The adjuvant (and neo-adjuvant) systemic therapy reduces the clinically significant metastasis according to subtype of the primary non-metastasised breast carcinoma to differing proportions. The patient expects the attending physician to weigh the benefits (better tumour-specific survival) against the so-called costs (worsened quality of life caused by the therapy). In the comparison between tumour-specific survival and overall survival, however, are to be included, even to a minor degree, cases of treatment-delayed mortality (through cardiotoxic drugs or the development of solid secondary tumours or acute forms of leukaemia), which must be added to the costs. For the evaluation of the individual risk of distant metastasis, the established prognosis factors, size of the tumour, lymph node status, grading, PVI (peritumoral venous invasion) and the estrogen receptor and progesteron receptor status as well as the HER-2/new-overexpression were taken into account. This risk-adapted selection for adjuvant therapy is reflected in the St. Gallen conferences on breast carcinoma. Additionally, in 2009 , in this regard, the proliferation index (Ki67 labelling index and/or the histopathological description of the mitosis index) and also gene signatures were discussed.
The determination of the proteins uPA (urokinase-type plasminogen activator) and its counterpart PAI-1 (bio-marker PAI-1 and uPA [2, 3]), particularly propagated in Germany, was unable to assert itself internationally. Instead, gene signatures on the basis of “micro array analysis” or the “RT-PCR method” are becoming increasing established commercially as Oncotype DX  or “MammaPrint” . In German-speaking pathology, to ensure independence from the aforesaid commercial suppliers, the Endopredict-Test  has been developed. Additionally, by way of genome analysis using DNA micro arrays, subtypes have been defined , the prognostic significance of which was finally highlighted at the 2011 St. Gallen Conference .
A number of other research areas concerning prognosis and histological differentiation of breast carcinoma will only be mentioned briefly. Apart from the identification of appropriate gene signatures, a model of human breast cancer progression has been in development for a number of years. While researchers until recently assumed a linear path from flat epithelial atypia (FEA) via atypical ductal hyperplasia (ADH) and DCIS to invasive ductal carcinoma, new findings using transcriptomic and epigenetic technologies are pointing to at least one further molecular genetic pathway [see  for a summary of molecular based publications]. A number of review articles on a multitude of prognostic paraters including AgNOR have been published [see  for a summary] without yet entering the therapy recommendations of the relevant consensus conferences. Nevertheless, women carrying a germline mutation on the BRCA-1 or BRCA-2 gene are accepted into an early recognition program reflecting a risk for not only earlier but more aggressive forms breast cancer . The β1 integrin expression is not only correlated to survival, but as a cell adhesion molecule represent a prognosis factor for metastasis that is independent of cell proliferation . Mammaglobin-A and –B are parameters specific to breast carcinoma .
Besides the individual imprecision in the prognosis with regard to individual patients, there has been repeated discussion on the inter- and intra-observer variability of the classical, histological prognosis parameters. Moreover, the standardisation of the immune histochemical results is criticised because it involves a semi-quantitative procedure. The results for HER-2/new are given as approximately 20% inaccurate . Also other studies criticised this imprecision  and attempted to establish alternative methods of diagnosis .
For this reason, we took the opportunity to conduct a long-term analysis in regard to overall survival by means of automated microscopic image analysis of the nucleolar organizer regions (AgNORs) to objectify the tumour grading in the case of breast carcinoma.
This involves a selective depiction of argyrophilic proteins that are associated with the nucleolus organizer regions. The quantity of the AgNOR particles and/or their surface parameters correlate with the proliferation activity and hence could constitute a standardised parameter for the tumour grading as prognosis marker.
Research via PubMed (1 February 2012), revealed only 114 hits for the combination of “AgNOR” and “breast cancer” during the years from 1989 to 2011. In the Charité, since the mid-1980s, various “AgNOR” working groups engaged themselves with a variety of different tumour entities also including, for example, breast cancer and its preliminary stages (overview)[18–21]. Originally, the AMBA (automatic microscopic image analysis) of the AgNOR promised to obtain more precisely defined information in relation to survival compared with the conventional method of grading in the case of breast cancer.
Therefore, only those AgNOR parameters that in earlier evaluations showed an univariate, significant correlation with overall survival were included in the analysis. The individual AgNOR parameters are described in detail elsewhere [22, 23].