Correlation of Her-2 neu over-expression with clinico pathological features of carcinoma breast
 

Correlation of Her-2 neu over-expression with clinico pathological features of carcinoma breast

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The classical clinico pathological features such as tumour

The classical clinico pathological features such as tumour
size, axillary node status, histological type and grade have a
well-established prognostic role in breast cancer.

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Correlation of Her-2 neu over-expression with clinico pathological features of carcinoma breast Correlation of Her-2 neu over-expression with clinico pathological features of carcinoma breast Document Transcript

  • Correlation of Her-2 neu over-expression with clinico pathological features of carcinoma breast
  • a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 1 3 e3 1 7 Available online at www.sciencedirect.com ScienceDirect journal homepage: www.elsevier.com/locate/apme Research Article Correlation of Her-2 neu over-expression with clinico pathological features of carcinoma breast Uma Krishnaswamy*, Premkumar Balachandran, I. Rajakumar, K. Balachandar, Mohamed Mansoor Department of General Surgery, Apollo (Main) Hospitals, Chennai, Tamil Nadu, India article info abstract Article history: Purpose: To determine the relationship between Her-2 neu over-expression and clinico Received 17 August 2012 pathological features of carcinoma breast. Accepted 29 October 2013 Methods: 150 patients with carcinoma breast, were assessed for Her-2 neu over-expression Available online 27 November 2013 as a prospective study. Oestrogen (ER) and progesterone receptor (PR) status along with other clinico pathological parameters of tumour size, node status, type and grade of Keywords: tumour were assessed. Her-2 neu amplification Results: Her-2 neu over-expression was seen in 32.30% of patients who were ER and PR Oestrogen receptor negative and in 11.94% of those who were ER and PR positive. It was unrelated to the other Progesterone receptor clinico pathological parameters. Conclusions: Significant correlation between Her-2 neu amplification and ER/PR negative tumours was found but not with other clinico pathological parameters. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. 1. Introduction The classical clinico pathological features such as tumour size, axillary node status, histological type and grade have a well-established prognostic role in breast cancer. However, they do not allow patients to be stratified for appropriate therapy on an individual basis. Biological markers such as oestrogen (ER) and progesterone receptors (PR) are of value in individualizing therapy and have become standard of care. Similarly, assessment of Her-2 neu over-expression has become the norm because it provides both prognostic and therapeutic information. There is no consensus in literature on the relationship between Her-2 neu over-expression and the classical clinico pathological features.1,2 But, nearly all investigators report an inverse relationship between Her-2 neu status and hormone receptors in diverse populations.3e5 The purpose of this study was to verify whether such correlations existed in our patients. To this end, the association between Her-2 neu overexpression and oestrogen and progesterone receptor status (both independently and jointly) and other clinico pathological features, that is, tumour size, node status, type of tumour and grade of tumour were studied. 2. Patients and methods This was a prospective study accumulating 150 breast cancer patients over a 5 year period from 2004. All specimens of definitive surgery were fixed in 10% formaldehyde, embedded * Corresponding author. Flat 1, No 3 (Old 9), Tiruveedi Amman Street, Ramakrishna Nagar, Chennai 600028, India. Tel.: þ91 44 24937926, þ91 98410 33426 (mobile). E-mail address: umaks@vsnl.com (U. Krishnaswamy). 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. http://dx.doi.org/10.1016/j.apme.2013.10.012
  • 314 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 1 3 e3 1 7 Table 1 e Clinico pathological features (n [ 150). Categorical variables Age 40 years !41 years T stage Tis T1 T2 T3 T4 N stage N0 N1 N2 N3 Type Infiltrating In situ Grade (infiltrating duct cancer) 1 2 3 ER Positive Negative PgR Positive Negative Her-2/neu status Positive Negative Number Percentage 25 125 16.66 83.33 6 32 63 39 10 4.0 21.3 42.0 26.0 6.7 82 59 8 1 54.7 39.3 5.3 0.7 144 6 96.0 4.0 10 67 56 7.51 50.37 42.10 82 68 54.7 45.3 70 80 46.7 53.3 35 115 23.3 76.7 in paraffin, sectioned and stained with Haematoxylin/Eosin. Pathological staging (pTNM),6 determination of tumour type as per WHO classification,7 and grading by the Nottingham system8,9 was done. ER and PR status were assessed by immuno histochemistry either on the pre operative core biopsy sample or the surgical specimen on 4 mm sections of formalin-fixed, paraffinembedded tissues. Monoclonal antibody 6F11, (mouse anti human oestrogen receptor alpha specific product, MCA1799T, AbD Serotec, UK) was used to detect ER. For detection of PR, the monoclonal antibody 1A6 (mouse anti human progesterone receptor specific product MCA1800T, AbD Serotec, UK) was used. With the use of monoclonal antibody and antigen retrieval, immuno histochemical reaction for ER and PR is usually an all-or-none phenomenon. Therefore, quantitation of results was not done. HER-2 neu expression was assessed on either the pre operative core biopsy samples or the surgical specimen on 4 mm sections of formalin-fixed, paraffin-embedded tissues after an antigen retrieval procedure, (monoclonal antibody to c-erbB-2 protein, Mouse IgG1, Biogenex). Her-2 neu was scored on a 0e3 scale according to the criteria set by Dako.10 No staining or membrane staining in less than 10% of tumour cells is score 0 (Her-2 neu negative), faint incomplete membrane staining in more than 10% of the tumour cells is score 1þ (trace negative), a weak to moderate complete membrane staining in more than 10% of the tumour cells is score 2þ (weak positive) and a strong complete membrane staining in more than 10% of the tumour cells is score 3þ (strong positive). A score of 0 or 1þ is interpreted as negative, 3þ is considered positive for Her-2 neu over-expression. A score of 2þ was considered borderline and was confirmed by fluorescence in situ hybridization (FISH) test, which assesses whether Her-2 neu gene amplification has occurred in breast cancer cells11 (Religare SRL Diagnostics. Probe: PathVysionä Her-2 DNA Probe Kit, Vysis (Abbott); FDA approved. Image Analysis method: Metasystems Isis, Carl Zeiss; Germany). The cut-off point for Her-2 neu amplification is a Her-2/CEP17 (centromere 17) ratio of more than or equal to 2.0 with appropriate positive and negative controls run with the test sample. 3. Statistical analysis All statistical analyses were performed with SPSS software version 15.1 for Windows (SPSS Inc, Chicago, Illinois, USA) and Epi Infoä (Version 6). The c2 test was used to examine the association between Her-2/neu status and the various categorical variables in univariate analysis. p values less than 0.05 were accepted as significant. 4. Results Table 1 summarises the clinico pathological features of all 150 patients. Her-2 neu over-expression was seen in 35 (23.3%) out of the 150 patients. The mean age of the patients was 51.29 years. The youngest patient was 26 and the oldest 85 years. Only 7 out of 25 patients (28%) who were age 40 were Her-2/neu positive. In the 125 who were !41 years, 28 (22.4%) were Her-2 neu positive. For younger vs. older patients: Odds ratio ¼ 1.35. 95% CI 0.46e3.87. Relative risk ¼ 1.25 (p ¼ 0.7298443 Yates corrected). Her-2 neu over-expression was present in 2 out of 6 (33.33%) Tis tumours, 5 out of 32 (15.62%) T1 lesions, 15 out of 63 (23.80%) T2 lesions, 11 out of 39 (28.20%) T3 lesions and 2 out of 10 (20%) T4 lesions. Out of 38 lesions <2 cm in size, 7 (18.42%) were Her-2/neu positive. In 112 lesions >2 cm size, 28 (25%) were Her-2 neu positive. For larger tumours vs. smaller tumours: Odds ratio ¼ 0.68. 95% CI 0.24e1.84. Relative risk ¼ 0.74 (p ¼ 0.5441040 Yates corrected). Her-2 neu over-expression was seen in 21 out of 82 (25.60%) N0 cases, 10 out of 59 (16.94%) N1 cases, 3 out of 8 (37.5%) N2 cases and 1 out of 1 N3 case. A total of 14 patients out of 68 (20.58%) node positive disease (N1, N2 and N3) were Her-2 neu positive. For node positive vs. node negative disease: Odds ratio ¼ 1.33. 95% CI 0.58e3.08. Relative risk ¼ 1.24 (p ¼ 0.5961294 Yates corrected). There were 2 instances of Her-2 neu over-expression out of 6 (33.33%) patients with ductal carcinoma in situ and in 33 instances out of 144 (22.60%) infiltrating carcinomas. For infiltrating carcinoma vs. in situ lesions: Odds ratio ¼ 1.68. 95% CI 0.20e11.39. Relative risk ¼ 1.16 (p ¼ 0.6242803 Fisher exact 2tailed). The infiltrating duct carcinomas were mainly not otherwise specified variety (NOS) (78.66%). There were 2 instances of infiltrating lobular carcinoma which did not show Her-2 neu over-expression. There was 1 instance of Her-2 neu over-expression out of 10 (10%) grade 1 tumours, 13 out of 67 (19.40%) grade 2 tumours
  • 315 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 1 3 e3 1 7 and 18 out of 56 (32.14%) grade 3 tumours. For high grade vs. lower grade tumours (infiltrating duct carcinomas only): Odds ratio ¼ 0.47. 95% CI 0.19e1.13. Relative risk ¼ 0.57 (p ¼ 0.0980697 Yates corrected). Her-2 neu was amplified in 13 out of a total of 82 (15.85%) ER positive cases and in 22 out of 68 (32.35%) ER negative cases. For ER negative vs. ER positive disease: Odds ratio ¼ 0.39. 95% CI 0.17e0.92. Relative risk ¼ 0.80 (p ¼ 0.0289233 Yates corrected). It was amplified in 9 out of 70 (1.28%) PR positive cases and in 26 out of 80 (32.5%) PR negative cases. For PR negative vs. PR positive disease: Odds ratio ¼ 0.31. 95% CI 0.12e0.76. Relative risk ¼ 0.77 (p ¼ 0.0081887 Yates corrected). Table 2 summarises the frequency of Her-2 neu expression according to all of the above independent variables. When ER and PR status was looked at jointly, it was noted that out of 67 patients who were both ER and PR positive, 8 (11.94%) were Her-2 neu positive. Out of 65 patients who were ER and PR negative, 21 (32.30%) were Her-2 neu positive. Out of 15 patients who were ER positive but PR negative, 5 (33.33%) were Her-2 neu positive. For ER and PR negative vs. ER and PR positive lesions: Odds ratio ¼ 0.28. 95% CI 0.10e0.76. Relative risk ¼ 0.37 (p ¼ 0.0089154 Yates corrected). For ER positive PgR negative lesions vs. ER positive PR positive lesions: Odds ratio ¼ 3.69. 95% CI 0.84e16.25. Relative risk ¼ 2.79 (p ¼ 0.0552503 Fisher Exact). Table 3 summarises the frequency of Her-2 neu expression according to joint ER/PR status. 5. Discussion Classical clinical and morphological prognostic factors, such as tumour size, axillary node status, histological grade and Table 2 e Frequency of Her-2 neu status and clinico pathological variables. Categorical variables Her-2 neu positive Number (%) Age 40 years !41 years T stage <2 cm >2 cm N stage Node negative Node positive Type In situ Infiltrating Grade Low (1e2) Higher (3) ER Positive Negative PgR Positive Negative Her-2 neu negative p Value Number (%) 18 (72) 97 (77.6) 7 (28) 28 (22.4) Not significant 31 (81.57) 84 (75) 7 (18.43) 28 (25) Not significant 61 (74.39) 54 (79.41) 21 (25.61) 14 (20.59) Not significant 4 (66.66) 111 (77.08) 2 (33.34) 33 (22.92) Not significant 63 (81.81) 38 (67.85) 14 (18.19) 18 (32.15) Not significant 69 (84.15) 46 (67.65) 13 (15.85) 22 (32.35) 0.0289233 61 (98.72) 54 (67.5) 9 (1.28) 26 (32.5) 0.0081887 Table 3 e Frequency of Her-2 neu status by joint ER/PR expression. Categorical variables PgRþ PgRÀ PgRþ PgRÀ Her-2 neu positive Number (%) ERþ ERþ ERÀ ERÀ Her-2 neu negative Number (%) 59 10 2 44 (88.05) (66.66) (66.66) (6.15) 8 5 1 21 (11.94) (33.33) (33.33) (32.30) Total 67 15 3 65 type, vascular invasion etc. have a well-established role in the management of breast cancer. Advances in the understanding of the molecular and genetic alterations underlying breast cancer development and progression have resulted in the identification of a great number of cell biological markers which are of potential value in individualizing therapy.12,13 The HER-2 neu gene encodes a 185 kDa transmembrane phosphoglycoprotein with tyrosine kinase activity and is a member of the human epidermal growth factor receptor gene family. The HER-2 neu proto-oncogene (also known as c-erbB2) is homologous with, but distinct from, the epidermal growth factor receptor. Her-2 neu (c-erbB-2) gene amplification, which usually results in over-expression of the encoded transmembrane protein, occurs in approximately 15%e30% of invasive breast cancers.14 In this study, 35 (23.3%) out of 150 patients were Her-2 neu positive. This figure appears to be within the commonly accepted rate of occurrence. It has been suggested that Her-2 neu gene amplification is more common in younger patients,15 but this study failed to reveal such a relationship in a statistically significant manner as this has been the case with other authors as well.16 Tumour size is a valuable predictor of behaviour in breast cancer. Higher rates of Her-2 neu over-expression in larger tumours have been documented by some.17 But, this study shows no such tendency. This is in keeping with other studies.18 Axillary lymph node status too is a powerful prognosticator. In this study, as well as that of others, there was no association between Her-2 neu over-expression and axillary lymph node status.19 Literature suggests that there is generally no correlation between Her-2 neu status and histological type of cancer.20 A later study indicated that Her-2 neu over-expression was more likely in infiltrating duct carcinomas than in infiltrating lobular carcinomas.21 In this study too, there was no correlation with histological type, but as the number of infiltrating lobular carcinomas were very small (only 2), when compared to infiltrating duct carcinomas, no definite conclusions could be reached. Her-2 amplification/over-expression in different histological grades of breast cancer has been a subject of interest. Most studies have correlated Her-2 neu over-expression with poor histological or nuclear grade of the primary tumour22 whereas others have not.23,24 This study did show a numerically increasing incidence of Her-2 neu positivity with increasing tumour grade, but this was not statistically significant.
  • 316 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 1 3 e3 1 7 Oestrogen and progesterone receptor studies are established procedures in the routine management of breast cancer, primarily as predictive factors for response to hormonal therapy. Despite the great variation in levels of Her-2 neu positivity, nearly all investigators report a negative relationship between Her-2 neu status and steroid receptors levels.25e27 In this study too, Her-2 neu protein over-expression was associated with a statistically significant higher rate of ER and PR negative status. Interestingly some authors highlight the negative relationship between PR and Her-2 neu status and that this is seen after age 45. They found increased Her-2 neu positivity (2.75fold increase) in ER positive PR negative tumours compared with ER positive PR positive tumours.28,29 In this study too a 2.79-fold increase in Her-2 neu positivity was seen in ER positive, PR negative tumours when compared to ER positive and PR positive lesions with the mean age of these patients being 48 years. However, no further conclusions could be reached on an age-related association between Her-2 neu and PR in ER positive breast cancers because of the limited number of patients in this study. In a country such as India, with severe financial constraints, while ER testing is offered for establishing hormone receptor status, Her-2 neu testing is not, because of the crippling cost of Trastuzumab. The trend of a negative relationship between steroid receptors and Her-2 neu amplification/ over-expression may be helpful to the clinician in determining the diagnostic pathway in selected instances where financial considerations are paramount. 6. Conclusion The estimation of ER, PR and Her-2 neu in breast cancer is now standard of care, but the relationship between these and other traditional prognosticators is still not clear. In this study of 150 breast cancers, significant correlation between Her-2 neu amplification and ER/PR negative tumours was found but such was not so with other clinico pathological parameters. Presentation details Organisation: Association of Surgeons of India, Tamil Nadu & Pondicherry State Chapter Conference (NAGASICON 2009). Place: Kanya Kumari, Tamil Nadu. Date: 2nd August, 2012. Conflicts of interest All authors have none to declare. references 1. Prati R, Apple SK, He J, Gornbei JA, Chanh HR. Histopathologic characteristics predicting HER-2/neu amplification in breast cancer. Breast J. 2005;11:433e439. 2. Huang HJ, Neven P, Drijkoningen M, et al. Association between tumour characteristics and HER-2/neu by immunohistochemistry in 1362 women with primary operable breast cancer. J Clin Pathol. 2005;58:611e616. 3. Almasri NM, Al Hamad M. Immunohistochemical evaluation of human epidermal growth factor receptor 2 and estrogen and progesterone receptors in breast carcinoma in Jordan. Breast Cancer Res. 2005;7:598e604. ` ` 4. Traina A, Agostara B, Marasa L, Calabro M, Zarcone M, Carruba G. HER2/neu expression in relation to clinicopathologic features of breast cancer patients. Ann N Y Acad Sci. 2006;1089:159e167. 5. Peredo R, Sastre G, Serrano J, Hunter Mellado R. Her-2/neu oncogene expression in Puerto Rican females with breast cancer. Cell Mol Biol (Noisy-le-grand). 2001;47(6):1025e1032. 6. Sobin LH, Wittekind C, eds. UICC TNM Classification of Malignant Tumours. 6th ed. New York, NY: Wiley-Liss; 2002:131e141. 7. Histological typing of breast tumours, International Classification of Tumours. 2nd ed. Geneva, Switzerland: World Health Organization; 1981. 8. Bloom HJG, Richardson WW. Histological grading and prognosis in breast carcinoma: a study of 1049 cases of which 359 have been followed for 15 years. Br J Cancer. 1957;11:359e377. 9. Fitzgibbons PL, Page DL, Weaver D, et al. Prognostic factors in breast cancer: College of American Pathologists consensus statement 1999. Arch Pathol Lab Med. 124:966e978. 10. DAKO HercepTestÒ Package insert. Carpinteria, Calif: DAKO Corp; 2004. 11. Carlson RW, Moench SJ, Hammond MAY, et al. HER2 testing in breast Cancer: NCCN Task Force report and recommendations. J Natl Compr Canc Netw. 2006;4(suppl 3):S1e22. 12. Schnitt SJ. Traditional and newer pathologic factors. J Natl Cancer Inst Monogr. 2001;30:22e26. 13. Cameron D, Bell R. Optimizing treatment for patients with breast cancer. Semin Oncol. 2004;31:4e5. 14. Piccart MJ, Mano M, Lohrisch C, Di Leo A. Herceptin for the treatment of breast cancer: what we know-and what we have yet to learn. Cancer Futures. 2002;1:73e79. 15. Eppenberger-Castori S, Moore II DH, Thor AD, et al. Ageassociated biomarker profiles of human breast cancer. Int J Biochem Cell Biol. 2002;34:1318e1330. 16. Ariga R, Zarif A, Korasick J, Reddy V, Siziopicou K, Gattuso P. Correlation of Her-2/neu gene amplification with other prognostic and predictive factors in female breast carcinoma. Breast J. 2005;11:278e280. 17. Bhatavdekar JM, Patel DD, Shah NG, et al. Prognostic significance of immunohistochemically localized biomarkers in stage II and stage III breast cancer: a multivariate analysis. Ann Surg Oncol. 2000;7:305e311. 18. Paik S, Brayant J, Park C, et al. ErbB-2 and response to doxorubicin in patients with axillary lymph-node positive, hormone receptor-negative breast cancer. J Natl Cancer Inst. 1998;90:1361e1370. 19. Bozcuk H, Uslu G, Pestereli E, et al. Predictor of distant metastasis at presentation in breast cancer: a study also evaluating associations among common biological indicators. Breast Cancer Res Treat. 2001;68:239e248. 20. Moriki T, Takahashi T, Hiroi M, Yamane T, Hara H. Histological grade in invasive ductal carcinoma of breast correlates with the proliferative activity evaluated by BrdU: an immunohistochemical study including correlations with p53, c-erbB-2 and estrogen receptor status. Pathol Int. 1996;46:417e425. 21. Boussen H, Bouzaiene H, Ben Hassouna J, Gamoudi A, Benna F, Rahal K. Inflammatory breast cancer in Tunisia: reassessment of incidence and clinicopathological features. Semin Oncol. 2008;35:17e24.
  • a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 3 1 3 e3 1 7 22. Hoff ER, Tubbs RR, Myles JL, Procop GW. HER-2/neu amplification in breast cancer. Stratification by tumour type and grade. Am J Clin Pathol. 2002;117:916e921. 23. Ali IU, Cmpbell G, Liderau R, Callahan R. Lack of evidence for the prognostic significance of c-erbB-2 amplification in human breast carcinoma. Oncogene Res. 1988;3:139e146. 24. Andrulis IL, Bull SB, Blackstein ME, et al. Neu/erbB-2 amplification identifies a poor-prognosis group of women with node-negative breast cancer. Toronto Breast Cancer Study Group. J Clin Oncol. 1998;16:1340e1349. 25. Ansquer Y, Mandelbrot L, Lehy T, et al. Expression of BRCA1, HER-1 (EGFR) and HER-2 in sporadic breast cancer and relationships to other clinicopathological prognostic features. Anticancer Res. 2005;25:4535e4541. 317 26. Konecny G, Pauletti G, Pegram M, et al. Quantitative association between HER-2/neu and steroid hormone receptors in hormone receptor-positive primary breast cancer. J Natl Cancer Inst. 2003;95:142e153. 27. Taucher S, Rudas M, Mader RM, et al. Do we need HER-2/neu testing for all patients with primary breast carcinoma? Cancer. 2003;98:2547e2553. 28. Huang HJ, Neven P, Drijkoningen M, et al. Association between HER-2/neu and the progesterone receptor in oestrogen-dependent breast cancer is age related. Breast Cancer Res Treat. 2005;91:81e87. 29. Cui X, Schiff R, Arpino G, et al. Biology of progesterone receptor loss in breast cancer and its implications for endocrine therapy. J Clin Oncol. 2005;23:7721e7735.
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