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GATA3 expression in morphologic subtypes of breast carcinoma: a comparison with gross cystic disease fluid protein 15 and mammaglobin
Annals of Diagnostic Pathology 19 (2015) 6–9
Contents lists available at ScienceDirect
Annals of Diagnostic Pathology
GATA3 expression in morphologic subtypes of breast carcinoma: a comparison with gross cystic disease fluid protein 15 and mammaglobin Scott M. Wendroth, MD, Mark J. Mentrikoski, MD, Mark R. Wick, MD ⁎ Department of Pathology, University of Virginia Health System, Charlottesville, VA
a r t i c l e
i n f o
Keywords: GATA3 GCDFP-15 mammaglobin breast carcinomas immunohistochemistry
a b s t r a c t GATA3 is a transcription factor, which is involved in the growth and differentiation of several human tissues. Immunohistochemical staining for this marker has proven to be useful in recognizing a number of tumors, most notably those in the urinary tract and breasts. To date, no study has specifically assessed the distribution of GATA3 among different histomorphologic subtypes of breast carcinoma. The surgical pathology archive at our institution was searched, to retrieve cases of breast carcinomas of the following microscopic types—ductal, lobular, mucinous, metaplastic, medullary, apocrine, signet-ring cell, and micropapillary. Tissue microarrays were created, with four 0.6-mm punch specimens from each case. The tissue microarrays were cut at a 5-μm thickness and stained with monoclonal antibodies to GATA3 (Biocare Medical Inc, Concord, CA), mammaglobin (Dako, Carpinteria, CA), and gross cystic disease fluid protein 15 (Dako). Tumors were considered to be positive for those markers if more than 5% of the cells were labeled. Of 55 ductal adenocarcinomas, 51 (92.7%) expressed GATA3. All 4 GATA3negative tumors were Nottingham grade III lesions that were also nonreactive for estrogen receptor protein. GATA3 was present in 28 (96.6%) of 29 lobular adenocarcinomas, 10 (90.9%) of 11 apocrine adenocarcinomas, 10 (83.3%) of 12 medullary carcinomas, 5 (55.5%) of 9 metaplastic carcinomas, and 1 of 2 signet-ring cell carcinomas. Mucinous carcinomas (23 cases) and micropapillary carcinomas (12 cases) uniformly and strongly labeled for GATA3. GATA3 equaled or surpassed the sensitivity of mammaglobin and gross cystic disease fluid protein 15 in all histologic subgroups of breast cancer in the study. Although most ductal adenocarcinomas were labeled for GATA3, it was absent in high-grade tumors that also lacked estrogen receptor protein. Favorable prognosis types of breast carcinoma (eg, mucinous carcinoma) and aggressive variants such as micropapillary carcinoma were equally reactive for this marker. A proportion of medullary and metaplastic carcinomas was GATA3 negative (17% and 44%, respectively). Thus, those pathologic entities cannot be excluded diagnostically by an absence of GATA3 immunoreactivity. © 2014 Elsevier Inc. All rights reserved.
1. Introduction GATA3 is 1 of 6 members of a zinc-finger transcription factor family that is found in mammals. It is involved in the transcriptional regulation of several tissues via the binding of its homonymous sequence [1,2]. The effects of GATA3 are seen from embryonic development through adulthood; they impact development of the skin, cutaneous appendages, breasts, sympathetic neurons, and urinary tract as well as T-lymphocytic differentiation [3-6]. In the breast, GATA3 is necessary for glandular development; specifically, it induces luminal differentiation of the mammary epithelium, and its loss has been implicated in the pathogenesis of breast carcinoma [7-9]. The expression of GATA3 in breast cancers is closely associated with that of estrogen receptor protein α (ERa) through a crossregulatory loop, wherein each factor is required for the expression of the other [10]. Although data are inconsistent regarding the
⁎ Corresponding author. Tel.: +1 434 242 2410; fax: +1 434 924 9617. E-mail address: [email protected] (M.R. Wick). http://dx.doi.org/10.1016/j.anndiagpath.2014.12.001 1092-9134/© 2014 Elsevier Inc. All rights reserved.
independent prognostic significance of GATA3, its expression in ERapositive tumors does appear to predict better survival for women who receive hormonal or systemic chemotherapy [11-14]. The immunohistochemical (IHC) detection of the GATA3 gene product has become a useful diagnostic test for a number of tumors, most prominently those in the bladder and breasts [15-17]. Before the availability of GATA3, gross cystic disease fluid protein 15 (GCDFP-15) and mammaglobin were the 2 most commonly used IHC markers of mammary epithelial differentiation. However, those determinants are less than completely sensitive, especially with regard to highgrade breast carcinomas, with several studies showing diagnostic sensitivities of less than 50% [18,19]. In comparison, Miettinen et al [16] found that GATA3 was 93% sensitive and 100% specific for breast carcinoma in an analysis of 230 ductal tumors and 38 lobular lesions. Comparable sensitivity data have been generated in other studies, including some that used fine needle aspiration biopsy specimens and pleural fluid cytology [17,20]. Although it is important to note that GATA3 is not entirely specific for breast neoplasms, as a great majority of other tumor types—including urothelial carcinomas, squamous carcinomas and basal-cell carcinomas of the skin, yolk
S.M. Wendroth et al. / Annals of Diagnostic Pathology 19 (2015) 6–9
sac carcinomas, choriocarcinomas, mesotheliomas, and cutaneous adnexal tumors—it also demonstrates GATA3 immunoreactivity [16,17]. To date, no study has analyzed comparative immunostaining for GATA3 among the various histomorphologic subtypes of breast carcinoma. The morphologic heterogeneity in this group of lesions may well require the use of IHC to prove that a metastatic carcinoma is of mammary origin (Figure). In this assessment, our goal was to document GATA3 staining patterns in a spectrum of breast cancers and to compare the relative diagnostic sensitivities of GATA3, GCDFP-15, and mammaglobin in that context.
7
2. Materials and methods After obtaining approval by the institutional review board, the electronic database for surgical pathology was searched between the years of 2000 and 2014 for cases of breast carcinoma. The following morphologic subtypes were included: ductal, lobular, mucinous, metaplastic, medullary, apocrine, signet ring, and micropapillary carcinomas. Hematoxylin and eosin–stained slides from each case were reviewed by the authors, and the diagnoses were confirmed. Fifty-five ductal, 29 lobular, 23 mucinous, 12 micropapillary, 11 apocrine, 12 medullary, 5 metaplastic, and 2 signet-ring cell carcinomas were included in the study group.
A
B
C
D
E
F
G
H
Figure. Morphologic subtypes of breast carcinoma stained with hematoxylin and eosin. Low-grade ductal carcinoma (A). High-grade ductal carcinoma (B). Lobular carcinoma (C). Mucinous carcinoma (D). Micropapillary carcinoma (E). Medullary carcinoma (F). Metaplastic carcinoma (G). Apocrine carcinoma (H).
8
S.M. Wendroth et al. / Annals of Diagnostic Pathology 19 (2015) 6–9
Archival formalin-fixed and paraffin-embedded tissue from the cases was used to construct tissue microarrays using a manual microarrayer case (Beecher Instruments, Sun Prairie, WI). It comprised four 0.6-mm cores of tumor from each case. Histologic sections of the tissue microarrays were cut at 5 μm and mounted on adhesive glass slides. All immunostains were done using an automated platform (Dako, Carpinteria, CA). The GATA3 antibody (clone L50-823) was obtained from Biocare Medical Inc and used at a dilution of 1:250. Gross cystic disease fluid protein 15 (prediluted; Dako) and mammaglobin (prediluted; Dako) staining was performed contemporaneously. Peritumoral lymphocytes were used as positive internal controls for GATA3, and native breast epithelium served as a positive internal control for GCDFP-15 and mammaglobin. Only nuclear staining was considered for GATA3, whereas cytoplasmic staining characterized mammaglobin and GCDFP-15 preparations. The percentage of immunoreactive cells was recorded; results were considered positive if more than 5% of cells were labeled. Immunohistochemical data for ERa reactivity were collated retrospectively for cases of ductal, mucinous, medullary, and apocrine breast carcinomas; they had been accrued routinely during the initial diagnostic evaluation of those tumors. 3. Results The number of immunoreactive cases in each morphologic subgroup stained for GATA3, mammaglobin, and GCDFP-15 is shown in Table. In all morphologic categories, GATA3 was at least equal in diagnostic sensitivity to mammaglobin and GCDFP-15. Only 4 cases of ductal adenocarcinoma were negative for GATA3; each of them was a Nottingham grade III tumor that also lacked ERa immunoreactivity. GATA3 was seen in a higher percentage of lobular carcinomas (96.6%) as compared with mammaglobin (69.0%) and GCDFP-15 (48.3%). All mucinous carcinomas were positive for GATA3, whereas 47.8% and 56.5% of those tumors expressed mammaglobin and GCDFP-15, respectively. Each mucinous carcinoma was immunoreactive for ERa. On the other hand, tumors with apocrine features were predominantly GATA3 positive (90.9%), but all of them were ERa negative. Medullary carcinomas were more likely to express GATA3 (83.3%) than mammaglobin (33.3%) or GCDFP-15 (16.7%). All micropapillary carcinomas stained for GATA3; 75% of them also expressed mammaglobin, but only one-third were labeled for GCDFP-15. None of the 3 IHC markers was particularly sensitive for metaplastic or signet ring-cell breast carcinomas. In those tumors, GATA3 was respectively present in 5 of 8 and 1 of 2 lesions. Mammaglobin and GCDFP-15 were seen in less than or equal to 50% of the latter cases. 4. Discussion Determining the origin of a metastatic carcinoma can be difficult using morphologic examination alone. For that reason, a multitude of IHC markers are now used toward that end. Stains for mammaglobin and GCDFP-15 have been employed to potentially label secondary deposits Table Immunoreactivity for GATA3, mammaglobin, and GCDFP-15 in morphologic subtypes of breast carcinoma GATA3
Mammaglobin
GCDFP-15
Subtype
Positive/ Positive Positive/ Positive Positive/ Positive total cases (%) total cases (%) total cases (%)
Ductal Lobular Mucinous Apocrine Medullary Micropapillary Metaplastic Signet ring
51/55 28/29 23/23 10/11 10/12 12/12 5/9 1/2
92.7 96.6 100.0 90.9 83.3 100.0 55.6 50.0
29/54 20/29 11/23 4/11 4/12 9/12 3/8 1/2
54.0 69.0 47.8 36.4 33.3 75.0 37.5 50.0
30/55 14/29 13/23 9/11 2/12 4/12 2/8 1/2
54.5 48.3 56.5 81.8 16.7 33.3 25.0 50.0
of breast cancer, and the sensitivity of those markers has ranged from 10% to 80% in various reports [18,19]. In particular, their expression is said to be limited in high-grade ductal and lobular mammary adenocarcinomas [18,19]. That is a troublesome finding because high-grade tumors are more likely to metastasize to distant sites [21,22]. Recently, GATA3 has been identified as a more sensitive marker for mammary epithelial differentiation. In 1 study, GATA3 was expressed respectively in 93% and 100% of 230 ductal and 38 lobular breast carcinomas [16]. Because several additional histotypes of breast cancer also exist, the current study was undertaken to evaluate the expression of GATA3 as well as for GCDFP-15 and mammaglobin in these more rare variants. The frequency of GATA3 expression in our study corroborates the findings of other authors [16,17]. The 4 ductal carcinomas, which were negative for GATA3, were high-grade lesions that lacked ERa. Because GATA3 and ERa expression is interdependent through a positive crossregulatory loop, that finding has logical underpinnings [10]. GATA3 expression was lost in that particular cohort of poorly differentiated tumors, but its overall sensitivity for ductal breast carcinoma (96.6%) was distinctly greater than that of mammaglobin (54.0%) and GCDFP15 (54.5%), regardless of tumor grade. All 23 mucinous breast carcinomas expressed GATA3, but only 47.8% and 56.5% were labeled for mammaglobin and GCDFP-15, respectively. In light of the knowledge that mucinous breast carcinoma is a lowgrade tumor that usually expresses ERa, that finding was also not unexpected [23]. Apocrine breast carcinoma is a rare subtype with unique morphologic and immunophenotypical properties. Its characteristic receptor profile includes the absence of ERa and progesterone receptor protein, the presence of androgen receptor protein, and reactivity for either Human Epidermal Growth Factor Receptor-2 (HER2/neu) or epidermal growth factor receptor; as such, patients with this subtype of breast carcinoma may be eligible for targeted therapies [24,25]. All apocrine carcinomas included in our study lacked ERa, and it was therefore surprising that all but one also expressed GATA3. Because GATA3 expression in the breast is otherwise dependent on the coexpression of estrogen receptor proteins, these findings may imply a secondary or aberrant pathway for GATA3 expression in apocrine carcinomas. Medullary breast carcinoma also typically lacks ERa and progesterone receptor protein as well as HER2/neu [26,27]. Mammaglobin and GCDFP-15 are likewise absent in most such tumors [26,28]. Indeed, our results showed limited diagnostic sensitivity for mammaglobin and GCDFP-15 about this tumor type. All of the medullary carcinomas that we evaluated were negative for ERa, but 10 of 12 were labeled for GATA3. This observation again suggests the possible existence of an ERa independent method for cellular GATA3 expression. Micropapillary breast carcinoma has a relatively high risk of lymphnodal metastases, when compared with “usual” ductal adenocarcinoma [29]. In this current series, GATA3 was the most sensitive marker for micropapillary tumors, with labeling of all 12 cases. In comparison, 75% expressed mammaglobin and 33% were reactive for GCDFP-15. Because of potential morphologic overlap with ovarian low-grade serous carcinoma, another ERa-positive tumor, it is possible that GATA3 may have diagnostic usefulness in distinguishing the latter lesions from micropapillary breast cancers. Although this scenario has not been exclusively evaluated in the literature to date, in the series reported by Miettinen et al [16], only 4 (5%) of 73 ovarian serous carcinomas showed overexpression of GATA3, suggesting that GATA3 may prove valuable if this situation arises clinically. Of all the subtypes evaluated in the current cohort, GATA3 was most often absent in metaplastic and signet-ring cell subtypes. Mammaglobin and GCDFP-15 also were lacking in more than 50% of those tumors, and they were also negative for ERa. Lesions in these histologic subgroups may therefore present possible diagnostic difficulties insofar as IHC for breast-related markers are concerned; however, the small number of cases evaluated suggests that this conclusion is yet to be completely confirmed. Overall, our results show that GATA3 is a sensitive marker for both ductal and lobular adenocarcinoma of the breast. Moreover, it labeled
S.M. Wendroth et al. / Annals of Diagnostic Pathology 19 (2015) 6–9
a higher percentage of tumors when compared with mammaglobin and GCDFP-15, in mammary carcinomas of all histologic subtypes that were considered in this study. However, it is important to remember that GATA3 has imperfect “specificity” for breast cancers. As shown in other studies, its expression can be seen in urothelial carcinomas, squamous and basal cell carcinomas of the skin, yolk sac carcinomas, choriocarcinomas, mesotheliomas, and benign cutaneous adnexal tumors [16,17]. If any of the latter entities come into differential diagnosis with metastatic breast carcinoma in a given case, a multiantibody IHC panel will be required for final interpretation.
References [1] Pandolfi PP, Roth ME, Karis A, Leonard MW, Dzierzak E, Grosveld FG, et al. Targeted disruption of the GATA3 gene causes severe abnormalities in the nervous system and in fetal liver haematopoiesis. Nat Genet 1995;11:40–4. [2] Bates DL, Chen Y, Kim G, Guo L, Chen L. Crystal structures of multiple GATA zinc fingers bound to DNA reveal new insights into DNA recognition and self-association by GATA. J Mol Biol 2008;381:1292–306. [3] Kaufman CK, Zhou P, Pasolli HA, Rendl M, Bolotin D, Lim KC, et al. GATA-3: an unexpected regulator of cell lineage determination in skin. Genes Dev 2003;17:2108–22. [4] Grote D, Souabni A, Busslinger M, Bouchard M. Pax 2/8-regulated Gata 3 expression is necessary for morphogenesis and guidance of the nephric duct in the developing kidney. Development 2006;133:53–61. [5] Martinez-Monedero R, Yi E, Oshima K, Glowatzki E, Edge AS. Differentiation of inner ear stem cells to functional sensory neurons. Dev Neurobiol 2008;68:669–84. [6] Tsarovina K, Pattyn A, Stubbusch J, Muller F, van der Wees J, Schneider C, et al. Essential role of Gata transcription factors in sympathetic neuron development. Development 2004;131:4775–86. [7] Kouros-Mehr H, Slorach EM, Sternlicht MD, Werb Z. GATA-3 maintains the differentiation of the luminal cell fate in the mammary gland. Cell 2006;127:1041–55. [8] Asselin-Labat ML, Sutherland KD, Barker H, Thomas R, Shackleton M, Forrest NC, et al. Gata-3 is an essential regulator of mammary-gland morphogenesis and luminal-cell differentiation. Nat Cell Biol 2007;9:201–9. [9] Usary J, Llaca V, Karaca G, Presswala S, Karaca M, He X, et al. Mutation of GATA3 in human breast tumors. Oncogene 2004;23:7669–78. [10] Tlsty TD. Luminal cells GATA have it. Nat Cell Biol 2007;9:135–6. [11] Parikh P, Palazzo JP, Rose LJ, Daskalakis C, Weigel RJ. GATA-3 expression as a predictor of hormone response in breast cancer. J Am Coll Surg 2005;200:705–10. [12] Yoon NK, Maresh EL, Shen D, Elshimali Y, Apple S, Horvath S, et al. Higher levels of GATA3 predict better survival in women with breast cancer. Hum Pathol 2010;41: 1794–801.
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[13] Voduc D, Cheang M, Nielsen T. GATA-3 expression in breast cancer has a strong association with estrogen receptor but lacks independent prognostic value. Cancer Epidemiol Biomarkers Prev 2008;17:365–73. [14] Gulbahce HE, Sweeney C, Surowiecka M, Knapp D, Varghese L, Blair CK. Significance of GATA-3 expression in outcomes of patients with breast cancer who received systemic chemotherapy and/or hormonal therapy and clinicopathologic features of GATA-3-positive tumors. Hum Pathol 2013;44:2427–31. [15] Ordonez NG. Value of GATA3 immunostaining in tumor diagnosis: a review. Adv Anat Pathol 2013;20:352–60. [16] Miettinen M, McCue PA, Sarlomo-Rikala M, Rys J, Czapiewski P, Wazny K, et al. GATA3: a multispecific but potentially useful marker in surgical pathology: a systematic analysis of 2500 epithelial and nonepithelial tumors. Am J Surg Pathol 2014;38:13–22. [17] Liu H, Shi J, Wilkerson ML, Lin F. Immunohistochemical evaluation of GATA3 expression in tumors and normal tissues: a useful immunomarker for breast and urothelial carcinomas. Am J Clin Pathol 2012;138:57–64. [18] Luo MH, Huang YH, Ni YB, Tsang JY, Chan SK, Shao MM, et al. Expression of mammaglobin and gross cystic disease fluid protein-15 in breast carcinomas. Hum Pathol 2013;44:1241–50. [19] Darb-Esfahani S, von Minckwitz G, Denkert C, Ataseven B, Hogel B, Mehta K, et al. Gross cystic disease fluid protein 15 (GCDFP-15) expression in breast cancer subtypes. BMC Cancer 2014;14:546–56. [20] Braxton DR, Cohen C, Siddiqui MT. Utility of GATA3 immunohistochemistry for diagnosis of metastatic breast carcinoma in cytology specimens. Diagn Cytopathol 2014 [Epub ahead of print]. [21] Bevilacqua JL, Kattan MW, Fey JV, Cody III HS, Borgen PI, Van Zee KJ. Doctor, what are my chances of having a positive sentinel node? A validated nomogram for risk estimation. J Clin Oncol 2007;25:3670–9. [22] Yoshihara E, Smeets A, Laenen A, Reynders A, Soens J, Van Ongeval C, et al. Predictors of axillary lymph node metastases in early breast cancer and their applicability in clinical practice. Breast 2013;22:357–61. [23] Yang M, Li X, Chun-Hong P, Lin-Ping H. Pure mucinous breast carcinoma: a favorable subtype. Breast Care (Basel) 2013;8:56–9. [24] Vranic S, Schmitt F, Sapino A, Costa JL, Reddy S, Castro M, et al. Apocrine carcinoma of the breast: a comprehensive review. Histol Histopathol 2013;28:1393–409. [25] Bedford T, Alperstein A, Nathani Y, Marx R, DeVito P. A rare presentation of triple-negative apocrine breast carcinoma with metastases. J Surg Case Rep 2014 [online publication]. [26] Reyes C, Gomez-Fernandez C, Nadji M. Metaplastic and medullary mammary carcinomas do not express mammaglobin. Am J Clin Pathol 2012;137:747–52. [27] Dieci MV, Orvieto E, Dominici M, Conte P, Guarneri V. Rare breast cancer subtypes: histological, molecular, and clinical peculiarities. Oncologist 2014;19:805–13. [28] Mazoujian G, Bodian C, Haagensen Jr DE, Haagensen CD. Expression of GCDFP-15 in breast carcinomas. Relationship to pathologic and clinical factors. Cancer 1989;63: 2156–61. [29] Chen AC, Paulino AC, Schwartz MR, Rodriguez AA, Bass BL, Chang JC, et al. Population-based comparison of prognostic factors in invasive micropapillary and invasive ductal carcinoma of the breast. Br J Cancer 2014;111:619–22.
Contents lists available at ScienceDirect
Annals of Diagnostic Pathology
GATA3 expression in morphologic subtypes of breast carcinoma: a comparison with gross cystic disease fluid protein 15 and mammaglobin Scott M. Wendroth, MD, Mark J. Mentrikoski, MD, Mark R. Wick, MD ⁎ Department of Pathology, University of Virginia Health System, Charlottesville, VA
a r t i c l e
i n f o
Keywords: GATA3 GCDFP-15 mammaglobin breast carcinomas immunohistochemistry
a b s t r a c t GATA3 is a transcription factor, which is involved in the growth and differentiation of several human tissues. Immunohistochemical staining for this marker has proven to be useful in recognizing a number of tumors, most notably those in the urinary tract and breasts. To date, no study has specifically assessed the distribution of GATA3 among different histomorphologic subtypes of breast carcinoma. The surgical pathology archive at our institution was searched, to retrieve cases of breast carcinomas of the following microscopic types—ductal, lobular, mucinous, metaplastic, medullary, apocrine, signet-ring cell, and micropapillary. Tissue microarrays were created, with four 0.6-mm punch specimens from each case. The tissue microarrays were cut at a 5-μm thickness and stained with monoclonal antibodies to GATA3 (Biocare Medical Inc, Concord, CA), mammaglobin (Dako, Carpinteria, CA), and gross cystic disease fluid protein 15 (Dako). Tumors were considered to be positive for those markers if more than 5% of the cells were labeled. Of 55 ductal adenocarcinomas, 51 (92.7%) expressed GATA3. All 4 GATA3negative tumors were Nottingham grade III lesions that were also nonreactive for estrogen receptor protein. GATA3 was present in 28 (96.6%) of 29 lobular adenocarcinomas, 10 (90.9%) of 11 apocrine adenocarcinomas, 10 (83.3%) of 12 medullary carcinomas, 5 (55.5%) of 9 metaplastic carcinomas, and 1 of 2 signet-ring cell carcinomas. Mucinous carcinomas (23 cases) and micropapillary carcinomas (12 cases) uniformly and strongly labeled for GATA3. GATA3 equaled or surpassed the sensitivity of mammaglobin and gross cystic disease fluid protein 15 in all histologic subgroups of breast cancer in the study. Although most ductal adenocarcinomas were labeled for GATA3, it was absent in high-grade tumors that also lacked estrogen receptor protein. Favorable prognosis types of breast carcinoma (eg, mucinous carcinoma) and aggressive variants such as micropapillary carcinoma were equally reactive for this marker. A proportion of medullary and metaplastic carcinomas was GATA3 negative (17% and 44%, respectively). Thus, those pathologic entities cannot be excluded diagnostically by an absence of GATA3 immunoreactivity. © 2014 Elsevier Inc. All rights reserved.
1. Introduction GATA3 is 1 of 6 members of a zinc-finger transcription factor family that is found in mammals. It is involved in the transcriptional regulation of several tissues via the binding of its homonymous sequence [1,2]. The effects of GATA3 are seen from embryonic development through adulthood; they impact development of the skin, cutaneous appendages, breasts, sympathetic neurons, and urinary tract as well as T-lymphocytic differentiation [3-6]. In the breast, GATA3 is necessary for glandular development; specifically, it induces luminal differentiation of the mammary epithelium, and its loss has been implicated in the pathogenesis of breast carcinoma [7-9]. The expression of GATA3 in breast cancers is closely associated with that of estrogen receptor protein α (ERa) through a crossregulatory loop, wherein each factor is required for the expression of the other [10]. Although data are inconsistent regarding the
⁎ Corresponding author. Tel.: +1 434 242 2410; fax: +1 434 924 9617. E-mail address: [email protected] (M.R. Wick). http://dx.doi.org/10.1016/j.anndiagpath.2014.12.001 1092-9134/© 2014 Elsevier Inc. All rights reserved.
independent prognostic significance of GATA3, its expression in ERapositive tumors does appear to predict better survival for women who receive hormonal or systemic chemotherapy [11-14]. The immunohistochemical (IHC) detection of the GATA3 gene product has become a useful diagnostic test for a number of tumors, most prominently those in the bladder and breasts [15-17]. Before the availability of GATA3, gross cystic disease fluid protein 15 (GCDFP-15) and mammaglobin were the 2 most commonly used IHC markers of mammary epithelial differentiation. However, those determinants are less than completely sensitive, especially with regard to highgrade breast carcinomas, with several studies showing diagnostic sensitivities of less than 50% [18,19]. In comparison, Miettinen et al [16] found that GATA3 was 93% sensitive and 100% specific for breast carcinoma in an analysis of 230 ductal tumors and 38 lobular lesions. Comparable sensitivity data have been generated in other studies, including some that used fine needle aspiration biopsy specimens and pleural fluid cytology [17,20]. Although it is important to note that GATA3 is not entirely specific for breast neoplasms, as a great majority of other tumor types—including urothelial carcinomas, squamous carcinomas and basal-cell carcinomas of the skin, yolk
S.M. Wendroth et al. / Annals of Diagnostic Pathology 19 (2015) 6–9
sac carcinomas, choriocarcinomas, mesotheliomas, and cutaneous adnexal tumors—it also demonstrates GATA3 immunoreactivity [16,17]. To date, no study has analyzed comparative immunostaining for GATA3 among the various histomorphologic subtypes of breast carcinoma. The morphologic heterogeneity in this group of lesions may well require the use of IHC to prove that a metastatic carcinoma is of mammary origin (Figure). In this assessment, our goal was to document GATA3 staining patterns in a spectrum of breast cancers and to compare the relative diagnostic sensitivities of GATA3, GCDFP-15, and mammaglobin in that context.
7
2. Materials and methods After obtaining approval by the institutional review board, the electronic database for surgical pathology was searched between the years of 2000 and 2014 for cases of breast carcinoma. The following morphologic subtypes were included: ductal, lobular, mucinous, metaplastic, medullary, apocrine, signet ring, and micropapillary carcinomas. Hematoxylin and eosin–stained slides from each case were reviewed by the authors, and the diagnoses were confirmed. Fifty-five ductal, 29 lobular, 23 mucinous, 12 micropapillary, 11 apocrine, 12 medullary, 5 metaplastic, and 2 signet-ring cell carcinomas were included in the study group.
A
B
C
D
E
F
G
H
Figure. Morphologic subtypes of breast carcinoma stained with hematoxylin and eosin. Low-grade ductal carcinoma (A). High-grade ductal carcinoma (B). Lobular carcinoma (C). Mucinous carcinoma (D). Micropapillary carcinoma (E). Medullary carcinoma (F). Metaplastic carcinoma (G). Apocrine carcinoma (H).
8
S.M. Wendroth et al. / Annals of Diagnostic Pathology 19 (2015) 6–9
Archival formalin-fixed and paraffin-embedded tissue from the cases was used to construct tissue microarrays using a manual microarrayer case (Beecher Instruments, Sun Prairie, WI). It comprised four 0.6-mm cores of tumor from each case. Histologic sections of the tissue microarrays were cut at 5 μm and mounted on adhesive glass slides. All immunostains were done using an automated platform (Dako, Carpinteria, CA). The GATA3 antibody (clone L50-823) was obtained from Biocare Medical Inc and used at a dilution of 1:250. Gross cystic disease fluid protein 15 (prediluted; Dako) and mammaglobin (prediluted; Dako) staining was performed contemporaneously. Peritumoral lymphocytes were used as positive internal controls for GATA3, and native breast epithelium served as a positive internal control for GCDFP-15 and mammaglobin. Only nuclear staining was considered for GATA3, whereas cytoplasmic staining characterized mammaglobin and GCDFP-15 preparations. The percentage of immunoreactive cells was recorded; results were considered positive if more than 5% of cells were labeled. Immunohistochemical data for ERa reactivity were collated retrospectively for cases of ductal, mucinous, medullary, and apocrine breast carcinomas; they had been accrued routinely during the initial diagnostic evaluation of those tumors. 3. Results The number of immunoreactive cases in each morphologic subgroup stained for GATA3, mammaglobin, and GCDFP-15 is shown in Table. In all morphologic categories, GATA3 was at least equal in diagnostic sensitivity to mammaglobin and GCDFP-15. Only 4 cases of ductal adenocarcinoma were negative for GATA3; each of them was a Nottingham grade III tumor that also lacked ERa immunoreactivity. GATA3 was seen in a higher percentage of lobular carcinomas (96.6%) as compared with mammaglobin (69.0%) and GCDFP-15 (48.3%). All mucinous carcinomas were positive for GATA3, whereas 47.8% and 56.5% of those tumors expressed mammaglobin and GCDFP-15, respectively. Each mucinous carcinoma was immunoreactive for ERa. On the other hand, tumors with apocrine features were predominantly GATA3 positive (90.9%), but all of them were ERa negative. Medullary carcinomas were more likely to express GATA3 (83.3%) than mammaglobin (33.3%) or GCDFP-15 (16.7%). All micropapillary carcinomas stained for GATA3; 75% of them also expressed mammaglobin, but only one-third were labeled for GCDFP-15. None of the 3 IHC markers was particularly sensitive for metaplastic or signet ring-cell breast carcinomas. In those tumors, GATA3 was respectively present in 5 of 8 and 1 of 2 lesions. Mammaglobin and GCDFP-15 were seen in less than or equal to 50% of the latter cases. 4. Discussion Determining the origin of a metastatic carcinoma can be difficult using morphologic examination alone. For that reason, a multitude of IHC markers are now used toward that end. Stains for mammaglobin and GCDFP-15 have been employed to potentially label secondary deposits Table Immunoreactivity for GATA3, mammaglobin, and GCDFP-15 in morphologic subtypes of breast carcinoma GATA3
Mammaglobin
GCDFP-15
Subtype
Positive/ Positive Positive/ Positive Positive/ Positive total cases (%) total cases (%) total cases (%)
Ductal Lobular Mucinous Apocrine Medullary Micropapillary Metaplastic Signet ring
51/55 28/29 23/23 10/11 10/12 12/12 5/9 1/2
92.7 96.6 100.0 90.9 83.3 100.0 55.6 50.0
29/54 20/29 11/23 4/11 4/12 9/12 3/8 1/2
54.0 69.0 47.8 36.4 33.3 75.0 37.5 50.0
30/55 14/29 13/23 9/11 2/12 4/12 2/8 1/2
54.5 48.3 56.5 81.8 16.7 33.3 25.0 50.0
of breast cancer, and the sensitivity of those markers has ranged from 10% to 80% in various reports [18,19]. In particular, their expression is said to be limited in high-grade ductal and lobular mammary adenocarcinomas [18,19]. That is a troublesome finding because high-grade tumors are more likely to metastasize to distant sites [21,22]. Recently, GATA3 has been identified as a more sensitive marker for mammary epithelial differentiation. In 1 study, GATA3 was expressed respectively in 93% and 100% of 230 ductal and 38 lobular breast carcinomas [16]. Because several additional histotypes of breast cancer also exist, the current study was undertaken to evaluate the expression of GATA3 as well as for GCDFP-15 and mammaglobin in these more rare variants. The frequency of GATA3 expression in our study corroborates the findings of other authors [16,17]. The 4 ductal carcinomas, which were negative for GATA3, were high-grade lesions that lacked ERa. Because GATA3 and ERa expression is interdependent through a positive crossregulatory loop, that finding has logical underpinnings [10]. GATA3 expression was lost in that particular cohort of poorly differentiated tumors, but its overall sensitivity for ductal breast carcinoma (96.6%) was distinctly greater than that of mammaglobin (54.0%) and GCDFP15 (54.5%), regardless of tumor grade. All 23 mucinous breast carcinomas expressed GATA3, but only 47.8% and 56.5% were labeled for mammaglobin and GCDFP-15, respectively. In light of the knowledge that mucinous breast carcinoma is a lowgrade tumor that usually expresses ERa, that finding was also not unexpected [23]. Apocrine breast carcinoma is a rare subtype with unique morphologic and immunophenotypical properties. Its characteristic receptor profile includes the absence of ERa and progesterone receptor protein, the presence of androgen receptor protein, and reactivity for either Human Epidermal Growth Factor Receptor-2 (HER2/neu) or epidermal growth factor receptor; as such, patients with this subtype of breast carcinoma may be eligible for targeted therapies [24,25]. All apocrine carcinomas included in our study lacked ERa, and it was therefore surprising that all but one also expressed GATA3. Because GATA3 expression in the breast is otherwise dependent on the coexpression of estrogen receptor proteins, these findings may imply a secondary or aberrant pathway for GATA3 expression in apocrine carcinomas. Medullary breast carcinoma also typically lacks ERa and progesterone receptor protein as well as HER2/neu [26,27]. Mammaglobin and GCDFP-15 are likewise absent in most such tumors [26,28]. Indeed, our results showed limited diagnostic sensitivity for mammaglobin and GCDFP-15 about this tumor type. All of the medullary carcinomas that we evaluated were negative for ERa, but 10 of 12 were labeled for GATA3. This observation again suggests the possible existence of an ERa independent method for cellular GATA3 expression. Micropapillary breast carcinoma has a relatively high risk of lymphnodal metastases, when compared with “usual” ductal adenocarcinoma [29]. In this current series, GATA3 was the most sensitive marker for micropapillary tumors, with labeling of all 12 cases. In comparison, 75% expressed mammaglobin and 33% were reactive for GCDFP-15. Because of potential morphologic overlap with ovarian low-grade serous carcinoma, another ERa-positive tumor, it is possible that GATA3 may have diagnostic usefulness in distinguishing the latter lesions from micropapillary breast cancers. Although this scenario has not been exclusively evaluated in the literature to date, in the series reported by Miettinen et al [16], only 4 (5%) of 73 ovarian serous carcinomas showed overexpression of GATA3, suggesting that GATA3 may prove valuable if this situation arises clinically. Of all the subtypes evaluated in the current cohort, GATA3 was most often absent in metaplastic and signet-ring cell subtypes. Mammaglobin and GCDFP-15 also were lacking in more than 50% of those tumors, and they were also negative for ERa. Lesions in these histologic subgroups may therefore present possible diagnostic difficulties insofar as IHC for breast-related markers are concerned; however, the small number of cases evaluated suggests that this conclusion is yet to be completely confirmed. Overall, our results show that GATA3 is a sensitive marker for both ductal and lobular adenocarcinoma of the breast. Moreover, it labeled
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a higher percentage of tumors when compared with mammaglobin and GCDFP-15, in mammary carcinomas of all histologic subtypes that were considered in this study. However, it is important to remember that GATA3 has imperfect “specificity” for breast cancers. As shown in other studies, its expression can be seen in urothelial carcinomas, squamous and basal cell carcinomas of the skin, yolk sac carcinomas, choriocarcinomas, mesotheliomas, and benign cutaneous adnexal tumors [16,17]. If any of the latter entities come into differential diagnosis with metastatic breast carcinoma in a given case, a multiantibody IHC panel will be required for final interpretation.
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