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Summary of guideline recommendations for ER and PR testing by immunohistochemistry in breast cancer patients

Summary of guideline recommendations for ER and PR testing by immunohistochemistry in breast cancer patients
Optimal algorithm for ER/PR testing
Recommendation Comments
Positive for ER or PR if finding of ≥1% of tumor cell nuclei are immunoreactive. These definitions depend on laboratory documentation of the following:
  1. Proof of initial testing validation using clinically validated antibody
  2. Ongoing internal quality assurance procedures
  3. Participation in external proficiency testing
  4. Biennial accreditation by valid accrediting agency
Negative for ER or PR if finding of <1% of tumors cell nuclei are immunoreactive in the presence of evidence that the sample can express ER or PR (positive intrinsic controls are seen).
Optimal testing conditions
Recommendation Comments
Large, preferably multiple core biopsies of tumor are preferred for testing if they are representative of the tumor (grade and type) at resection. Specimen should be rejected and repeated on a separate sample if any of the following conditions exist:
  1. External controls are not as expected (scores recorded daily show variation)
  2. Artifacts involve most of sample
Specimen may also be rejected and repeated on another sample if:
  1. Slide has no staining of included normal epithelial elements and/or normal positive control on same slide
  2. Specimen decalcified using strong acids
  3. Specimen shows an ER-/PR+ phenotype (to rule out a false-negative ER assay or a false-positive PR assay)
  4. Sample has prolonged cold ischemia time or fixation duration <6 hours or >72 hours and is negative on testing in the absence of internal control elements
Interpretation follows guideline recommendation.
  • Positive ER or PR requires ≥1% of tumor cells are immunoreactive; both average intensity and extent of staining are reported
  • Image analysis is a desirable method of quantifying percentage of tumor cells which are immunoreactive
  • H Score, Allred Score or Quick Score may be provided
  • Negative ER or PR requires <1% of tumor cells with ER or PR staining
Interpreters have method to maintain consistency and competency documented regularly.
Accession slip and report must include guideline-detailed elements.  
Optimal tissue handling requirements
Recommendation

Time from tissue acquisition to fixation should be as short as possible. Samples for ER and PR testing are fixed in 10% neutral buffered fomalin (NBF) for 6 to 72 hours. Samples should be sliced at 5 mm intervals after appropriate gross inspection and margins designation and placed in sufficient volume of NBF to allow adequate tissue penetration.

If tumor comes from remote location, it should be bisected through the tumor on removal and sent to the laboratory immersed in a sufficient volume of NBF. Cold ischemia time, fixative type, and time the sample was placed in NBF must be recorded.
Storage of slides for more than six weeks prior to analysis is not recommended.
Time tissue is removed from patient, time tissue is placed in fixative, duration of fixation and fixative type must be recorded and noted on accession slip or in report.
Guidelines from a combined panel from the American Society of Clinical Oncology (ASCO) and the College of American Pathologists (CAP).
ER: estrogen receptor; NBF: neutral buffered formalin; PR: progesterone receptor.
Hammond ME, Hayes DF, Dowsett M, et al. American Society of Clinical Oncology/College Of American Pathologists guideline recommendations for immunohistochemical testing of estrogen and progesterone receptors in breast cancer. J Clin Oncol 2010; 28:2784.
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