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Breast Cancer Hormone Receptor
Scoring
[you are now on a page on Dr. Shaw's personal
website]
I think that it is best for a pathologist to use
"eyeballs" and instruments to help bracket cancers as to whether their receptor status
is negative vs. weakly, moderately, or strongly positive & to include any considerations
of homogeneity or heterogeneity. Four formal & "named systems" have been in use, all
originally relying on some serious quantitative "eyeballing" as to prevalence &
intensity. Let's begin with the informal, classical surgical pathology approach (which can be
morphed with modern assessment):
- the oldest is a
comprehensive & quick "eyeball" assessment that includes intensity and prevalence of
receptor IHC marking: either "flat out" negative, to mild (1+), moderate (2+), or strong (3+) "positivity".
But, in 2011, I am suggesting another set of options short of the formal systems,
below.
prevalence:
manual: a quick (not hasty) vs. thoughtful "eyeball"
estimate of % positive nuclei...this depends on retina sensitivity and brain
computer assisted: carefully use VIAS or Virtuoso or some other system
that counts % positive nuclei...this uses a light spectrum analysis segment defined by the manufacturer.
intensity:
manual: [note the intensity criteria in "H score, below;
&, in doing true H scores for 2010, I note that 1+ is a narrow range of shades of IHC
"marking", 2+ has a broad range of not-weak & not-densely-dark shades, and 3+ is a pretty
narrow range] A quick (not hasty) vs. thoughtful "eyeball" estimate of average intensity
of nuclear stain. The "quick" (not hasty) is just a low to medium power quick judgment of weak,
moderate, or strong intensity. The latter (thoughtful) means some expeditious but thoughtful
thinking such as, "this all looks weak, 1+" vs. "this is weak but with some 2+ nuclei such that
it seems about a third of the way between 1+ and 2+ or about 1.3+" vs. "this looks pretty
strong & has enough 3+, 2+, and 1+ nuclei that I'm thinking that it is about halfway
between 2+ & 3+ or about 2.5+. That estimate of average intensity number is then multiplied times the percentage of positive nuclei.
computer assisted: as of 10/2013, I'm not aware of a
computer system able to grade intensity.
Magee Risk Calculator: HERE. This calculator uses tumor size, the 9-point scoring system for grade, Ki67 percentage, and quantitated ER, PR, and Heu-2. All of these can be gotten off of a very well done pathology report.
the path report: in current times (2/2011) in
general practice, I'm hoping that our group might at least use (1) the VIAS percentage &
(2) one's "eyeball estimate" of mildly (in 1+ range), moderately (in 2+ range), and strong (in
3+ range) so as to actually report a diagnosis designation such as "ER strong 95%" in the path
report diagnosis template. Short of using a formal system, as below, one might report an
"informal H-score" (a "working man's H score") of % nuclear staining times either a "quick" vs.
"thoughtful" eyeball estimate of intensity, as explained, above. Examples: let's say that ER by
VIAS is 65%, quick eyeball intensity is 2+, and thoughtful eyeball intensity is 1.75+.
The former gives an informal H score of 2 x 65 = 130; the latter gives an informal H score of
1.75 x 65 = 114 (both "moderate" intensity scores. Brackets: "mild" =1-99,
"moderate"=100-199, & "strong" = 200-300.
19891, the "H score": sum (1) the
percentage at each intensity (2) times each of 0-3+
intensity.
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percentage...multiplied by
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intensity level =
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Products to sum
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% fraction eyeballed as negative
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0
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% fraction eyeballed as weak
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1+
(weak color)
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% fraction eyeballed as distinct
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2+
(distinct color)
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% fraction eyeballed as dense-dark
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3+
(dense, dark, strong color)
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(the above total 100%)
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sum = _________________
(range 0-300)
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19902, the "Quick
score": the sum of % score plus intensity score
(range 0-7; 2-3=low, 4-5 =med., & 6-7=high).
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% staining
SCORE
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% nuclei
staining
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intensity
SCORE
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est. average
intensity
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1
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less than 10%
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1
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1
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2
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less than 30%
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2
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2
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3
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less than 70%
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3
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3
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4
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greater than 70%
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19964, the "Q score": the sum of % score plus intensity
score.
| % staining SCORE |
% nuclei staining |
intensity SCORE |
est. average intensity |
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0
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0%
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0
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(none at all)
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1
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1-25%
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1
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(weak, see @ high power)
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2
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26-50%
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2
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(mod., see @ low power)
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3
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51-75%
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3
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(strong @ low power)
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4
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greater than 75%
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19983, the "Allred
score": the sum of % score plus intensity score (range 0-8).
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% staining
SCORE
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% nuclei
staining
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intensity
SCORE
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est. average
intensity
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0
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none
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none
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0
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1
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less than 1 per 100
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1
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1
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2
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1-10%
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2
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2
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3
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10%
to 1/3rd
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3
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3
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4
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between 1/3-2/3rds
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5
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> 2/3rds
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References:
- Kinsel LB, et. al.,
"Immunocytochemical Analysis of Estrogen Receptors as a Predictor of Prognosis in Breast Cancer
Patients: Comparison with Quantitative Biochemical Methods", Cancer Research 49:1052-1056, 15
February 1989.
- Reiner A, et. al.,
"Immunocytochemical localization of estrogen and progesterone receptor and prognosis in human
primary breast cancer", Cancer Research 50:7057-7061, 1 November
1990.
- Allred, DC, et. al. "Prognostic and predictive factors in breast cancer by immunohistochemical analysis",
Modern Path. 11(2):155-168, 1998.
- Lee H., et. al.,
"The effect of fixation and processing on the sensitivity of oestrogen receptor assay by
immunohistochemistry in breast carcinoma", J Clin Pathol, 55:236-238, 2002 [Qui J, et. al.,
"Effect of Delayed...in Breast Cancer", AJCP 134:813-819, 11/2010 & referring through ref.
#5 to Barnes DM, et. al, "Immunohistochemical Determination...Breast Cancer Patients", Br. J.
Ca. 74(9):1445-1451, Nov. 1996].
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(posted 31
October 2010; addition 10 December 2015)
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