What to expect from the 2018 ASCO/CAP HER2 guideline in the reflex in situ hybridization test of immunohistochemically equivocal 2+ cases?

  • Mónica Curado
  • Ana Sofia Caramelo
  • Catarina Eloy
  • António PolóniaEmail author
Original Article


To evaluate the effect of the 2018 ASCO/CAP guideline in the identification of HER2-positive breast carcinomas (BC) in reflex in situ hybridization (ISH) test. A total of 592 primary invasive BC cases from before and after the publication of the updated ASCO/CAP guideline were evaluated for HER2 amplification by silver ISH according to the 2013 and 2018 guidelines. Cases were mostly (95%) HER2 equivocal by immunohistochemistry (IHC), not centrally reviewed. Other reasons for referring cases were IHC confirmation, IHC discordancy (either between needle-core-biopsy (NCB) and surgical excision specimen (SES) or between different laboratories) and IHC result unexpected for histopathologic features. Cases evaluated with the 2013 guideline (1st cohort) were 14.6% HER2-positive, decreasing significantly after the reclassification with the 2018 guideline due to the exclusion of group 2 cases without HER2 protein overexpression. Cases studied after the implementation of the 2018 guideline (2nd cohort) were 8.7% HER2-positive, a frequency that was not significantly different from the reclassification of the 1st cohort with the 2018 guideline. All cases referred for IHC confirmation had the expected ISH result. Cases with IHC discordancy between NCB and SES were ISH concordant. Only one out of 14 cases with an IHC score 3+ and classified as histological grade 1 or with a Ki67 below 10% was classified as ISH HER2-positive. The 2018 ASCO/CAP guideline resulted in a decrease of HER2-positive cases in reflex ISH test, selecting less patients for anti-HER2-targeted therapy.


ASCO/CAP Breast cancer HER2 SISH 



MC, AC, CE, and AP: designed the research study; MC and AC: retrieved and analyzed the data and wrote the manuscript. AC: performed the laboratory work. CE, AP: conducted HER2 SISH interpretation, analyzed the data, wrote and critically revised the manuscript. All authors read and approved the final manuscript.


This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Compliance with ethical standards

This study has been performed in accordance with the national regulative law for the handling of biological specimens from tumor banks, being the samples exclusively available for research purposes in retrospective studies, as well as under the international Helsinki declaration. Ethical approval and informed consent were not required for this study.

Conflict of interest

The authors declare that they have no conflict of interest.

Supplementary material

428_2019_2567_MOESM1_ESM.pdf (358 kb)
ESM 1 (PDF 357 kb)


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.Department of Pathology, Ipatimup Diagnostics, Institute of Molecular Pathology and ImmunologyUniversity of PortoPortoPortugal
  2. 2.I3S–Instituto de Investigação e Inovação em SaúdeUniversity of PortoPortoPortugal
  3. 3.Faculty of MedicineUniversity of PortoPortoPortugal

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