|Year : 2021 | Volume
| Issue : 1 | Page : 55-64
Prognostic significance of expressed androgen receptor, p53, and p53 mutation in molecular subtypes of breast cancer
Hassan F Huwait1, Altaf A Abdulkhaliq2, Hanan M Abd Elmoneim MD, PhD 1, Asmaa Nafady3, Huda R Elzahrany4, Azzahra Edrees5, Nada Babtain6, Hamed Elgendy7, Hanaa Nafady-Hego8
1 Department of Pathology, Faculty of Medicine, Minia University, Minia, Egypt
2 Department of Biochemistry, Faculty of Medicine, Minia University, Minia, Egypt
3 Department of Clinical Pathology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
4 Department of Clinical and Chemical Pathology, Qena Faculty of Medicine, South Valley University, Qena, Egypt
5 Department of Cardiac Surgery, King Faisal Specialist Hospital and Research Center, Jeddah Saudi, Saudi Arabia
6 Internal Medicine, Faculty of Medicine, Umm Al-Qura University, Makkah, Saudi Arabia
7 Department of Anaesthesia, Hamad Medical Corporation, Doha; Weill Cornell Medicine, Doha, Qatar
8 Weill Cornell Medicine, Doha; Microbiology and Immunology, Faculty of Medicine, Assiut University, Assiut, Egypt, Qatar
|Date of Submission||01-Oct-2020|
|Date of Decision||18-Nov-2020|
|Date of Acceptance||01-Dec-2020|
|Date of Web Publication||16-Feb-2022|
MD, PhD Hanan M Abd Elmoneim
Department of Pathology, Faculty of Medicine, Umm Al-Qura University, Makkah
Source of Support: None, Conflict of Interest: None
Background Despite the introduction of several methods and new therapeutics to classify and treat breast cancer, it remains the most common cancer among women and contributes to higher mortality rates worldwide.
Purpose This study aimed to analyze the expression levels of the androgen receptor (AR), P53 protein, and P53 mutations among molecular subtypes of breast cancers and their correlation with patients’ outcome.
Patients and methods Immunostaining for estrogen receptor (ER), progesterone receptor (PR), Ki-67, and human epidermal growth factor receptor 2 (HER2) to stratify breast cancers into basal-like, HER2 type, luminal A or B types. AR, P53 expressions, and P53 mutations was compared among groups.
Results Overall, 37.5% of basal-like and 7.1% of HER2 types of invasive breast carcinomas were AR positive. P53 was expressed in 62.5 and 50% of basal-like and HER2 types, respectively. The P53 mutation varied significantly among the molecular subtypes (P<0.0001) and was found in 43.8 and 42.9% of basal-like and HER2 types, respectively. Extensive nodal status, higher stage, and P53 mutation independently predicted the overall survival. AR-negative and P53 mutation-positive tumors had intermediate or poor Nottingham Prognostic Index and were more often nodal positive, higher grade, and higher stage than AR-positive and P53 mutation-negative tumors, respectively, and P53-expressing tumors.
Conclusion Our findings highlight the importance of AR, P53, and P53 mutations as differentiating cofactors and suggest that the targeting of these marker pathways could lead to novel therapies for those patients with limited therapeutic options. AR could be a potential therapeutic target for the management of breast cancer.
Keywords: androgen receptor, breast cancer, molecular classification, P53 mutation
|How to cite this article:|
Huwait HF, Abdulkhaliq AA, Abd Elmoneim HM, Nafady A, Elzahrany HR, Edrees A, Babtain N, Elgendy H, Nafady-Hego H. Prognostic significance of expressed androgen receptor, p53, and p53 mutation in molecular subtypes of breast cancer. Egypt J Pathol 2021;41:55-64
|How to cite this URL:|
Huwait HF, Abdulkhaliq AA, Abd Elmoneim HM, Nafady A, Elzahrany HR, Edrees A, Babtain N, Elgendy H, Nafady-Hego H. Prognostic significance of expressed androgen receptor, p53, and p53 mutation in molecular subtypes of breast cancer. Egypt J Pathol [serial online] 2021 [cited 2023 Jun 2];41:55-64. Available from: http://www.xep.eg.net/text.asp?2021/41/1/55/337749
| Introduction|| |
Although several methods have been introduced to classify breast cancer, and although new therapies have been developed based on these classifications, it remains the most common cancer among women and contributes to higher mortality rates worldwide (Siegel et al., 2016). The molecular classification of breast cancer with gene-expression profiles used hormonal-receptor expression to classify breast cancer into different subgroups, including luminal subtypes A and B. Both of these are estrogen receptor (ER)-positive and/or progesterone receptor (PR)-positive. Here, the human epidermal growth factor receptor 2 (HER2) subtype is expressed as HER2, and the triple-negative (TN) basal group fails to express ER, PR, or HER2 (Brenton et al., 2005; Carey et al., 2006). The addition of Ki-67 to the previous classification to differentiate luminal A from B was previously suggested and enabled better understanding of patients’ outcomes and the response to newly introduced drugs (Brenton et al., 2005; Hugh et al., 2009; Millar et al., 2009). However, the role of other related antigens is still elusive. For example, the role of androgen/androgen receptors (AR), unlike the previous sex hormones ER or PR, in the development of breast cancer is still under debate. Previous studies revealed that AR contributed to breast cancer (Rakha et al., 2007; Collins et al., 2011; Loibl et al., 2011; Safarpour et al., 2014) and was expressed in about 60–85% of breast tumors; in some tumors, its expression was even higher than that of the well-known sex hormones ER or PR (Gonzalez et al., 2008; Ogawa et al., 2008; Niemeier et al., 2009). In addition, the circulating androgen was associated with higher probability of development of breast cancer, especially in postmenopausal women (Wysowski et al., 1987; Toth-Fejel et al., 2004; Kaaks et al., 2005; Hardin et al., 2007; Rakha et al., 2007; Baglietto et al., 2010). However, to date, the role of androgen has not been recognized in tumor classification or patient follow-up. Another example is P53, which is known for its role in tumor suppression and is encoded by the TP53 gene. Moreover, a mutation in the TP53 gene can lead to the inactivation of tumor suppression and is frequently found to be associated with markers of increased cell proliferation and high Ki-67 expression, as in an aggressive tumor phenotype (Shokouh et al., 2015). Therefore, the aim of the present study was to determine the significance of the expressions of AR, P53, and P53 mutations in terms of pathologic characteristics, tumor grade, stage, and patients’ outcomes. This, in turn, can determine additional prognostic and predictive markers, which can be used to better classify breast cancer and identify the aggressive behavior of some of them among 120 cases.
| Patients and methods|| |
Patient and tumor characteristics
The present retrospective study was carried out on 120 paraffin blocks of breast carcinoma taken from patients after mastectomies between March, 2014 and April, 2019. All participants provided informed consent. All women with a positive histopathological diagnosis of breast cancer and who were older than 18 years were included in this study. All data for age, tumor size, grade, stage, and lymph node involvement were retrieved from patients’ files in the Pathology Department, Minia University, Upper Egypt. Patients with metastatic breast tumors or those on replacement therapy were excluded from the study. The WHO classifies breast carcinoma into two major groups: invasive and noninvasive breast carcinomas. The invasive group was further divided into ductal, lobular, tubular, mucinous, and medullary categories. Herein, invasive duct carcinoma was diagnosed in 87 (66%) patients; invasive lobular carcinoma was diagnosed in 18 (14%) patients; ductal carcinoma was diagnosed in situ in eight (7%) patients; lobular carcinoma was diagnosed in situ in four (3%) patients; mucoid carcinoma was diagnosed in four (3%) patients; medullary carcinoma was diagnosed in four (3%) patients ; and tubular carcinoma was diagnosed in six (5%) patients. Tumor grade was determined according to the modification of Elston and Ellis (1991) on the Bloom and Richardson grading system, and tumor staging was performed according to the TNM classification. The Human Research Ethics Committee of Minia University approved this study. All samples were taken after approval of patients and signing an informed consent according to the latest update of Declaration of Helsinki.
Breast carcinomas of the same morphology were classified according to routine immunohistochemical analysis of ER or PR, HER2, and Ki-67 into four subtypes that vary in prognosis and response to different therapeutic measures as follows: luminal A (if ER/PR positive, Ki-67 low, and HER2 negative); luminal B (if ER/PR positive, Ki-67 high, and HER2 negative); TN/basal-like (if ER/PR negative and HER negative); and HER2 positive (if ER/PR negative and HER2 positive) (Safarpour et al., 2014; Wu et al., 2016).
Slides of 4 μm thickness were prepared from paraffin-embedded blocks; next, antigen sections were deparaffinized using xylene and rehydrated through passage into graded concentrations of ethanol. After that, the slides were incubated for 15 min with Tris-EDTA at pH=9 in a microwave to retrieve the antigen. To inhibit endogenous peroxidases sections were washed with Tris-buffer saline and tap water, rehydrated, and treated with 3% aqueous hydrogen peroxide (H2O2) for 10 min. Next, reagents of a blocking kit were used to block any nonspecific binding of the system of biotin/avidin as follows: after incubation with normal goat serum, sections were incubated for 15 min with a blocking solution of avidin D, rinsed briefly with buffer, and then incubated in a blocking solution of biotin for another 15 min. These steps were performed before adding the primary antibody. A total of a 1 : 50 dilution of anti-AR mouse monoclonal antibody (Clone AR441); a 1 : 200 dilution of anti-ER (clone 6F11); a 1 : 200 dilution of anti-PR (clone 1A6); a 1 : 1000 dilution of anti-HER2 (clone CB11); 1 : 200 anti-Ki-67 (clone MM1); and 1 : 100 anti-P53 (clone DO-7) were prepared as primary antibodies. The slides were rinsed in saline for 5 min and dried around the sections, and the primary antibody was applied (1 h). Slides were washed in saline for 5 min, immersed in 0.05% DAB solution for 10 min, and then counterstained with hematoxylin.
HER2 interpretations were used in all 120 cases, according to ASCO/CAP guidelines 2011, and semiquantitatively scored on the following scale: 0 (no staining or faint/weak membrane staining in ≤10% of tumor cells), 1+ (faint partial membrane staining detected in >10% of invasive tumor cells), 2+ (weak to moderate complete membrane staining in >10% of invasive tumor cells), and 3+ (uniform, intense membrane staining in >30% of invasive tumor cells). Scores of 0 and 1+ are considered negative, a score of 2+ as indeterminate, and a score of 3+ as positive. The positive expression of ER and PR was considered if more than or equal to 1% of tumor cells’ nuclei were positive independently on intensity (1+ to 3+). The specific percentage of positive cells and their intensity of staining (1+ to 3+) with each receptor were recorded for all cases (Hammond et al., 2011; Wolff et al., 2014). AR expression was considered positive if at least 1% of nuclear staining of any intensity (1+ to 3+) was detected (Safarpour et al., 2014). The assessment of Ki-67 was performed based on the percent of positive nuclei in 500 (5×100) cells from different tumor sites; a percentage of more than or equal to 14% was considered positive. To report P53 protein expression, those with less than 10% stained were considered as negative, while more than 10% stained tumor nuclei were considered positive (Fountzilas et al., 2016).
Molecular subtype classification
Molecular phenotyping of breast cancers was performed as follows: luminal A that was positive for ER and/or PR, negative for HER2, and Ki-67 (ER+ and/or PR+, HER2−, low Ki-67); luminal B that was positive for ER and/or PR, HER2 positive or negative, and high Ki-67 (ER+ and/or PR+, HER2+ or HER2− with high Ki-67); TN/basal-like that was negative for all ER, PR, and HER2 (ER−, PR−, HER2−); and HER2 types that were negative for ER and PR and positive for HER2 (ER−, PR−, HER2+). Eight samples did not fit in any of the previous categories and were classified as ‘others’ (Barnard et al., 2015).
DNA extraction and amplification were performed according to standard procedures; genomic DNA was extracted using proteinase K digestion from paraffin-embedded sections. For each case, five sections of 5 μm each were incubated for DNA extraction. Amplification was performed using P53 primers. The reaction was carried out in a 25 μl reaction volume of 22.5 μl ready loadmaster mix (Advanced Biotechnologies, Eldersburg, Maryland, USA), which contained (NH4)2SO4 20 mM MgCl2 1.5 mM Tween 20, 0.01% (v/v) dATP, dCTP, dGTP, and dTTP, each 0.2 mM, 0.8 μM each primer, and 500 ng of DNA. Next, amplification was carried out for every exon at a denaturing temperature of 94°C for 1 min; exon 5, 5′-TTCCTCTTCCTACAGTACTCC-3′ and 5′-GCCCCAGCTGCTCACCATCG-3′; for 45 cycles with annealing temperature at 57°C for 2 min, exon 6, 5’-CACTGATTGCTCTTAGGTCT-3’ and 5’-AGTTGCAAACCAGACCTCAGG-3’ for 40 cycles with annealing temperature at 62°C for 1 min; exon 7, 5′-TCTCCTAGGTTGGCTCTGAC-3′ and 5′-CAAGTGGCTCCTGACCTGGA-3′ for 40 cycles at an annealing temperature of 65°C for 1 min; and exon 8, 5′-CCTATCCTGAGAGTAGTGGTAA-3′, and 5′-CCTGCTTGCTTACCTCG-3′ for 40 cycles at an annealing temperature of 65°C for 1 min. We created heteroduplexes by DNA denaturing by heating at 99°C for 10 min, followed by incubation at 60°C for 1 h, and finally overnight incubation at room temperature. PCR product of 15 μl was loaded onto denaturing gradient gels (16×20×0.1 cm) that contained 6% acrylamide in TAE buffer [40 mM Tris acetate/1 mM EDTA (pH 8.0)]. In each run, one negative control and one positive control of genomic DNA from blood were included. After electrophoresis, the gel was stained with TAE buffer containing ethidium bromide and photographed by ultraviolet transillumination.
For fragment sequence and mutation by DGGE, the PCR samples were run on a 1% agarose gel; the bands were then cut, and DNA extraction from gel bands was performed using Pharmacia gel extraction kits. Electrophoresis of extracted DNA was performed on a 6% denaturing polyacrylamide gel and exposed to a film. All P53 gene mutations were confirmed on a second sequencing gel following reamplification of the 1.8-kb fragment from tumor DNA.
| Results|| |
The present study was carried out on 120 breast cancer patients whose mean age was 56.8±11.9 years. Invasive ductal carcinoma was the most prevalent, in 85 (70.8%) patients. Other invasive tumors of breast cancer were present in 32 (26%) patients, and the least prevalent was carcinoma in situ, found in only three (2.5%) patients. Involvement of the lymph nodes was found in 84 (70%) patients. In terms of tumor grades, the most prevalent grade was grade 2, which was found in 52 (43%) patients, and grade 1 was the least prevalent, found in 30 (25%) patients. In terms of the Nottingham Prognostic Index (NPI), 43 (35.8%) patients had a classification of ‘good,’ 52 (43%) patients had a classification of ‘intermediate,’ and 25 (20.8%) patients had a classification of ‘poor.’ In terms of tumor stages, stage 1 was the most prevalent, identified in 72 (60%) patients, and stage 3 was the least prevalent, identified in 19 (15.8%) patients. AR expression showed that 41 (34.2%) of tumors had positive staining, PR expression was found in 43 (35.8%) tumors and ER positive expression in 38 (31.7%) tumors. HER2/neu expression was found in 96 (80%) tumors. A total of 62 (51.7%) tumors were positive for P53, and 21 (17.5%) of these showed positivity to the P53 mutation ([Figure 1]).
|Figure 1 Positive immunohistochemical expressions of AR, HER2, and p53 in the invasive breast cancer cases are shown. (a) AR is expressed in the tumor cell nucleus. (b) HER2/neu shows cytoplasmic membrane staining. (c) P53 is expressed in the tumor cell nuclei (all are ×40 of original magnification). (d) DGGE of the P53 mutation with heteroduplexes indicated by an arrow.|
Click here to view
Analysis of cases based on the molecular subtypes
Based on molecular phenotyping, breast cancers in our series were classified into four distinct molecular subtypes. The first type is known as luminal A (ER+ and/or PR+, HER2−, and low Ki-67), which was found in 75 patients. The second type is known as luminal B (ER+ and/or PR+, HER2+ or HER2− with high Ki-67), which was found in seven patients. The third type is known as TN/basal-like (ER−, PR−, and HER2−), which was found in 16 patients. The fourth type is the HER2 type (ER−, PR−, HER2+), which was found in 14 (39) patients. The remaining eight cases were categorized in the ‘others’ group. [Table 1] presents the details of tumor grades, NPI, and P53 mutation. A number of patients who had a recurrence after 3 years, a significant relationship to the molecular type of cancer was found (P<0.0001, P=0.001, P<0.0001, and P=0.044, respectively).
Risk factors for overall survival after tumor excision
Within the 5-year follow-up period, a total of 22 (18.3%) patients died. The average survival period was 3.3±0.93 years. The percentage of overall survival (OS) was 81.7 and 78.2 at 3 and 5 years, respectively. The main cause of death was cancer as per clinical and laboratory investigations. Analysis of associated risk factors revealed that having no or lower than three lymph nodes, a tumor stage of 2, and a negative P53 mutation were found to be factors that significantly contributed to increased survival of patients by both univariate and multivariate analyses. The results of the univariate analysis were as follows: P value equal to 0.001, heart rate (HR)=0.06, P value less than 0.0001, HR=6.235, P value less than 0.0001, and HR=5.96. The results of the multivariate analysis results were as follows: P value equal to 0.033, HR=0.072, P value equal to 0.05, HR=2.912, P value of 0.05, and HR=2.726. However, some markers were found to be associated with OS, but not independent risks: a lower tumor grade, better NPI, a positive AR expression, and a negative Ki-67 expression. The results of the univariate analysis were as follows: P value of 0.01, HR=0.446, P value less than 0.0001, HR=0.128, P value of 0.036, HR=0.272, P value of 0.005, and HR=3.351 ([Table 2]). The OS of patients based on molecular subtypes in breast cancers had no significant relation with prognosis (P=0.431) ([Figure 2]).
|Table 2 Univariable and multivariable analyses with respect to the 3-year overall survival in 120 breast cancer cases|
Click here to view
|Figure 2 Relation of molecular subtypes and overall and disease-free survival in patients with breast cancer. To the right, the overall survival of patients based on molecular subtypes in breast cancers had no significant relation to prognosis. To the left, a significant difference in the disease-free survival rate was observed between molecular subtypes of breast cancer.|
Click here to view
Risk factors for disease-free survival after tumor excision
Thirty (18.3%) patients experienced recurrence events after surgical removal of a tumor during the follow-up period. The average disease-free survival (DFS) was 3.2±0.95 years. The percentage of DFS was 75 and 67.5 at 3 and 5 years, respectively. Univariate analysis revealed that no or lower than three lymph nodes, a tumor stage of 2, lower NPI, low AR, ER, HER2 expressions, P53 mutation, and molecular subtypes (P<0.05) were protective against recurrence by univariate analysis. The results of the multivariate analysis showed that no or lower than three lymph nodes (P=0.034, HR=0.14), ER expression (P=0.034, HR=5.114), negative P53 mutation (P=0.04, HR=0.386), and molecular subtypes (P=0.025, HR=0.2) had independent prognostic significance ([Table 3]).
|Table 3 Univariable and multivariable analyses with respect to the 3-year disease-free survival in 120 breast cancer cases|
Click here to view
A significant difference in the DFS rate was observed between molecular subtypes of cancer [luminal A: 12 (16%), luminal B: 2 (28.6%), basic-like: 7 (43.8%), HER2: 5 (35.7%), and others: 4 (50%)] (P=0.044) ([Table 2] and [Figure 2]).
Relationship between androgen receptor and breast cancer
Overall, AR-negative tumors at presentation had intermediate or poor NPI (P<0.0001), had more frequent node involvement (P=0.007), higher grade (P<0.0001), and higher stage (P=0.014) than AR-positive tumors ([Figure 3]a).
|Figure 3 Relation of androgen receptor (a), P53 status (b), P53 mutation (c), and the clinicopathological variables [Nottingham Prognostic Index (NPI), grade, stage, lymph node involved] in patients with breast cancer.|
Click here to view
The relationship between P53 and breast cancer
Overall, P53-negative tumors at presentation had good or intermediate NPI (P<0.0001), lower grade (P=0.003) than P53-positive tumors, and had comparable nodal involvement and stage (P=0.096 and 0.28) ([Figure 3]b).
Relationship between the P53 mutation and breast cancer
Overall, tumors with a P53 mutation at presentation had intermediate or poor NPI (P<0.0001), had more frequent node involvement (P=0.007), and were of higher grade (P<0.0001) and higher stage (P=0.004) than tumors without P53 ([Figure 3]c).
| Discussion|| |
As a result of poverty, ignorance, intake of alternative medication, and the misconception that mastectomy may interfere with womanhood, most patients from developing countries have breast cancers of higher tumor grading and tumor stage, with advanced lymph node involvement (Al-Kuraya et al., 2005; Mahmood et al., 2015; Shokouh et al., 2015; Elkablawy et al., 2016). Both tumor stage and nodal status had a significant and major influence on OS and DFS (Gupta et al., 2015; Saadatmand et al., 2015; Boughorbel et al., 2016). Furthermore, NPI − although currently used to improve the delivery of therapy in breast cancer patients − did not independently predict OS (Rakha et al., 2014). In addition, molecular subtypes independently predicted DFS, but not OS, although we used Ki-67 in the molecular subtyping to identify luminal A and B. Therefore, search for other possible oncogenic markers could help in identifying new therapeutics and improve patients’ outcomes. Identifying the impact of AR in breast cancer molecular subtypes can lead to the clinical availability of new, potent AR antagonists to potentially improve drugs that are currently available for treatment of ER-positive/ER-negative breast tumors (Chia et al., 2015). For ER-positive tumors, AR inhibits estrogen signaling; hence, it can be used as a marker for the diagnosis and management of breast cancer in these patients. Our data showed that about 34% of breast cancers were positive for AR; this is considered lower than those reported in some studies, ranging from 74.8 to 80% (Gonzalez et al., 2008; Ogawa et al., 2008; Niemeier et al., 2009; Collins et al., 2011), but similar in the coexpression of ER and AR in the majority of tumors. Unlike the results of Niemeier et al. (2009) and Collins et al. (2011), we found a lower proportion of HER2-type breast cancers expressing AR, and a higher proportion of basal-like breast cancers expressing androgen, while it is worth noting that the populations in those studies are larger than our population. Previous evidence has suggested the adverse effects of both androgens and estrogens, and that androgens might oppose the effects of estrogen and confer protection against breast-tumor development (Clendenen et al., 2019). In support of this argument, we and others found that AR-positive tumors were more likely to have good or intermediate NPI and of lower grade, lower stage, and with less lymph node involvement. Moreover, the expression of AR has been shown to be an independent risk factor for DFS. In this study, AR expression was detected in all molecular subtypes of invasive breast cancer, with the highest frequency among luminal A and B subtypes (Abd-Elghany et al., 2020). Detection of AR expression may not be sensitive enough to identify all TNBC tumors in which AR-mediated signaling is active, or to identify patients likely to respond to the AR-targeted treatments. Moreover, studies have shown AR to be an independent predictor for the complete pathological response in breast cancer (Bhattarai et al., 2019). Herein, we found that a significant number of ER-negative tumors, which are considered to be hormonally unresponsive, expressed AR. Androgen has been described as a potential tumor suppressor in ER-positive breast cancers, with its antiproliferative effect presumed to result from cross-talk between steroid receptor signaling pathways (Astvatsaturyan et al., 2018). We found AR expression in 37.5% of cancers in the TN/basal-like group and 7.1% of those in the HER2 group; thus, targeting the AR pathway in those populations may provide this subgroup, who currently have limited disease-management options, with a potential therapeutic target (Gucalp and Traina, 2010; Collins et al., 2011). Thus, the optimal management of breast cancer should inhibit not only ER but also AR in ER-positive breast cancers and antagonize both AR and HER2 in ER-negative and HER2-type breast cancers (Garreau et al., 2006; Macedo et al., 2006; Hardin et al., 2007). Mostly, TNBC can be driven in part by activated ligand-bound AR, while AR expression by immunohistochemistry is the traditional means of determining AR expression in breast cancer. AR expression in cells within the tumor microenvironment could have significant effects on tumor growth and progression (Christenson et al., 2018). Similar to the previous studies, we found that AR-negative tumors had higher grades, more extensive lymph node involvement, and poor prognosis (20, 25–29). Extended studies on the AR oncogenic role in either ER-positive or ER-negative breast cancers would clarify doubts and provide more details about how these receptors can lead to a new era of breast cancer management (Qi et al., 2012; Gerratana et al., 2018; Abd-Elghany et al., 2020).P53 is well known for its antiproliferative function in breast cancers (Zhu et al., 2016). The previous report correlated P53 mutations with higher tumor grades, but not with advanced tumor stage or involvement of lymph nodes; thus, its anti-oncogenic role remains unclear (Shokouh et al., 2015). In our study, a P53 mutation that did not have a low P53 level was an independent risk for OS and DFS. In support of our finding, Kurshumliu et al. (2014) could not find any correlation between P53 protein and NPI groups of breast cancers. They explained their findings, stating that immunohistochemical staining of the P53 protein might not be related to P53 mutations measured by the molecular technique because P53 mutations sometimes do not produce a stable protein to be detected by immunohistochemistry. In addition, wild-type P53 may accumulate in some conditions, bind other cellular proteins, and thus produce false-positive immunohistochemistry results (Peng, 2012). Tumors with the P53 mutation were also more likely to have a higher grade, more extensive lymph node involvement, and poor prognosis.
| Conclusion|| |
The lack of AR and the presence of the P53 mutation were associated with a poor prognosis. Expression of AR in TN/basal-like and HER2 types of invasive breast cancer could play a crucial role in differentiating subgroups of those breast cancers. Moreover, targeting the androgen-signaling pathway with new therapies will give hope to those patients with tumors previously considered to be hormone nonresponders. P53 mutation modifications can signal a new era in gene therapy for breast cancer.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abd-Elghany M, El FEZ, Toni N, Boshra M (2020). GATA-binding protein 3 and androgen receptor expressions in invasive breast cancer: the relationship with molecular phenotypes, disease progression, and survival outcomes. Egypt J Pathol 39:212–227.
Al-Kuraya K, Schraml P, Sheikh S, Amr S, Torhorst J, Tapia C et al.
(2005). Predominance of high-grade pathway in breast cancer development of Middle East women. Mod Pathol 18:891–897.
Astvatsaturyan K, Yue Y, Walts AE, Bose S (2018). Androgen receptor positive triple negative breast cancer: clinicopathologic, prognostic, and predictive features. PLoS ONE 13:e0197827.
Baglietto L, Severi G, English DR, Krishnan K, Hopper JL, Mclean C et al.
(2010). Circulating steroid hormone levels and risk of breast cancer for postmenopausal women. Cancer Epidemiol Biomarkers Prev 19:492–502.
Barnard ME, Boeke CE, Tamimi RM (2015). Established breast cancer risk factors and risk of intrinsic tumor subtypes. Biochim Biophys Acta 1856:73–85.
Bhattarai S, Klimov S, Mittal K, Krishnamurti U, Li XB, Oprea-Ilies G et al.
(2019). Prognostic role of androgen receptor in triple negative breast cancer: a multi-institutional study. Cancers (Basel) 11:7.
Boughorbel S, Al-Ali R, Elkum N (2016). Model comparison for breast cancer prognosis based on clinical data. PLoS ONE 11:e0146413.
Brenton JD, Carey LA, Ahmed AA, Caldas C (2005). Molecular classification and molecular forecasting of breast cancer: ready for clinical application? J Clin Oncol 23:7350–7360.
Carey LA, Perou CM, Livasy CA, Dressler LG, Cowan D, Conway K et al.
(2006). Race, breast cancer subtypes, and survival in the Carolina Breast Cancer Study. JAMA 295:2492–2502.
Chia K, O’Brien M, Brown M, Lim E (2015). Targeting the androgen receptor in breast cancer. Curr Oncol Rep 17:4.
Christenson JL, Trepel JB, Ali HY, Lee S, Eisner JR, Baskin-Bey ES et al.
(2018). Harnessing a different dependency: how to identify and target androgen receptor-positive versus quadruple-negative breast cancer. Horm Cancer 9:82–94.
Clendenen TV, Ge W, Koenig KL, Afanasyeva Y, Agnoli C, Brinton LA et al.
(2019). Breast cancer risk prediction in women aged 35-50 years: impact of including sex hormone concentrations in the Gail model. Breast Cancer Res 21:42.
Collins LC, Cole KS, Marotti JD, Hu R, Schnitt SJ, Tamimi RM (2011). Androgen receptor expression in breast cancer in relation to molecular phenotype: results from the Nurses’ Health Study. Mod Pathol 24:924–931.
Elkablawy MA, Albasri AM, Mohammed RA, Hussainy AS, Nouh MM, Alhujaily AS (2016). Ki67 expression in breast cancer. Correlation with prognostic markers and clinicopathological parameters in Saudi patients. Saudi Med J 37:137–141.
Elston CW, Ellis IO (1991). Pathological prognostic factors in breast cancer. I. The value of histological grade in breast cancer: experience from a large study with long-term follow-up. Histopathology 19:403–410.
Fountzilas G, Giannoulatou E, Alexopoulou Z, Zagouri F, Timotheadou E, Papadopoulou K et al.
(2016). TP53 mutations and protein immunopositivity may predict for poor outcome but also for trastuzumab benefit in patients with early breast cancer treated in the adjuvant setting. Oncotarget 7:32731–32753.
Garreau JR, Muller P, Pommier R, Pommier S (2006). Transgenic introduction of androgen receptor into estrogen-receptor-, progesterone-receptor-, and androgen-receptor-negative breast cancer cells renders them responsive to hormonal manipulation. Am J Surg 191:576–580.
Gerratana L, Basile D, Buono G, De Placido S, Giuliano M, Minichillo S et al.
(2018). Androgen receptor in triple negative breast cancer: a potential target for the targetless subtype. Cancer Treat Rev 68:102–110.
Gonzalez LO, Corte MD, Vazquez J, Junquera S, Sanchez R, Alvarez AC et al.
(2008). Androgen receptor expresion in breast cancer: relationship with clinicopathological characteristics of the tumors, prognosis, and expression of metalloproteases and their inhibitors. BMC Cancer 8:149.
Gucalp A, Traina TA (2010). Triple-negative breast cancer: role of the androgen receptor. Cancer J 16:62–65.
Gupta D, Gupta V, Marwah N, Gill M, Gupta S, Gupta G et al.
(2015). Correlation of hormone receptor expression with histologic parameters in benign and malignant breast tumors. Iran J Pathol 10:23–34.
Hammond ME, Hayes DF, Wolff AC (2011). Clinical notice for American Society of Clinical Oncology-College of American Pathologists guideline recommendations on ER/PgR and HER2 testing in breast cancer. J Clin Oncol 29:e458.
Hardin C, Pommier R, Calhoun K, Muller P, Jackson T, Pommier S (2007). A new hormonal therapy for estrogen receptor-negative breast cancer. World J Surg 31:1041–1046.
Hugh J, Hanson J, Cheang MC, Nielsen TO, Perou CM, Dumontet C et al.
(2009). Breast cancer subtypes and response to docetaxel in node-positive breast cancer: use of an immunohistochemical definition in the BCIRG 001 trial. J Clin Oncol 27:1168–1176.
Kaaks R, Berrino F, Key T, Rinaldi S, Dossus L, Biessy C et al.
(2005). Serum sex steroids in premenopausal women and breast cancer risk within the European Prospective Investigation into Cancer and Nutrition (EPIC). J Natl Cancer Inst 97:755–765.
Kurshumliu F, Gashi-Luci L, Kadare S, Alimehmeti M, Gozalan U (2014). Classification of patients with breast cancer according to Nottingham prognostic index highlights significant differences in immunohistochemical marker expression. World J Surg Oncol 12:243.
Loibl S, Muller BM, von Minckwitz G, Schwabe M, Roller M, Darb-Esfahani S et al.
(2011). Androgen receptor expression in primary breast cancer and its predictive and prognostic value in patients treated with neoadjuvant chemotherapy. Breast Cancer Res Treat 130:477–487.
Macedo LF, Guo Z, Tilghman SL, Sabnis GJ, Qiu Y, Brodie A (2006). Role of androgens on MCF-7 breast cancer cell growth and on the inhibitory effect of letrozole. Cancer Res 66:7775–7782.
Mahmood H, Faheem M, Mahmood S, Sadiq M, Irfan J (2015). Impact of age, tumor size, lymph node metastasis, stage, receptor status and menopausal status on overall survival of breast cancer patients in Pakistan. Asian Pac J Cancer Prev 16:1019–1024.
Millar EK, Graham PH, O’Toole SA, Mcneil CM, Browne L, Morey AL et al.
(2009). Prediction of local recurrence, distant metastases, and death after breast-conserving therapy in early-stage invasive breast cancer using a five-biomarker panel. J Clin Oncol 27:4701–4708.
Niemeier LA, Dabbs DJ, Beriwal S, Striebel JM, Bhargava R (2009). Androgen receptor in breast cancer: expression in estrogen receptor-positive tumors and in estrogen receptor-negative tumors with apocrine differentiation. Mod Pathol 23:205–212.
Ogawa Y, Hai E, Matsumoto K, Ikeda K, Tokunaga S, Nagahara H et al.
(2008). Androgen receptor expression in breast cancer: relationship with clinicopathological factors and biomarkers. Int J Clin Oncol 13:431–435.
Peng Y (2012). Potential prognostic tumor biomarkers in triple-negative breast carcinoma. Beijing Da Xue Xue Bao 44:666–672.
Qi JP, Yang YL, Zhu H, Wang J, Jia Y, Liu N et al.
(2012). Expression of the androgen receptor and its correlation with molecular subtypes in 980 chinese breast cancer patients. Breast Cancer (Auckl) 6:1–8.
Rakha EA, El-Sayed ME, Green AR, Lee AH, Robertson JF, Ellis IO (2007). Prognostic markers in triple-negative breast cancer. Cancer 109:25–32.
Rakha EA, Soria D, Green AR, Lemetre C, Powe DG, Nolan CC et al.
(2014). Nottingham Prognostic Index Plus (NPI+): a modern clinical decision making tool in breast cancer. Br J Cancer 110:1688–1697.
Saadatmand S, Bretveld R, Siesling S, Tilanus-Linthorst MM (2015). Influence of tumour stage at breast cancer detection on survival in modern times: population based study in 173, 797 patients. BMJ 351:h4901.
Safarpour D, Pakneshan S, Tavassoli FA (2014). Androgen receptor (AR) expression in 400 breast carcinomas: is routine AR assessment justified? Am J Cancer Res 4:353–368.
Shokouh TZ, Ezatollah A, Barand P (2015). Interrelationships between Ki67, HER2/neu, p53, ER, and PR status and their associations with tumor grade and lymph node involvement in breast carcinoma subtypes: retrospective-observational analytical study. Medicine (Baltimore) 94:e1359.
Siegel RL, Miller KD, Jemal A (2016). Cancer statistics, 2016. CA Cancer J Clin 66:7–30.
Toth-Fejel S, Cheek J, Calhoun K, Muller P, Pommier RF (2004). Estrogen and androgen receptors as comediators of breast cancer cell proliferation: providing a new therapeutic tool. Arch Surg 139:50–54.
Wolff AC, Hammond ME, Hicks DG, Dowsett M, Mcshane LM, Allison KH et al.
(2014). Recommendations for human epidermal growth factor receptor 2 testing in breast cancer: American Society of Clinical Oncology/College of American Pathologists clinical practice guideline update. Arch Pathol Lab Med 138:241–256.
Wu X, Baig A, Kasymjanova G, Kafi K, Holcroft C, Mekouar H et al.
(2016). Pattern of local recurrence and distant metastasis in breast cancer by molecular subtype. Cureus 8:e924.
Wysowski DK, Comstock GW, Helsing KJ, Lau HL (1987). Sex hormone levels in serum in relation to the development of breast cancer. Am J Epidemiol 125:791–799.
Zhu A, Li Y, Song W, Xu Y, Yang F, Zhang W et al.
(2016). Antiproliferative effect of androgen receptor inhibition in mesenchymal stem-like triple-negative breast cancer. Cell Physiol Biochem 38:1003–1014.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]