were measured in years, tumor size was measured in millimeters, Ki-67 index was measured as a proportion of positive tumor cells and logarithmised and for the number of positive axillary lymph nodes the square root was taken of in order to normalize the distribution of the variables and improve model fit. DMFS and OS were estimated using Kaplan-Meier analysis. Log-rank tests were performed to compare the survival of
Among an initial cohort of 428 patients, we excluded 24 patients who were treated in other cancer centers in Slovenia, nine patients who had de novo metastatic lobular cancer, eight patients who received neoadjuvant ChT, five patients with other histological subtypes of breast cancer (IBC, NOS, ILC and IBC, NOS), five patients with very small tumors (less than 5 mm in size) and five patients whose biopsies were from years before 2003. Two patients were lost very early in the follow up as they moved out of country, so they were excluded from the analysis.
Characteristics of the included patients and their tumors
62.8 (33–90) | 63.1 | 62.4 | |
21 | 19 | 21 | |
|
209 (57) | 100 (61) | 109 (54) |
|
84 (23) | 37 (22) | 47 (23) |
|
26 (7) | 1 (7) | 15 (8) |
|
46 (13) | 16 (10) | 30 (15) |
|
52 (14) | 20 (12) | 32 (16) |
|
270 (74) | 134 (82) | 136 (68) |
|
43 (12) | 10 (6) | 33 (16) |
|
299 (82) | 136 (46) | 159 (54) |
|
39 (11) | 14 (36) | 25 (64) |
|
20 (6) | 9 (45) | 11 (55) |
|
7 (2) | 2 (29) | 5 (71) |
3 (1–50) | 2.5 (1–50) | 3 (1 |
|
|
284 (78) | 138 (84) | 146 (73) |
|
55 (15) | 19 (12) | 36 (18) |
|
26 (7) | 7 (4) | 19 (9) |
24 (7) | 4 (2) | 20 (10) | |
3 (1 |
3 | 3 | |
10.8 (0.1 |
10.8 | 10.7 |
ER = estrogen receptor; HER = 2–human epidermal growth factor receptor-2;
IHC = immunohistochemically defined subtype; PR = progesterone receptor; LVI = lymphovascular invasion; TILs = tumor-infiltrating lymphocytes
78 patients had PIK3CA mutation on exon 9, 76 patients on exon 20; five patients had dual PIK3CA mutation on exon 9 and five patients had both, exon 9 and exon 20 PIK3CA mutations
Systemic therapy exposure of all included patients is shown in Table 2. As expected, the majority of patients received ET with either TAM (106, 29%), AIs (127, 35%) or a switch approach TAM-AI (107, 29%). Ninety-one (25%) patients received ChT and ET and only 13 (4%) patients received ChT alone. Among 25 patients who did not receive any ET, 10 patients were
Distribution of systemic therapy in all patients and according to PIK3CA mutation status
12 (3) | 5 (3) | 7 (3) | |
249 (68) | 115 (70) | 134 (67) | |
13 (4) | 5 (3) | 8 (4) | |
91 (25) | 39 (24) | 52 (26) | |
25 (7) | 10 (6) | 15 (7) | |
106 (29) | 45 (27) | 61 (30) | |
127 (35) | 54 (33) | 73 (37) | |
107 (29) | 55 (34) | 52 (26) | |
5 (0.2–16.7) | 5 (0.4–16.7) | 5 (0.2–11.2) |
AIs = aromatase inhibitors; ChT = chemotherapy; ET = endocrine therapy; pts = patients, TAM = tamoxifen (TAM)
Median OS was 15.7 years for patients with
Patients who received AIs in comparison to those who received tamoxifen were on average 10 years older at the time of diagnosis, therefore a Cox proportional hazards model was used for adjustment. In a simple model, neither type of ET nor its duration and patient age at the time of diagnosis were associated with the risk of relapse (Table 3). In advanced Cox proportional hazards model only a higher number of positive axillary lymph nodes increased the risk of distant relapse (HR 1.64, adj.p < 0.001; see Table 4).
Simple Cox proportional hazards model for DMFS in the PIK3CA mutated patient cohort
0.99 | 0.96–1.02 | 1.0 | |
0.92 | 0.75–1.14 | 1.0 | |
1.07 | 0.90–1.28 | 1.0 |
Adj p = adjusted p value; AIs = aromatase inhibitors; CI = confidence interval, HR = hazard ratio; TAM = tamoxifen,
Advanced Cox proportional hazards model for DMFS in the PIK3CA mutated patient cohort
1.01 | 0.97–1.05 | 1.0 | |
0.99 | 0.57–1.71 | 1.0 | |
|
Ref | ||
|
0.91 | 0.26–3.22 | 1.0 |
|
1.03 | 0.16–6.83 | 1.0 |
1.35 | 0.93–1.95 | 1.0 | |
1 | 0.99–1.02 | 1.0 | |
|
Ref | ||
|
2.19 | 1.01–4.80 | 0.582 |
1.64 | 1.30–2.06 | < 0.001 | |
1.02 | 0.81–1.29 | 1.0 | |
1.06 | 0.87–1.28 | 1.0 |
Adj p = adjusted p value; AIs = aromatase inhibitors; CI = confidence interval; HR = hazard ratio; LNs = lymph nodes; No. = number; PR = progesterone receptor; TAM = tamoxifen
We found that each year of aging increased the risk of death by 5%. Each year of treatment with tamoxifen decreased the risk of death by 27% in comparison to no ET for a patient of the same age (Table 5). Similarly, each year of treatment with AIs decreased the risk of death by 21% compared to no ET for a patient of the same age (Table 5).
Simple Cox proportional hazards model for OS in the PIK3CA mutated patient cohort
1.05 | 1.02–1.07 | < 0.001 | |
0.73 | 0.61–0.88 | 0.002 | |
0.79 | 0.67–0.93 | 0.005 |
Adj p = adjusted p value; AIs = aromatase inhibitors; CI = confidence interval; HR = hazard ratio; TAM = tamoxifen
In the advanced Cox proportional hazards model age at the time of diagnosis, grade 3 and higher number of positive axillary lymph nodes were all associated with higher risk of death (HR 1.05,
Advanced Cox proportional hazards model for OS in the PIK3CA mutated patient cohort
1.05 | 1.02–1.08 | 0.014 | |
1.38 | 0.90–2.10 | 0.84 | |
|
Ref | ||
|
1.41 | 0.59–3.38 | 1.0 |
|
5.52 | 1.67–18.18 | 0.04 |
0.94 | 0.72–1.22 | 1.0 | |
1 | 0.99–1.01 | 1.0 | |
|
Ref | ||
|
1.32 | 0.79–2.21 | 1.0 |
1.58 | 1.32–1.88 | < 0.001 | |
0.68 | 0.55–0.86 | 0.01 | |
0.73 | 0.60–0.88 | 0.01 |
Adj p = adjusted p value; AIs = aromatase inhibitors; CI = confidence interval; HR = hazard ratio; No. = number; PR = progesterone receptor; TAM = tamoxifen
ILC of the breast is a distinct entity with unique clinical, histological and molecular characteristics that differ from more common invasive breast cancer subtypes. The majority of older studies demonstrated that the outcome of ILC patients was better, however more recent data have suggested ILC has worse outcome compared to invasive ductal carcinoma, especially in the long term. It seems that delay and difficulty in early diagnosis, acquired resistance to conventional therapy and risk of late relapse pose challenges in management of patients with ILC.25
In this retrospective study our main goal was to evaluate the association between the
Previous data exploring the prognostic effect of specific somatic mutations in ER+/HER-2− early-stage breast cancer have shown that
The majority of first- and second-generation gene-expression profiles that have been used for molecular prognostication in early-stage breast cancer were developed initially in invasive ductal carcinomas and therefore their use in ILC is uncertain. However recent data have shown they could also be informative for prognostication in ILC patients. ILC tumors are quite homogenous clinically especially relating to classical prognostic features. The majority are grade 2, ER and PR positive, HER-2 negative and have a relatively low proliferative activity.28 In contrast, it has been shown recently that a 194-gene signature called LobSig may be the best in prognosticating ILC tumors. LobSig outperformed Nottingham Prognostic Index (NPI), Prosigna ROR, Oncotype Dx and Genomic Grade Index (GGI) in a multivariate Cox proportional hazards model, especially in grade 2 ILC moderate NPI cases.29 The authors reported that ILCs that were associated with a high-risk score were enriched for mutations in
We also aimed to explore the predictive effect of
An interesting study evaluating the relationship of
Our study has several limitations. First, due to the retrospective nature of this study our findings need to be interpreted with caution and possibly validated in the prospective setting. Second, our cohort of ILC patients is very likely molecularly heterogeneous which limits the generalizability of our findings. Third, longer duration of ET in this study is associated with significantly improved OS but not DMFS. This indicates that the impact of immortal time bias may persist despite the use of time-dependent Cox model in our analysis. Fourth, we used a PCR based assay which detects five hot spot mutations in the
In conclusion, the presence of