|Year : 2017 | Volume
| Issue : 1 | Page : 13-18
Immunohistochemical expression of HER-2/neu receptors in gastric carcinoma
Elia A Ishaky1, Sonia L El-Sharkawy2, Menar M Ayob1, Hafiza A Sharaf2, Rofanda M Bakeer2
1 Department of Pathology, Cairo University, Giza, Egypt
2 Department of Pathology, Medical Division, National Research Centre, Giza, Egypt
|Date of Submission||27-Apr-2017|
|Date of Acceptance||21-May-2017|
|Date of Web Publication||22-Jun-2017|
Rofanda M Bakeer
Department of Pathology, Medical Division, National Research Centre, El Bohoth Street, Dokki, Giza, 12311
Source of Support: None, Conflict of Interest: None
Background/aim Gastric carcinoma is the fourth most commonly diagnosed cancer and the second most common cause of cancer-related death. It is associated with patient morbidity and mortality worldwide. Adenocarcinomas represent 90% of gastric carcinoma cases and are classified into intestinal and diffuse types. Human epidermal growth factor receptor 2 (HER-2)/neu overexpression is a predictor of poor prognosis. This study aimed to evaluate HER-2/neu expression in gastric carcinomas and to correlate its expression with clinicopathological parameters and other prognostic factors.
Patients and methods Forty-five cases of primary gastric carcinoma were included in this study. Thirty-two cases were of intestinal type and 13 cases were of the diffuse type. All specimens were formalin fixed, routinely processed, stained with hematoxylin and eosin, and immunohistochemically stained with HER-2/neu.
Results Overexpression of HER-2/neu was detected in five out of 30 (11.1%) gastric carcinomas. There was a nonsignificant difference (P>0.05) in different histologic types. Also HER-2/neu expression showed a nonsignificant correlation with both histologic grade and tumor stage.
Conclusion Our results revealed a limited effect of HER-2/neu on the biologic behavior of gastric carcinoma. However, further study with a larger sample size is recommended to clarify the therapeutic role of trastuzumab (Herceptin) in gastric carcinoma patients expressing HER-2/neu.
Keywords: gastric carcinoma, HER-2/neu, immunohistochemistry
|How to cite this article:|
Ishaky EA, El-Sharkawy SL, Ayob MM, Sharaf HA, Bakeer RM. Immunohistochemical expression of HER-2/neu receptors in gastric carcinoma. J Arab Soc Med Res 2017;12:13-8
|How to cite this URL:|
Ishaky EA, El-Sharkawy SL, Ayob MM, Sharaf HA, Bakeer RM. Immunohistochemical expression of HER-2/neu receptors in gastric carcinoma. J Arab Soc Med Res [serial online] 2017 [cited 2022 Jan 18];12:13-8. Available from: http://www.new.asmr.eg.net/text.asp?2017/12/1/13/208864
| Introduction|| |
Gastric cancer is the most common cause of cancer-related death and is considered the fourth most commonly diagnosed neoplasm worldwide ,. Men are twice as likely to be affected with gastric cancer than are women. This may be explained by the protective effect of estrogen against gastric cancer development ,.
Many factors may be responsible for gastric cancer. Although Helicobacter pylori infection is an important risk factor in most cases of stomach carcinoma, only 2% of patients develop gastric cancer . Smoking is another risk factor increasing the incidence of gastric cancer − from 40% in current smokers to 82% in heavy smokers ,. Dietary factors, although not proved as essential risk factors, such as consumption of red meat, processed meat, smoked food, and salt-rich food, may be correlated with gastric cancer development ,.
About 10% of cases occur in families wherein genetic factors constitute the primary cause in 1–3% of cancer cases, such as hereditary diffuse gastric cancer .
Adenocarcinomas represent more than 95% of gastric carcinoma cases . Since 1965, the most commonly used classification for gastric cancer is the Laurén classification , which groups gastric carcinoma into intestinal and diffuse types . The intestinal type has been shown to be associated with intestinal metaplasia of the gastric mucosa and has been correlated with H. pylori infection, which was not established in diffuse type ,.
Gastric carcinogenesis is a multistep and multifactorial process. Whereas environmental factors such as lifestyle and H. pylori infection are associated with the intestinal type of gastric cancer, the diffuse type is often related to genetic abnormalities .
During gastric carcinogenesis, an accumulation of genetic and molecular abnormalities occurs, including activation of oncogenes, overexpression of growth factors/receptors, inactivation of tumor suppression genes, DNA repair genes and cell adhesion molecules , loss of heterogeneity and point mutations of tumor suppressor genes . Understanding of the molecular events and pathways has led to the application of molecular pathology in prevention, early diagnosis, tumor classification, and therapeutic intervention. The application of molecular techniques for testing molecular abnormalities such as human epidermal growth factor receptor 2 (HER-2) expression in cases of stomach carcinoma has had a significant impact on medical practice .
HER-2 is a proto-oncogene located on chromosome 17q21 that encodes a transmembrane protein with tyrosine kinase activity, a member of the HER receptor family and involved in signal transduction pathways, leading to cell growth and differentiation .
Amplification of the HER-2 gene and overexpression of its product were first discovered in breast cancer and are significantly associated with worse outcomes . In previous studies, HER-2 is also present in several other malignancies, including colorectal cancer, ovarian cancer, prostate cancer, lung cancer, and, particularly, gastric and gastroesophageal cancer ,,.
As one of the first molecular-targeted drugs to be developed, trastuzumab is a monoclonal antibody directed against HER-2. It was first introduced for the treatment of HER-2-positive advanced breast cancer . With the recent introduction of trastuzumab for the treatment of patients with advanced gastric cancer, the clinical demand for HER-2 assessment is rapidly increasing . Patients with gastric cancer highly expressing HER-2/neu showed the greatest benefit from trastuzumab therapy. Therefore, it is now recommended to assess HER-2/neu status in all cases of gastric carcinoma at the time of initial diagnosis .
This study aimed to evaluate HER-2/neu expression in gastric carcinomas and to correlate its expression with clinicopathological parameters and other prognostic factors.
| Patients and methods|| |
This study included 45 cases of primary gastric carcinoma from patients who underwent radical or partial gastric resection; these patients had been referred to the pathology department at Kasr El-Aini hospitals and a private laboratory between January and December 2007. The Ethical Committee on human research at our Institute approved the protocol for this study.
Each specimen had been fixed in 10% phosphate buffered formalin and routinely processed to be embedded in paraffin blocks. Serial sections of 4 μm thickness were cut from each block and stained as follows:
- With hematoxylin and eosin to revise the diagnosis, type, and grade of the tumor, and perform the pathologic staging of the tumor.
- According to Laurén’s classification , 32 cases were of intestinal type and 13 cases were of the diffuse type.
- All cases were assessed according to the WHO grading system : 25 cases were grade II and 20 cases were grade III.
- All cases were staged according to the TNM staging system of the WHO : three were of tumor stage T2, 40 were of T3, and two were of T4.
- Sections were obtained from each case and mounted on super frost Tissue Mounting (TM) slides for immunohistochemical analysis. Sections were deparaffinized and brought to water. Antigen retrieval was performed using citrate buffer (pH 6) in a water bath. Immunohistochemical staining was performed using an automated immunostainer (Dako Cytomation Autostainer S3400; Dako). The primary antibody used was Dako Cytomation rabbit anti-HER-2 polyclonal antibody (Dako Cytomation, a0485) at a dilution of 1 : 50 for 30 min. Binding and detection were performed using the Dako Cytomation En Vision TM peroxides dual link kit (K5007):
- HER-2 positivity was defined as continuous membranous staining in at least 10% of tumor cells.
- A paraffin section of invasive breast carcinoma stained with HER-2/neu was used as a positive control.
Data were analyzed using the statistical package SPSS for Windows (IBM, New York, New York, USA). Statistical analysis was performed using Fisher’s exact test. P values less than 0.05 were considered statistically significant.
| Results|| |
In this study, a total of 45 cases of primary gastric carcinoma have been studied. Intestinal type constituted 71% of the cases and diffuse type constituted 29% of the cases.
According to the WHO 2004 grading system, 25 (55.6%) cases were of grade II and 20 (44.4%) cases were of grade III.
According to the TNM staging system, three (6.7%) cases were of tumor stage T2, 40 (88.9%) cases were of stage T3, and two (4.4%) cases were of stage T4.
As regards tumoral N stage, 10 (22.2%) cases were N0, 17 (37.8%) cases were N1, 12 (26.7%) cases were N2, and six (13.3%) cases were N3.
Overexpression of HER-2/neu was detected in five (11.1%) out of 30 gastric carcinoma cases. Stromal and normal epithelial cells adjacent to the tumor tissue were negatively stained ([Figure 1],[Figure 2],[Figure 3]).
|Figure 1 Immunohistochemical staining of human epidermal growth factor receptor 2/neu in grade II intestinal gastric adenocarcinoma with strong membrane staining. Immunohistochemistry, ×400.|
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|Figure 2 Human epidermal growth factor receptor 2/neu membranous staining in diffuse gastric adenocarcinoma, small cell type. Immunohistochemistry, ×400.|
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|Figure 3 Infiltrating intestinal gastric adenocarcinoma of the stomach (grade II) showing negative staining for human epidermal growth factor receptor 2/neu. Immunohistochemistry, ×200.|
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There was a nonsignificant correlation (P>0.05) between HER-2/neu positivity and tumor histological type, wherein 9.4% of intestinal type and 15.4% of diffuse type were HER-2/neu positive ([Table 1]).
|Table 1 Relation between human epidermal growth factor receptor 2/neu positivity and tumor histological type of gastric carcinoma cases|
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It was found that 12% of grade II and 10% of grade III tumors were HER-2/neu positive, revealing a nonsignificant correlation (P>0.05) between HER-2/neu positivity and tumor histological grade ([Table 2]).
|Table 2 Relation between human epidermal growth factor receptor 2/neu positivity and grade in gastric carcinoma cases|
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As regards tumor stage, there was a nonsignificant correlation (P>0.05) between HER-2/neu positivity and tumor T stage, wherein the five HER-2/neu-positive cases were T3, representing 12.5% of T3 cases ([Table 3]).
|Table 3 Relation between human epidermal growth factor receptor 2/neu positivity and T stage in gastric carcinoma cases|
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It was also found that tumor N stage was nonsignificantly correlated with HER-2/neu positivity ([Table 4]).
|Table 4 Relation between human epidermal growth factor receptor 2/neu positivity and N stage in gastric carcinoma cases|
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| Discussion|| |
Gastric carcinoma is the fourth most commonly diagnosed cancer and the second most common cause of cancer-related death. It is associated with morbidity and mortality worldwide ,. Although its incidence is persistently declining because of changes in nutrition and better prevention and treatment, gastric cancer with palliative chemotherapy is still associated with a poor prognosis . Recent advances in molecular medicine have not only shed light on the carcinogenesis of gastric cancer but also offered novel approaches regarding prevention, diagnosis, and therapeutic intervention .
The humanized monoclonal antibody against HER-2, trastuzumab (Herceptin), when combined with chemotherapy (capecitabine or 5-fluorouracil and cisplatin), could effectively prolong overall survival and progression-free survival, and increase the response rate in HER-2-positive advanced gastric carcinoma .
The response of gastric carcinoma to trastuzumab is predicted well from the levels of HER-2 protein. On the other hand, the tumors with positive HER-2 amplification but with low or negative HER-2 expression do not respond well to trastuzumab. Therefore, immunohistochemistry is recommended to be used as the initial testing methodology, and fluorescence in-situ hybridization or silver in-situ hybridization is used to retest immunohistochemistry .
The most commonly used classification for gastric cancer was the Laurén classification, which classifies gastric carcinoma into intestinal and diffuse types . In another study, there was an unclassified group known as the atypical group . In our study, 21 out of 30 (70%) cases were of intestinal type, whereas nine (30%) cases were of the diffuse type. This is in agreement with the findings of Ghoshetal  and García et al . In contrast, a previous study showed that the number of diffuse-type gastric carcinoma cases exceeded that of intestinal type ,. Pinto-de-Sousa et al.  had classified their cases into intestinal type (51%), diffuse type (29.9%), and unclassified cases (19.1%).
According to the WHO 2004 grading system, 17 (56.7%) cases were of grade II and 13 (43.3%) were of grade III. According to the TNM staging system, two (6.7%) cases were of tumor stage T2, 27 (90%) were of stage T3, and one (3.3%) case was of stage T4.
HER-2/neu is a proto-oncogene located at chromosome 17q21. It is a growth regulatory factor and a cell motility factor that interferes with the signaling cascades involved in cell differentiation, proliferation, and survival . HER-2/neu was proved to be an important biomarker in many cancers, including gastric and gastroesophageal junction tumors .
This study aimed to evaluate HER-2/neu expression in gastric carcinomas and correlate its expression with clinicopathological parameters and other prognostic factors.
HER-2/neu was considered positive when expressed as membranous staining in at least 10% of malignant cells. In our study, HER-2/neu immunoreactivity was detected in three out of 30 (10%) cases. Previous studies showed HRT-2/neu overexpression in 7–34% of gastric carcinoma cases ,,,,,.
Using various techniques, HER-2/neu expression has been shown to have wide variation in different tumors. It was recommended by expert pathologists that if HER-2/neu expression showed less than 10% strongly stained tumor cells, these cases must be subjected to in-situ hybridization to exclude false-negative results ,.
As HER-2/neu is overexpressed in invasive ductal breast carcinoma more than in lobular carcinoma, our study revealed that HER-2/neu expression in intestinal type is nonsignificantly higher than that in diffuse type. This is in agreement with many previous studies ,,. Other studies found a significant HER-2/neu overexpression in intestinal type ,,,,,. Although intestinal type showed overexpression for HER-2/neu, not all intestinal-type gastric carcinomas showed this overexpression. HER-2/neu overexpression cannot be the only factor involved; other external factors may also be involved . In the present study, 11.8% of grade II gastric carcinomas and 7.7% of grade III tumors showed HER-2/neu overexpression, revealing a nonsignificant correlation with histologic grade. Previous studies revealed significant correlation between HER-2/neu overexpression and well-differentiated tumors ,, whereas other studies showed positive relation with poorly differentiated ones ,.
Several clinical and pathological parameters such as age at onset, tumor location, gastric wall invasion, and distant metastases may predict the prognosis of gastric cancer ,. Also several genetic alterations, including HER-2/neu overexpression, have been reported in gastric carcinoma ,.
As regards the prognosis of gastric carcinoma, our study revealed a nonsignificant correlation between HER-2/neu and tumor stage, where the three HER-2/neu-positive cases were T3, representing 11% of T3 cases. This was in agreement with other previous studies ,. Other reports showed HER-2/neu overexpression in advanced cases; however, there was a nonsignificant correlation between positivity and different poor prognostic factors . A significant correlation and close association between HER-2 expression and aggressiveness of the tumor was revealed in previous studies ,.Therefore, HER-2/neu expression in gastric carcinomas is related to their aggressive clinical behavior and poor survival rate ,.
In addition to the determination of the prognostic role of HER-2/neu expression in gastric carcinoma, fluorescence in-situ hybridization (FISH) or Chromogenic in situ hybridization (CISH) methods could be utilized to detect gene amplification to evaluate patient survival .
In conclusion, our results revealed a limited effect of HER-2/neu on the biologic behavior of gastric carcinoma. However, further study with a larger sample size is recommended to clarify the therapeutic role of trastuzumab (Herceptin) in gastric carcinoma patients expressing HER-2/neu.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Berlth B, Bollschweiler E, Drebber U, Hoelscher AH, Moenig S. Pathohistological classification systems in gastric cancer: diagnostic relevance and prognostic value. World J Gastroenterol 2014; 20:5679–5684.
Bing HB, El Hajj N, Sittler S, Lammert N, Barnes R, Ehrig AM. Gastric cancer: classification, histology and application of molecular pathology. J Gastrointest Oncol 2012; 3:251–261.
Chandanos E, Lagergren J. Oestrogen and the enigmatic male predominance of gastric cancer. Eur J Cancer 2008; 44:2397–2403.
Qin J, Liu M, Ding Q, Ji X, Hao Y, Wu X et al.
The direct effect of estrogen on cell viability and apoptosis in human gastric cancer cells. Mol Cell Biochem 2014; 395:99–107.
González CA, Sala N, Rokkas T. Gastric cancer: epidemiologic aspects. Helicobacter. 2013; 18:34–38.
Nomura A, Grove JS, Stemmermann GN, Severson RK. Cigarette smoking and stomach cancer. Cancer Res 1990; 50:7084–7090.
Trédaniel J, Boffetta P, Buiatti E, Saracci R, Hirsch A. Tobacco smoking and gastric cancer: review and meta-analysis. Int J Cancer 1997; 72:565–573.
Jakszyn P, González CA. Nitrosamine and related food intake and gastric and oesophageal cancer risk: a systematic review of the epidemiological evidence. World J Gastroenterol 2006; 12:4296–4303.
Amelot MEA, Avendaño M. Human carcinogenesis and bracken fern: a review of the evidence. Curr Med Chem 2002; 9:675–686.
Hansford S, Kaurah P, Li-Chang H, Woo M, Senz J, Pinheiro H et al.
Hereditary diffuse gastric cancer syndrome CDH1 mutations and beyond. JAMA Oncol 2015; 1:23–32.
Parkin DM, Bray FI, Devesa SS. Cancer burden in the year 2000. The global picture. Eur J Cancer 2001; 37:54–66.
Laurén T. The two histologic main types of gastric carcinoma. Acta Pathol Microbiol Scand 1965; 64:31–49.
Kaneko S, Yoshimura T. Time trend analysis of gastric cancer incidence in Japan by histological types, 1975-1989. Br J Cancer 2001; 84:400–405.
Yasui W, Sentani K, Motoshita J, Nakayama H. Molecular pathobiology of gastric cancer. Scand J Surg 2006; 95:225–231.
Kitaura K, Chone Y, Satake N, Akagi A, Ohnishi T, Suzuki Y et al.
Role of copper accumulation in spontaneous renal carcinogenesis in Long-Evans Cinnamon rats. Jpn J Cancer Res 1999; 90:385–392.
Akiyama T, Sudo C, Ogawara H, Toyoshima K, Yamamoto T. The product of the human c-erbB-2 gene: a 185-kilodalton glycoprotein with tyrosine kinase activity. Science 1986; 232:1644–1646.
Slamon DJ, Clark GM, Wong SG, Levin WJ, Ullrich A, McGuire WL. Human breast cancer: correlation of relapse and survival with amplification of the HER-2/neu oncogene. Science 1987; 235:177–182.
Yan M, Schwaederle M, Arguello D, Millis SZ, Gatalica Z, Kurzrock R. HER2 expression status in diverse cancers: review of results from 37,992 patients. Cancer Metastasis Rev 2015; 34:157–164.
Machado LFA, Neto CM. HER2 testing in gastric cancer: an update. World J Gastroenterol 2016; 22:4619–4625.
Rüschoff J, Hanna W, Bilous M, Hofmann M, Osamura RY, Liorca FP et al.
HER2 testing in gastric cancer: a practical approach. Mod Pathol 2012; 25:637–650.
James LA, Douglas BE, Christopher W, Cecilia FP. Pathology and natural history of gastric cancer [Chapter 2]. In: XX X, editors. Gastrointestinal oncology. XX: XX; 2004. pp. 281–294.
Parkin DM. International variation. Oncogene 2004; 23:6329–6340.
Ferlay J, Shin HR, Bray F, Forman D, Mathers C, Parkin DM. Estimates of worldwide burden of cancer in 200. Int J Cancer 2010; 127:2893–2917.
Wagner AD, Grothe W, Haeting J. Chemotherapy in advanced gastric cancer: a systemic review and meta-analysis based on aggregate data. J Clin Oncol 2006; 24:2903–2909.
Cutsem EV, Kang Y, Chung H, Shen L, Sawaki A, Lordick F et al.
Efficacy results from the ToGA trial: a phase III study of trastuzumab added to standard chemotherapy (CT) in first-line human epidermal growth factor receptor 2 (HER2)-positive advanced gastric cancer (GC). J Clin Oncol 2009; 27:18 s (suppl; abstr LBA 4509).
Rüschoff J, Hanna W, Bilous M, Hofmann M, Osamura RY, Penault-Llorca F et al.
HER2 testing in gastric cancer: a practical approach. Mod Pathol 2012;25:637–650.
Ghosh P, Chakrabarti I, Bhowmick S, Gangopadhyay M, Sinha MGM, Bhattacharya S. Overexpression of Her2/Neu in gastric carcinoma: association with histological type, tumor grade and H. pylori
infection. Ann Pathol Lab Med 2016; 3:184–188.
García I, Vizoso F, Martín A, Sanz L, Abdel-Lah O, Raigoso P, García-Muñiz JL. Clinical significance of the epidermal growth factor receptor and HER2 receptor in resectable gastric cancer. Ann Surg Oncol 2003; 10:234–241.
Park DI, Yun JW, Park JH, Oh SJ, Kim HJ, Cho YK et al.
HER-2/neu amplification is an independent prognostic factor in gastric cancer. Dig Dis Sci 2006; 51:1371–1379.
Raziee HR, Taghizadeh KA, Ghaffarzadegan K, Taghi SM, Ghavamnasiri MR. HER-2/neu expression in resectable gastric cancer and its relationship with histopathologic subtype, grade, and stage. Iran J Basic Med Sci 2007; 10:139–145.
Pinto-de-Sousa J, David L, Almeida R. C-erb B-2 expression is associated with tumor location and venous invasion and influences survival of patients with gastric carcinoma. Int J Surg Pathol 2002; 10:247–256.
Kuraoka K, Matsumura S, Hamai Y, Nakachi K, Imai K, Matsusaki K et al.
A single nucleotide polymorphism in the transmembrane domain coding region of HER-2 is associated with development and malignant phenotype of gastric cancer. Cancer 2003; 107:593–596.
Paik S, Bryant J, Tan-Chiu E, Yothers G, Park C, Wickerham D. HER2 and choice of adjuvant chemotherapy for invasive breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-15. J Natl Cancer Inst 2000; 92:1991–1998.
Tufan NLS, Bir F, Demirkan NC. Investigation of HER-2 codon 655 single nucleotide polymorphism frequency and c-ErbB-2 protein expression alterations in gastric cancer patients. World J Gastroenterol 2006; 12:3283–3287.
Gravalos C, Jimeno A. HER2 in gastric cancer: a new prognostic factor and a novel therapeutic target. Ann Oncol 2008; 19:1523–1529.
Laboissiere RS, Buzelin MA, Balabram D, Brot MD, Nunes CB, Rocha RM et al.
Association between HER2 status in gastric cancer and clinicopathological features: a retrospective study using whole-tissue sections. BMC Gastroenterol 2015; 15:157–162.
Son HS, Shin YM, Park KK, Seo KW, Yoon KY, Jang HK et al.
Correlation between HER2 overexpression and clinicopathological characteristics in gastric cancer patients who have undergone curative resection. J Gastric Cancer 2014; 14:180–186.
Dewan K, Madan R, Sengupta P. Correlation of Lauren’s histological type and expression of E-cadherin and HER-2/neu in gastric adenocarcinoma. Internet J Pathol Lab Med 2016; 2:1–5.
Jørgensen JT, Hersom M. HER2 as a prognostic marker in gastric cancer − a systematic analysis of data from the literature. J Cancer 2012; 3:137–144.
Ross JS, McKenna B. The HER-2/neu oncogene in tumors of the gastrointestinal tract. Cancer Invest 2001; 19:554–568.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]