DOI:http://dx.doi.org/10.7314/APJCP.2014.15.18.

7839
Clinico-Morphological Profile and Receptor Status in Breast Cancer Patients in a South Indian Institution

RESEARCH ARTICLE
Clinico-Morphological Profile and Receptor Status in Breast
Cancer Patients in a South Indian Institution

Saptarshi Ghosh1*, Shreyasee Sarkar2, Samara Simhareddy3, Sivasankar Kotne1,

Pammidimukkala Bramh Ananda Rao1, Satya Prakash Venkatachalam Turlapati2
Abstract
Background: Breast cancer is the most common malignancy in women worldwide and the second most common
cancer in females in India. Receptor status may be important for survival. Objective: To analyse and correlate
the clinical and morphological parameters with receptor status in breast carcinoma patients in a tertiary care
institution in Southern India. Materials and Methods: This retrospective study involved 320 patients of breast
cancer diagnosed in an oncology hospital over a period of 3 years. Data was analysed using SPSS Version 21.
Results: Some 60.6% patients with breast carcinomas belonged to the age group of 40 to 60 years. The most
common histological type was infiltrating ductal carcinoma, not otherwise specified, accounting for 84.4% of
patients. On immunohistochemistry, estrogen receptor (ER) and progesterone receptor (PR) were expressed in
56.3% and 53.1% of cases, respectively. Conclusions: Breast cancers in India, a developing country, occur in
younger women and tend to be more aggressive with lower rates of ER and PR expression and higher histological
tumor grades. Both ER and PR status of the tumors had significant associations with the patient age, pathological
TNM stage and histological tumor grade.
Keywords: Breast cancer - estrogen receptor - progesterone receptor - stage - grade - India
Asian Pac J Cancer Prev, 15 (18), 7839-7842

Introduction
Breast carcinoma is the most common malignancy in
females worldwide (Siegel et al., 2014). It is a leading
cause of death in women (Sin ghai R et al., 2011). At many
parts of India, breast carcinoma has now become the most
common malignancy replacing cervical cancer, especially
in urban India (Murthy et al., 2009).
Breast cancer has many clinical and morphological
parameters which alter the prognosis of these patients
like gross tumor size, lymph node metastases, histological
grade of tumor, tumor necrosis and lymphovascular space
invasion (LVSI).
Immunohistochemistry plays a very important role in
the prognostication and treatment determination of breast
carcinoma patients. But, due to the high cost and decreased
availability of these investigations in Indian scenario, it is
not routinely carried out in all centres in India.
The current study was initiated to analyse the clinical
parameters, morphological profile and hormone receptor
status in our breast cancer patients. The estrogen receptor
(ER) and progesterone receptor (PR) status were also
correlated with the clinico-morphological parameters.

Materials and Methods

The present study is a retrospective study on breast

cancer patients being treated in a tertiary care oncological

institute in South India from January 2011 to June 2014.
Patients with a histopathologically confirmed diagnosis
of breast carcinoma with immunohistochemistry report
of ER and PR were included in this study after informed
consent. Patients treated with neoadjuvant chemotherapy
and patients with distant metastatic disease at presentation
were excluded from the study. In the given time frame, 320
patients satisfied our study criteria. Institutional ethical
committee approval was taken.
All mastectomy specimens were fixed in formalin
and histopathological examination of paraffin embedded
tissues were done after staining with haematoxylin and
eosin. Histopathological tumor grading was done using
the Elston and Ellis modification of the Scarff Bloom
Richardson scoring (Elston and Ellis, 1991). TNM staging
was done as per the American Joint Committee on Cancer
(AJCC) 7th edition (Edge et al., 2010).
The status of ER and PR were obtained purely on the
basis of immunohistochemical staining using standard
techniques. ER or PR was considered to be positive
if more than or equal to 1% tumor cell nuclei were
immunoreactive.
Age, sex, tumor site, breast involved, tumor size, T
stage, lymph nodal involvement, TNM stage, histological
type, histological grade, lymphovascular invasion (LVSI),
tumor necrosis and postoperative margin status were noted

Departments of 1Radiation Oncology, 2Pathology and 3Community Medicine, GSL Medical College and General Hospital,
Rajahmundry, Andhra Pradesh, India *For correspondence: [email protected]
Asian Pacific Journal of Cancer Prevention, Vol 15, 2014

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Saptarshi Ghosh et al

along with the ER and PR status of the breast carcinoma

on a proforma.
Statistical analysis:-Data was tabulated in Microsoft
Excel 2013 and analysed by using Statistical Package
for Social Sciences (SPSS) Version 21. For all statistical
analysis, P value< 0.001 was considered as significant.

Results
In our study, 194 out of 320 patients (60.6%) with
breast cancer were 40 to 60 years of age. 4 out of 320
patients in the study were males. Left breast carcinoma
was slightly higher in prevalence than right breast cancer
accounting for 164 patients out of 320 (51.25%). The site
of tumor in the breast was most commonly the upper outer
quadrant in 148patients (46.25%) (Table 1).
Morphologically, 200 (62.5%) out of 320 patients
Table 1. Clinical and Morphological Characteristics
of Study Population
Variables

Age


Sex

Tumor Site




Breast Involved

Tumor Size


T Stage



N Stage



Histological Types



Histological Grade


LVSI

Tumor Necrosis

Margin Status

ER Status

PR Status

Frequency Percentage
(N=320) (%)

<40
40-60
>60
Females
Males
Central
Upper Outer
Lower Inner
Lower Outer
Upper Inner
Right
Left
2 Cm
>2-5 Cm
>5 Cm
1
2
3
4
N0
N1
N2
N3
IDC NOS
IPC
ILC
MC
I
II
III
Positive
Negative
Positive
Negative
Close/Positive
Negative
Positive
Negative
Positive
Negative

82 25.6
194 60.6
44 13.8
316 98.75
4 1.25
64
20
148
46.25
36
11.25
12
3.75
60
18.75
156
48.75
164 51.25
36
11.3
200
62.5
84
26.2
32
10
164 51.3
82 25.6
42 13.1
160
50
98 30.6
26 8.1
36 11.3
270
84.4
22 6.9
22 6.9
6 1.9
20
6.3
84 26.3
216 67.5
42 13.1
278 86.9
100
31.25
220 68.75
68
21.25
252 78.75
180
56.25
140 43.75
170
53.1
150 46.9

*LVSI = Lymphovascular space invasion, IDC NOS = Infiltrating ductal carcinoma,

not otherwise specified, IPC = Invasive papillary carcinoma, ILC = Infiltrating
lobular carcinoma, MC = Mucinous carcinoma

7840

Asian Pacific Journal of Cancer Prevention, Vol 15, 2014

had gross pathological tumor size ranging from more

than 2 cm up to 5 cm. 164 patients (51.3%) had T2 stage
tumors and 42 patients (13.1%) presented with skin
involvement-mostly skin ulceration and peau d orange.
160 (50%) patients had no lymph node metastases
pathologically (Table 1). 94 of the 320 patients presented
with pathological TNM Stage IIA (Figure 1).
Infiltrating ductal carcinoma, not otherwise specified,
is the most common histological type of breast tumor
encountered in 270 (84.4%) out of 320 patients. Other
histological types found were mucinous carcinoma,
invasive papillary carcinoma and infiltrating lobular
carcinoma. According to the modified Scarff Bloom
Richardson scoring, 216 patients (67.5%) had histological
grade III tumors. Lymphovascular space invasion
was noted in only 42 patients (13.1%). 100 out of 320
patients (31.25%) showed presence of tumor necrosis
histopathologically. 68 patients (21.25%) had close or
positive postoperative margins (Table 1). In our study,
close margin was defined as margin within 5 mm from the
tumor. In most of the margin close or involved patients, it
was the posterior margin which was affected.
On immunohistochemistry, 180 (56.25%) and 170
(53.1%) patients expressed ER and PR positive tumors
respectively (Table 1).
On correlating the study variables with ER and
PR status of the patients in the study, we obtained a
statistically significant association (p<0.001) between
ER, PR status of the tumor with the age of the patient.
Also the TNM pathological Stage and histological tumor
grade showed significant correlation (p<0.001) with both
ER and PR status. (Table 2).
Table 2. Distribution of Study Variables According to
ER and PR Status
Variables

ER+VE ER-VE p value PR+VE PR-VE p value

Age
40
36
46
36
46
(Years) >40-60
104 90 <0.001 96 98 <0.001

>60
140 4 38 6
Tumor Size 2
20
16
18
18
(Cm)
>2-5
124 76 0.012 114 86 0.179

>5 36 48
38 46
pT Stage 1 20 12
18 14

2 106 58 0.004 98 66 0.039

3 36 46
38 44

4 18 24
16 26
pN Stage 0 100 60
92 68

1 56 42 0.002 60 38 0.003

2 6 20
6 20

3 18 18
12 24
TNM Stage
Ia 12 6 10 8

IIa 68 26
62 32

IIb 44 26 <0.001 50 20 <0.001

IIIa 22 40
22 40

IIIb 16 24
14 26

IIIc 18 18
12 24
Tumor Grade
I
16 4 16 4

II
72 12 <0.001 66 18 <0.001

III
92 124
88 128
LVSI Positive 24 18 0.9 24 18 0.576

Negative 156 122
146 132
Tumor Necrosis

Positive 38 62 0.003 46 54 0.085

Negative
142 78 124 96

DOI:http://dx.doi.org/10.7314/APJCP.2014.15.18.7839
Clinico-Morphological Profile and Receptor Status in Breast Cancer Patients in a South Indian Institution
Frequency

94

70
62

40

36

18

IA

IIA

IIB

IIIA

IIIB

IIIC

Figure 1. Clustered Column Chart Depicting the

Frequency Distribution of Study Population in Various
TNM Stages of Breast Cancer

Discussion
Breast cancer is one of the most frequently diagnosed
cancer in developed countries (Siegel et al., 2014).
But now, breast cancer incidence has been on a rise
in developing countries too, especially in urban areas
(Murthy et al., 2009).
Most of the patients were in the age group of 40 to 60
years, with a mean age of 51.4 years. The mean age of
breast cancer patients in developed countries is almost one
decade higher when compared to Indian studies (Stead et
al., 2009; Sandhu et al., 2010). On correlating age with ER
and PR status, hormone receptor positivity was found to
be more common in elderly patients as has been found in
literature (Sofi et al., 2012). Men comprise of only around
1% of all diagnosed breast cancers (Sedighi et al., 2013).
As found in literature as well as the current study, upper
outer quadrant is the most common siteof primary breast
tumor (Sofi et al., 2012).
Most common histological type of breast cancer
was infiltrating ductal carcinoma similar to that found
in literature (Shet et al., 2009; Sofi et al., 2012). Most
commonly, the tumors were of 2 to 5 cm in size, as has
been also found in other studies (Sofi et al., 2012). 50%
patients in the study had lymph nodal involvement on
presentation, which indicates the aggressive nature of
the tumors found in Indian population. Though data from
developed countries suggest that most of the breast cancer
patients do not have any lymph node metastasis, Indian
studies have documented higher percentages of lymph
nodal involvement in breast cancer patients (Taucher
et al., 2003; Sofi et al., 2012; Rao et al., 2013). Most of
the patients presented in TNM Stage II as most of the
patients had tumor size between 2 to 5 cm and 50% of
the patients did not have any lymph nodal disease. Both
ER and PR status correlated significantly with the stage
of the disease, thereby indicating that ER, PR positive
tumors were associated with early stage breast tumors.
Similar correlation was also found in other studies (Zhou
et al., 2014).
An Indian study with 11780 patients of breast cancer,
found 70% of the tumors to be of histological grade III
(Shet et al., 2009). Similar results were found in the current
study. Alike some other studies, the hormone receptor
status in the present study significantly correlated with the
histological grade of breast tumors (Sofi et al., 2012; Shet

et al., 2009; Ambroise et al., 2011). Similar to a regional

study, lymphovascular space invasion was seen in less
than 20% of the patients (Rao et al., 2013). Presence of
histologic tumor necrosis has been found to be higher in
Indian studies (Rao et al., 2013).
The prevalence of ER and PR expression on
immunohistochemistrywere 56.25% and 53.1%
respectively in the present study as opposed to the
75% ER and 58% PR positivity documented in western
literature (Rhodes et al., 2000). In India, the prevalence
of hormone receptor positivity has been seen to be lower,
when compared to western literature (Shet et al., 2009;
Ambroise et al., 2011). In a study from Southern India, the
prevalence of ER, PR co-positivity was found to be 32%
only (Zubeda et al., 2014). An additional HER2/neu testing
in South Indian women with breast cancer demonstrated
46% of the breast tumors to be triple negative (Zubeda
et al., 2014). Triple negative breast cancers in Asian
population were found to be associated with younger age
of onset, increasing tumor size, increased prevalence of
axillary lymph nodal involvement, higher histological
grade of tumor and poor prognosis (Ma et al., 2013; Li
et al., 2014).
In conclusion, in context of developing countries
like India, breast cancer occurs in younger female when
compared to the developed world. The proportion of
histological high grade breast tumors, lymph node
involvement are also high, when compared to the data
from developed nations. Percentage of ER and PR
expressing breast tumors is lower when compared to that
documented in the western countries.ER, PR negative
tumors occur more commonly in young breast cancer
patients. ER, PR positive tumors are associated with early
stage breast cancers. Lack of expression of ER and PR
are also associated with higher histological tumor grades.
In developing countries like India, though breast cancer
is not yet the most common cancer affecting females, as
in the developing countries, breast cancer patients in the
developing nations present with more aggressive tumors
when compared to that of the west.

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