Abstract PO4-07-05: Clinical evaluation of image-based risk profiling in breast cancer histopathology and comparison to an established gene expression assay
Authors: Robertson Stephanie , Wang Yinxi , Sun Wenwen , Karlsson Emelie , Lövgren Sandy Kang , Rantalainen Mattias , Hartman Johan 
Published: May 2024

Abstract
Background: Among oestrogen receptor (ER)-positive and human epidermal growth factor receptor 2 (HER2)-negative early breast cancer, a significant proportion of patients are categorised as intermediate risk, based on classic clinico-pathological variables, thus providing limited information to guide adjuvant chemotherapy decisions. Prognostic risk profiling is an integrated part of modern breast cancer diagnostics to provide additional risk information for this patient group. Among the established prognostic assays based on gene expression, the Prosigna assay is widely used and provides an individual risk of recurrence (ROR) score and identifies intrinsic subtypes with associated survival outcomes. Pioneering artificial intelligence-based precision diagnostics, Stratipath Breast, is a deep learning-based image analysis tool that utilises digitised histopathological whole slide images to stratify intermediate risk patients in terms of risk of recurrence.
Materials and methods: The study included 234 invasive breast tumours from patients with early ER-positive HER2-negative breast cancer, clinically assessed as intermediate risk tumours and eligible for chemotherapy. All tumours had therefore previously been analysed by the Prosigna assay in clinical routine at point of diagnosis between 2020 and 2022 at the Karolinska University Hospital and Södersjukhuset, Stockholm, Sweden. Clinicopathological data including Prosigna results (ROR score, risk group and intrinsic subtype) were extracted from medical records, along with the corresponding archived haematoxylin and eosin (HE)-stained formalin-fixed paraffin-embedded tissue slides. The HE slides were subsequently digitised and analysed by the Stratipath Breast tool. The agreement between the two tests for risk stratification was evaluated in this real-world breast cancer case series.
Results: The Prosigna assay classified 76 (32.5%), 110 (47.0%) and 48 (20.5%) tumours as low, intermediate and high risk, respectively. The Stratipath Breast analysis identified 116 (49.6%) tumours as low risk and 118 (50.4%) as high risk. Among Prosigna intermediate risk tumours, 52 (47.3%) were stratified as low risk and 58 (52.7%) as high risk by Stratipath Breast. The overall agreement between the two tests for low risk and high risk groups was 71.0%, with a Cohen’s linear kappa of 0.42. Twelve of the 48 Prosigna high risk cases were classified as Stratipath low risk. ROR scores were higher in the Stratipath high risk group compared to the low risk group (p &lt; 0.001), across all cases as well as in the Prosigna intermediate group. Among the 176 histological grade (NHG) 2 tumours, 97 (55.1%) and 79 (44.9%) were stratified as Stratipath low risk and high risk, respectively, whereas 66 (37.5%), 83 (47.2%) and 27 (15.3%) were stratified as Prosigna low, intermediate and high risk, respectively. The majority of NHG1 (10 of 12) and NHG3 (37 of 46) tumours were stratified as Stratipath low risk and high risk, respectively. For both risk profiling tests, NHG and Ki67 proliferation index differed between risk groups.
Conclusions: In this study of clinically assessed intermediate risk ER-positive HER2-negative breast cancer, we observed a moderate agreement between Prosigna and Stratipath Breast for low risk and high risk groups. In addition, image-based risk profiling stratified more of the NHG2 tumours as high risk.
Citation Format: Stephanie Robertson, Yinxi Wang, Wenwen Sun, Emelie Karlsson, Sandy Kang Lövgren, Mattias Rantalainen, Johan Hartman. Clinical evaluation of image-based risk profiling in breast cancer histopathology and comparison to an established gene expression assay [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-07-05.