Assessment of Tissue Estrogen and Progesterone Receptor Levels: A Survey of Current Practice, Techniques, and...

The assessment of steroid hormone receptors in resected breast carcinoma tissue is currently the standard of practice. The traditional method for assessment of receptor status is the ligand binding assay. More recently, immunohistochemistry (IHC) has become a popular method for such testing. Despite the widespread use of IHC and the availability of many antibodies, standardization of quantitative IHC for assessment of estrogen and progesterone receptors has not been achieved. While the College of American Pathologists (CAP) offers a Quality Assurance (QA) program for IHC quantitation of estrogen receptor (ER) and progesterone receptor (PgR), no universal standard is currently recognized in assessment of ER and PgR by IHC. We surveyed 300 laboratories within the United States for their current practices regarding the assessment of ER and PgR status in breast cancer tissue specimens. Eighty usable responses were received. Forty-nine (61%) laboratories performed the assay in-house, while the remainder sent the material out for assay. All responding laboratories performing their steroid receptor analysis in-house used the IHC technique. Forty-three (80%) laboratories answering the question on material accepted for analysis performed the assay only on paraffin-embedded material, three (6%) used either paraffin block or frozen material, and two (4%) used only frozen material. Eighty-eight percent of laboratories performing steroid receptor analysis in-house used a manual quantitation technique. Four (8%) used computer-assisted image analysis, and a single laboratory used laser scanning cytometry. Eight different antibodies were used among the 44 laboratories documenting the antibody supplier, and for any given commercially prepared antibody a wide variety of dilutions were used, with the exception of the standard solution used with the Ventana antibody. Of the laboratories using manual estimation techniques, 61% simply estimated the percentage of positive cells, 29% evaluated both the intensity of staining and percentage of nuclei staining, 6% used formal H-score analysis, 2% evaluated only intensity of nuclear staining, and 2% mainly counted the percentage of nuclei staining for ER but used a formal H score in the assessment of PgR. Cutoff points for the separation of positive and negative results varied widely, with some laboratories assessing any demonstrable positivity as a positive result, while others required as many as 19% of the nuclei to stain before a specimen was declared positive. Standardization techniques differed considerably among laboratories. Eighty-six percent used the CAP program for QA. While all laboratories utilized some form of intralaboratory control for assessment of ER and PgR, the nature of that control varied from laboratory to laboratory. Our survey indicates that a majority of laboratories perform their steroid hormone receptor analysis in-house using IHC. There is considerable variability in the antibodies utilized, the dilutions applied, and the quantitation method and level of expression used to dichotomize specimens into positive and negative groups. Finally, no universal control for interlaboratory standardization appears to exist.