IS HER2 LOW BREAST CANCER A

REAL ENTITY?
Frederique Penault-Llorca, MD, PhD
DECLARATION OF INTERESTS
Frédérique Penault-Llorca

Personal financial interests:

AbbVie, Agendia, Astellas, AstraZeneca, Bayer, BMS, Eisai, Genomic Health, GSK, Janssen, Lilly, MERCK Lifa,
MSD, Myriad, Nanostring, Novartis, Pfizer, Pierre-Fabre, Roche, Sanofi, Servier

Institutional financial interests:

AstraZeneca, Bayer, BMS, Genomic Health, MSD, Myriad, Nanostring, Roche

Congress invitations
AbbVie, AstraZeneca, Bayer, BMS, MSD, Novartis, Roche, Lilly
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Constant and continuous expression of HER2 in
breast cancer
HER2 0 HER2 1+ HER2 2+ HER2 3+

HER2 protein
HER2 mRNA
HER2 low: an histopathological entity
based on Immunohistochemistry and
In Situ Hybridization
 HER2 “Low”
• Is a subset of HER2-expressing BC not addicted to ERBB-2/HER2 that
derives benefit from targeting this receptor with ADCs
• ~40-55% of all BC are HER2-low cancers (IHC 2+ non amplified and IHC 1+)
HER2 testing (invasive component) by validated IHC assay
Batch controls and on-slide controls show appropriate hybridization

Incomplete membrane Weak to moderate

staining that is complete
faint/barely perceptible membrane staining
and in >10% of tumour observed
cells in >10% of tumour cells

IHC 1+ IHC 2+ Non amplified

Wolff AC, et al. J Clin Oncol 2018;36:2105–22; Tarantino et al. J Clin Oncol. 2020;38(17):1951–62.
 HER2 low: the upper boundary is clear: ISH negative
Algorithm for HER2 gene status by ISH
HER2 testing (invasive component) by validated dual-
probe ISH assay
Batch controls and on-slide controls show appropriate
hybridization

HER2/CEP17 HER2/CEP17
ratio ≥ 2.0 ratio < 2.0

Group 1 Group 2 Group 3 Group 4 Group 5

Average HER2 Average HER2 Average HER2 Average HER2 copy Average HER2
copy number copy number copy number number copy number
≥ 4.0 < 4.0 ≥ 6.0 ≥ 4.0 and < 6.0 < 4.0
signals/cell signals/cell signals/cell signals/cell signals/cell

ISH ISH ISH ISH ISH

positive negative positive negative negative

In case of IHC 1+ or 2+ HER2 low HER2 low HER2 low

Wolff AC, et al. J Clin Oncol 2018;36:2105–22, Franchet C et al Ann Pathol 2021; 41(6):507–520.
IHC2+ : most of the cases are HER2 low as <1/4 are
HER2 “positive” after ISH testing

IHC 2+, FISH special categories (groups 2,3,4):

most of the cases are HER2 low, 0.5% are HER2
positive: group 3)
But….
 HER2 low: the lower boundary lacks a gold
standard reference (% in low intensity staining)
HER2 testing (invasive component) by validated IHC assay

Former « HER2 negative » by IHC

No staining is observed
or Membrane staining Incomplete membrane
that is incomplete and is staining that is
faint/barely perceptible faint/barely perceptible
and in ≤10% of tumour and in >10% of tumour
cells cells

IHC 0 IHC 1+
negative HER2 Low

1.AC Wolff and al. Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer : ASCO/CAP Clinical practice Guideline Focused Update. JCO 2018
 Heterogeneity of HER2 IHC staining is higher
for 1+

Homogeneous Clustered Mosaic

Zhang et al Modern Pathology; https://doi.org/10.1038/s41379-022-01019-5
Non-strictly linear correlation between Her2 IHC
staining and the number of receptors per cell

0 1+ 2+ 3+

103 / cell 5.106 / cell

Number of HER2 receptors/cell

Staining of normal breast tissue depends on the antibody, and on the technical
conditions as HER2 receptors are also expressed in normal cells
Herceptest

4B5 Ventana AO485

NOT CB11
CORRECT
CORRECT

3+
The baseline level of expression of HER2
should not be seen by IHC
Impact of the type of IHC HER2 assay on HER2 low determination

73,2% agreement
More HER2 low
with 4B5 vs
Herceptest

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Reproducibility studies

• Scans from 200 HER2 IHC stained slides from 100
independent cases /5 pathologists
• i.e., 0, 1+, 2+ and 3+
• overall kappa concordance score was 0.79 (p < 0.001)
• kappa were 0,82 for 0; 0,92 for 3+; 0,67 for 1+ and
0,74 for 2+ (p < 0.001)
• Evaluation of CAP US HER2 TESTS results over two
years (1391 to 1452 structures) 40 cores are read
per test and two tests /year
• ➔For 19% of cases: concordances ≤ 70% for score
0 vs 1+
• Internal study on digitized slides YALE group (18
pathologists): 26% concordance between 0 and 1+
vs 58%: concordance between 2+ and 3+

➔ more efforts are needed to standardize the scoring of HER2-low disease

(international efforts ongoing) and potentially implement new and more sensitive
assays that can help better discriminate HER2 levels within HER2- negative breast cancer.
npj Breast Cancer (2021) 7:1 ; https://doi.org/10.1038/s41523-020-00208-2 JAMA Oncol. 2022;8(4):1-4. doi:10.1001/jamaoncol.2021.7239
 • Absence of gold standard for 0 vs 1+ (unlike ISH for 2+ vs 3+)
• Impact of pre-analytical: is it more critical in the low marker category
vs 2+ vs 3+?
• Subtle differences between antibodies (and in particular 4B5 and
HercepTest): do they impact more the faint stainings?
• How does tissue heterogeneity affect 0 vs 1+ IHC and how many
samples should be used to be sure that a case is HER2 zero?

ERBB2, erb-B2 receptor tyrosine kinase 2; IHC, immunohistochemistry; ISH, in situ hybridisation.
Allison KH, et al. AMA Oncol. 2022. doi: 10.1001/jamaoncol.2021.7082. 15
Is it a biological
entity?
 HER2 low status: Primitive ➔ Metastasis: instability/enrichment
• 547 patients with relapsing disease
• HER2-low cases :
• eBC tumor 34.2%; relapse 37.3%
• Overall discordance rate 38%.
• 0 ➔HER2 low: 15%,
• HER2 low➔ 0: 14%
Miglietta F et al. NPJ Breast Cancer 2021. 7 : 137
• 457 patients with relapsing disease
• HER2-low cases 232 pt s :
• eBC tumor 53%, relapse 58,2%
Overall discordance rate 50%.
• 0 ➔HER2 low: 44%
• HER2 low➔ 0: 22%
• Younger pts
• Absence of impact of the metastatic site
Tarantino P et al. EJC; 163 (2022) 35e43
 HER2 low status: Primitive ➔ Metastasis: instability and
enrichment

47,3% 53,8% low 35,4% 36,2% 38% low

57% 63% low 36%
low 5,1%HER2+ low low 1,3%HER2+
low 6,4%HER2+ low

• HER2 low is highly unstable during disease progression.

• Importance of determining HER2 status on relapse as a non-
negligible number of HER2 0 tumors can become HER2 low.
• Absence of specific metastatic sites
Miglietta F et al. npj Breast Cancer 2021. 7 : 137 Tarantino P et al. EJC; 163 (2022) 35e43
Braso-Maristani F et al. Molecular Oncology 16 (2022) 69–87
 HR+
low TNBC
low

ERBB2
levels
HR+
0 TNBC
0

• 3689 eBC
• HER2 low 65,4% in HR+ & 36,6% in TNBC
• PAM50:
• HR+: ERBB2 & luminal-related genes more
expressed in HER2-low than HER2 0.
• TNBC: no gene ≠ expressed /HER2 expression.
• In HER2-low, ERBB2 levels : HR+>TNBC

1+ 2+

ERBB2
levels
Is HER2 low HR+ a biological entity ? 0
HR+

npj Breast Cancer (2021) 7:1 ; https://doi.org/10.1038/s41523-020-00208-2

PAM50 and Blue Print datas on eBC cohorts
PAM50 data 1576 pts eBC

Schettini et al npj Breast Cancer (2021) 7:1 ; https://doi.org/10.1038/s41523-020-00208-2

HER2 low 1+ ≠ HER2 low 2+
Blue Print data
HER2 low 1,2%
HER2 low RH+ HER2 low TNBC
4,6%
1,1%
Blue Print Data 281 pts eBC
31% HER2 low (87pts)
28,4% 33,3%
87% 1+, 13% 2+, 33,6% HR+, 15% TNBC
28,8%
66,7% Stage I-II, low grade, low Ki67
65,5% 70,4%
65,5% low risk mammaprint (lumA)
34,5% high Risk (lum B>basal>HER2e)
luminal A luminal B HER2e basal luminal A luminal B HER2 e Basal
luminal A luminal B HER2 e Basal
Adapted from Zhang et al Modern Pathology; https://doi.org/10.1038/s41379-022-01019-5 HER2 low RH+ ≠ HER2 low TNBC
 Is it a clinical
entity?
Caution most of the collections are
retrospective
 Clinicopathological data in eBC

3689 pts HER2-low more

59,4% HER2 low frequent in older
40,4% 1+ pts, male pts, more
19,3% 2+ N+ than HER2 zero
65.4% in HR+ 36.6% in TNBC

2310 pts from 4 NACT trials

47,5% HER2 low
64% HR+, 36,7% TNBC
HER2low ≠ HER2 zero, less pCR
except HR-
better DFS, OS (all and TNBC)➔
Lancet Oncol 2021; 22: 1151–61 HER2 low HR+ ≠ HER2 low TNBC

Caution: Retrospective collection of HER2 low status

Clinicopathological data in eBC
30491 national Korean registry
77.3% RH+ 22.7% TNBC
31,2% HER2 low
33.6% in HR+, 23.0% in TNBC
≠ Clinical presentation of HER2 low HR+
vs HER2 low TNBC
Improved BCSS in HER2 low group

28280 pts from Asian Cancer Cooperative

Group
43,4% HER2 low
31,3% 1+
12,1% 2+ NA
45,9% in HR+ 29,4% in TNBC
Worse clinical presentation vs HER2 zero
Better survival for HER2 low driven by
1+ (RH+ and TNBC)
Caution: Retrospective collection of HER2 low status
 Clinicopathological data in mBC
French ESME data base
J. S. Frenel, ESMO 2021, 291P

15608 mBC pts with

"Her2neg“ status, 15054
analyzed ➔31% HER2 low
(4671 HER2 low mBC pts)
4% HER2 low TNBC
27% HER2 low HR+

Austrian mBC data base • Older patients

Gampenrieder SP Breast • More frequently de novo
Cancer Res 2021 metastatic
• HR+>TNBC
1729 pts mBC pts, 1378 • Absence of impact on
HER2 « negative » survival
➔ 44,1% HER2 low
6% HER2 low TNBC
29,2% HER2 low RH+

Caution: Retrospective collection of HER2 low status

Conclusion
 HER2 low, real entity?

• Immunohistochemical entity: Definition based on level of

HER2 IHC expression and absence of HER2 amplification
• Major caveats:
• absence of gold standard for the lower boundary
• Technical variations influence of fixation and IHC technique
• Unstable phenotype
• Reproducibility

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 HER2 low, real entity?

• Is it a biological entity? Very likely

• More HER2 low in HR+ group
• HER2 low HR+≠ HER2 low TNBC
• HER2low 1+ ≠ HER2 low 2+
• Is it a clinical entity? Very likely ≠ from HER2 zero

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 Key take-home messages

• It is clinically important to accurately distinguish HER2-

low expressing breast tumours (IHC score 1+) from truly
HER2-negative breast cancer (IHC score 0)
• Standardisation of HER2 testing practices in breast
cancer is needed
• Many hopes in the potential help of artificial intelligence
• More explorations are needed to expand our knowledge
of this true entity!
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