Old women with a breast lesion.

Fig 1 20x

Fig 2-3: 100x

Fig 4-5: 200x

Fig 6. 400x

What are your differential diagnoses?

 对于这一肿瘤，我看了不少文献，有一些疑问请教一下：

1、二联阴性与三联阴性的标准：在实际的应用中，我们应采用哪一个？毕竟，有人做了近6000例的检测，结果认为，没有PR阳性而ER阴性者；我用后一种

2、基底/肌上皮标记物的阳性标准：有人采用“任何强度阳性”即为阳性，而有人采用>10%瘤细胞阳性，我也用后一种

3、对于基底细胞样癌的诊断，EGFR在单独阳性时（二联或三联阴性时），可以诊断吗？EGFR虽然在BLBC中表达率较高，但并不特异，且也不是基底/肌上皮标记物，以之作为诊断标准之一，是否牵强？

不知道老师是否有空指教，谢谢！

 From your questions I can tell you read a lot of papers already. I am trying to answer your quesions by my impression. I never did research on this topic. So they can be wrong.

1. There are four possibilities: ER+/PR+, ER+/PR-, ER-/PR-, ER-/PR+. The cases with ER-/PR+ are rare, but they can be present. We use triple negative.

2. Generally we use 4 markers (ck14, ck17, ck5 or ck5/ck6, EGFR). I did not meet the cases with positivity <10% for all four markers. Generally some markers may be more stronger or intensity stains than others.

3. EGFR is not specific and is positive for many tumors. Clinically anti-EGFR drugs can be used to treat the cancers with positive EGFR, for example lung carcinoma..In my impression EGFR often is weak staining or negative for basal-like breast carcinoma. People use this marker for basal-like ca becasue it was used in the begining study. If the cases with only EGFR positive and all other basal-like markers negative, I do not think they are basal-like ca.

just for your reference.

 非常感谢赵教授，我还有两个问题：

1、对于正常乳腺型，在免疫组化检查中，有什么特殊的吗？与Null型（negative for all the markers)有多少关系？

2、曾有人将腺腔型分为三个亚型，对于其中的C型，并没有仔细的阐述，只是提到在6种分型中，预后最差，这个C型又怎么诊断？

这些问题在看文献时都找不到明显答案，还请赐教，谢谢

Just call me Dr. Zhao or Zhao.

You may know more than I know in this topic.

One thing should keep in mind. There are two different classifications, gene profile and IHC. Recent studies stated that 正常乳腺型 is not present.

2. The 2000 paper mentioned 3 luminal types, A, B, C. The same group of researchers had another paper in 2003 mentioned the luminal C may not be present. Until you are doing the study in gene profile, the gene profile classification is not very useful in clinic now. We only use the term basal-like ca. If cases with triple negative and some basal markers positive, we diagnose invasive ductal carcinoma with basal-like phenotype. The clinical treatment is the same for the cases with or without basal-like pheonotype. The oncologists care the results of ER, PR, her2/neu.

Now a california company, Genomic Health can use tissue block to do RT-PCR for expression of 21 genes (including er. pr, her2), called Onco type DX.

Oncotype DX analyzes a panel of 21 genes within a tumor to determine a Recurrence Score. The Recurrence Score is a number between 0 and 100 that corresponds to a specific likelihood of breast cancer recurrence within 10 years of the initial diagnosis. With this information, it may be possible for doctors and patients to make more informed decisions about breast cancer treatment options.

A lot of breast oncologists like the methods. In fact it is not better than simple ER/PR/Her2 IHC. One test needs more than 2000 dollors. The company earns a lot of money. Now few people care the cost of treatment.

 Correction:

One Onco type test needs US $3800, not 2000.

 Dr. ZHAO

我看你们的工作中并没有采用肌上皮标记，这是为什么呢？仅仅是因为阳性率低吗？

 We use myoepithelial markers to rule out or confirm invasive carcinoma for some uncertained cases. Routinely we use two markers, p63 and smoth muscle myosin heavy chain.

We do not use myoepithelial markers for basal-like carcinoma.

 也就是说仅用于癌或非癌的鉴别诊断问题？

今天看了一篇有关“gene-expression profiling”的review，感觉世界发展太快了，有的东西国内跟不上