| Abstract|| |
This study was conducted to evaluate the expression of HER-2/neu oncogene in the lesions of the uterine cervix and to determine its correlation with histological type of malignancy, grade and clinical stage of presentation. One hundred cervical specimens were included in this study. These comprised cases with diagnosis of benign epithelial lesions, squamous cell carcinoma, adenocarcinoma, carcinoma cervix with glandular differentiation and cervical intraepithelial neoplasia. HER-2/neu immunostaining was performed by streptovidin-biotin peroxidase method. Higher expression of HER-2/neu was noted in malignant lesions as compared to benign lesions. Intensity of staining also correlated with clinical stage of presentation, lymph node metastasis and presence of parametrial extension. The over-expression of HER-2 oncoprotein is associated with poor prognosis, metastatic potential and aggressive biological behavior.
Keywords: Cervical lesions, cervix, HER-2/neu expression, immunostaining
|How to cite this article:|
Gupta N, Singh S, Marwah N, Kumar S, Chabra S, Sen R. HER-2/neu expression in lesions of uterine cervix: Is it reliable and consistent?. Indian J Pathol Microbiol 2009;52:482-5
|How to cite this URL:|
Gupta N, Singh S, Marwah N, Kumar S, Chabra S, Sen R. HER-2/neu expression in lesions of uterine cervix: Is it reliable and consistent?. Indian J Pathol Microbiol [serial online] 2009 [cited 2014 Aug 1];52:482-5. Available from: http://www.ijpmonline.org/text.asp?2009/52/4/482/56127
| Introduction|| |
Carcinoma of uterine cervix is the most prevalent cancer amongst Indian females.  The role of oncogenes in the development and prognosis of various cancers is a subject of intense investigation. The development of cancer is a multifactorial process which includes the sequential activation of oncogenes and other genetic derangements. 
The c-erbB-2 proto-oncogene, also called neu and HER-2/neu, is a gene localized on Chromosome 17q21 that encodes a growth factor receptor-like molecule with tyrosine kinase activity and has a structure similar to that of epidermal growth factor receptor. ,, Its expression has been detected in several human cancers and is believed to be associated with poor prognosis, aggressive biological behavior and metastatic potential.  The present study was conducted to evaluate the presence of c-erbB-2 in lesions of the uterine cervix, its pattern of expression and correlation with histological type, grade of tumor and clinical stage, wherever possible.
| Materials and Methods|| |
A total of 100 cases of cervical tissue obtained from hysterectomy specimens or cervical biopsies were included in the present study. The study comprised 25 cases of benign lesions of cervix, 10 cases of cervical intraepithelial neoplasia (CIN) and 65 cases of carcinoma cervix. Among malignant lesions, 48 cases were of squamous cell carcinoma, 13 cases were of adenocarcinoma and four cases were of adenosquamous carcinoma. Benign epithelial lesions included chronic cervicitis (15 cases), chronic cervicitis with squamous metaplasia (five cases) and endocervical polyp (five cases). On the basis of international federation of obstetricians and gynaecologists FIG O guidelines squamous cell carcinoma was graded as well-differentiated, moderately differentiated and poorly differentiated carcinoma.
Immunohistochemistry was performed on 3-4m-thick sections taken on poly-L-lysine-coated slides. Antigen retrieval was performed by heating the sections in citrate-buffer at pH 6.0 using microwave oven. Monoclonal antibody NCL-CB11 (Novocastra Laboratories) was used for HER-2/neu detection in 1:40 dilution by standard streptovidin-biotin peroxidase method. A positive reaction was taken as crisp golden brown membranous and cytoplasmic staining. Intensity of staining was graded as per the food and drug administration (FDA) scoring system as strong, complete membrane staining in more than 10% of malignant cells (3+); week to moderate complete staining in more than 10% of malignant cells (2+); no or fewer than 10% cells staining (0 to 1+) respectively.  Statistical analysis of data was performed using Fischer's-Exact Test. P value <0.05 was taken as statistically significant.
| Results|| |
A total of 60 cases exhibited epithelial staining for HER-2 oncoprotein which included 63% (41 of 65) cases of invasive carcinoma cervix, 60% (6 of 10) cases of cervical intraepithelial neoplasia and 52% (13 of 25) cases of benign epithelial lesions. Stroma was negative in all the cases.
Amongst the invasive carcinomas of the cervix, 26 (54.10%) cases of squamous cell carcinoma, 11 (84.61%) cases of adenocarcinoma and four (100%) cases of adenosquamous carcinoma exhibited positivity for the oncoprotein. These malignancies exhibited a variable degree [Figure 1], [Figure 2] of expression of HER-2 oncoprotein [Table 1] with significantly higher expression in high-grade squamous cell carcinomas [Table 2]. Of the 25 cases of benign epithelial lesions, most of the cases exhibited no or faint (1+) staining , except for three cases of endocervical polyp and one case of chronic cervicitis [Figure 3] which exhibited moderate (2+) intensity of staining. Cases of squamous metaplasia were negative for HER-2 expression.
A significant correlation was also exhibited between positive HER-2 expression and higher clinical stage of presentation [Table 3]. HER-2 expression was significantly higher in lymph node-positive cases than lymph node-negative cases, particularly in cases of squamous cell carcinoma [Table 3] and [Table 4]. HER-2 expression was also significantly high in cases of invasive squamous cell carcinoma presenting with parametrial extension. But no such relation was observed in cases of adenocarcinoma and carcinoma cervix with glandular differentiation [Table 3] and [Table 4].
| Discussion|| |
Cancer of the uterine cervix, the most prevalent cancers among the Indian females is an important cause of morbidity and mortality among women.  Currently, one of the oncogenes, c-erb-2/HER-2, thought to be associated with various tumors of the breast, ovary, endometrium, cervix, Fallopian tube More Details etc, is being studied extensively.  The exact function of HER-2/neu gene product is still unknown but it has tyrosine kinase activity and is thought to function as receptor for growth-regulating molecule. Over-expression and/or mutation of HER-2/neu results in quantitative and qualitative alteration in the membrane proteins which is the basis of its detection. , Although clinical correlation had not been firmly established, many series had suggested that amplification or over-expression of the oncogene might be a marker of poor prognosis in cancers of the ovary, endometrium, breast etc. ,, There have been reports in the literature that c-erbB-2 over-expression correlates with reduced benefit of adjuvant therapy as in cases of carcinoma breast with tamoxifen therapy. , Many studies have convincingly shown that regression of c-erbB-2 suppresses the malignant phenotypes of cancer cells over-expressing this oncoprotein, which may serve as an excellent target for developing anti-cancer agents specific for c-erbB-2 over- expression.  HER-2 over-expression can be estimated either by immunohistochemistry or by fluorescent in situ hybridization (FISH). However, some authors stress that the cases with moderate intensity (2+) staining require complementary FISH, to verify gene amplification. This combination is not necessary for low (0-1+) or high (3+) grades of immunohistochemical stain because the correlation with gene amplification status is acceptably high. 
In the light of the literature and controversy that exists regarding the expression of HER-2 in various disorders of the uterine cervix, this study was planned to compare the expression of HER-2 in cervical lesions among the women in this region of the country. In our study 63% cases of carcinoma cervix showed definite membranous staining for c-erbB-2 oncoprotein and these included squamous cell carcinoma (54.1%), adenocarcinoma (84.61%), adenosquamous carcinoma (100%) and CIN (60%). It was also observed that the positivity rate varied with differentiation and staging, lymph node metastasis and parametrial extension status. Poorly differentiated squamous cell carcinoma showed 80% positivity [Table 2] whereas positivity rate was 87.5% and 100% in case of Stage-III and IV tumors [Table 3]. Cases with lymph node metastasis revealed 92.86% positivity whereas with parametrial extension revealed 71.88% positivity [Table 3]. Out of 14 cases of lymph node metastasis, squamous cell carcinoma (11 cases) and adenocarcinoma (three cases) showed c-erbB-2 positivity rate of 90.9% and 100% respectively. There were 32 cases of parametrial extension of which HER-2 was positive in squamous cell carcinoma (67.86%), adenocarcinoma (100%), adenosquamous carcinoma (100%) [Table 4]. Thus, our study correlates well with several other studies  on expression of HER-2 in uterine lesion but with variable rates.
On careful study of the literature available, it was observed that the studies designed to examine HER-2 in lesions of the uterine cervix produced inconsistent results. HER-2 positive staining in invasive carcinoma cervix ranged from 14-100% in various studies. ,, Similarly, large variability was also observed in various types of carcinomas, lymph node metastasis and parametrial extension. Several articles on uterine lesions suggest HER-2 positivity is directly related with higher grade and more aggressive tumor, and having poor prognosis. , There are also reports revealing that over-expression/amplification of HER-2/neu is uncommon in invasive cervical carcinoma and expression of the oncogene does not appear to be related to prognosis or treatment outcome. , Thus, there are contradictory reports on expression of HER-2/neu and prognosis in various uterine lesions which may either be due to heterogeneity of lesions or technical problem with antigen retrieval. HER-2/neu has a complex activation pathway and its expression is controlled not only by the degree of gene amplification but also by several other factors like gene receptor alteration and rate of gene transcription, which help in tyrosine kinase activation leading to cellular transformation.  However, cellular proliferation may be inhibited either by a monoclonal antibody directed towards HER-2/neu receptor's extracellular domain (ECD) or message truncation ,secondary to alternate splicing of receptor mRNA.. Steroid hormones can also modulate gene expression by direct binding of hormone receptor complexes to specific DNA regulating sites. , It is quite evident that modification in any of these factors can alter the over-expression of HER-2/neu, thus altering the positivity rates on immunostaining in various malignant neoplasms including carcinoma cervix. Whether or not these factors are associated with the prognosis, is a matter of further investigation.
| Conclusion|| |
The data emphasize the importance of continued basic and transitional research on the HER family of receptors in cervical lesions. The high incidence of HER-2/neu amplification in cervical cancer suggests the role of this gene in tumorigenesis. Thus, a detailed study of various factors associated with HER-2/neu over-expression and its positivity rates in various tumors is required to resolve the issue of discrepancies in relation to c-erbB-2 expression.
| References|| |
|1.||Shanta V, Krishnamurthi S, Gajalakshmi CK, Swaminathan R, Ravichandran K. Epidemiology of cancer of the cervix:global and national perspective. J Indian Med Assoc 2000;98:49-52. |
|2.||Hung MC, Matin A, Zhang Y, Xing X, Sorgi F, Huang L, et al. HER-2/neu-targeting gene therapy-a review. Gene 1995;159:65-71. |
|3.||Ray A, Naik SL,Sharma BK. Distribution of prognostically unfavourable product of C-erb B-2 oncogene and EGFR in carcinomas of the breast and uterine cervix. Indian J Physiol Pharmacol 2002;46:423-33. |
|4.||Popescu NC, King CR, Kraus MH. Localisation of human erb B-2 gene on normal and rearrange chromosome 17 to band q12-21.32. Genomics 1989;4:362-6. |
|5.||Bargmann CI, Hung MC, Weinberg RA. The Neu oncogene encodes an epidermal growth growth factor receptor-related protein. Nature 1986;319:226-30. |
|6.||Nevin J, Laing D, Kaye P, McCulloch T, Barnard R, Silcocks P, et al.The significance of Erb-b2 immunostaining in cervical cancer. Gynecol Oncol 1999;73:354-8. |
|7.||Brunelli M, Manfrin E, Martignoni G, Bersani S, Remo A, Reghellin D, et al. HER-2/neu assessment in breast cancer using the original FDA and New ASCO/CAP guideline recommendations.Impact on selecting patients for Herceptin therapy. Am J Clin Pathol 2008;129:907-11. |
|8.||Cirisano FD, Karlan BY. The role of HER-2/neu oncogene in gynecologic cancers. J Soc Gynecol Investig 1996;3:99-105. |
|9.||Borg A,Tandon AK, Sigurdsson H, Clark GM, Fernφ M, Fuqua SA, et al. HER-2/neu amplification predicts poor survival in node-positive breast cancer. Cancer Res 1990;50:4332-7. |
|10.||Tsuda H, Hirohashi S, Shimosato Y, Tanaka Y, Hirota T, Tsugane S, et al. Immunohistochemical study on over expression of C-erb B2 protein in human breast cancer.Its correlation with gene amplification and long term survival of patients. Jpn J Cancer Res 1990;81:327-32. |
|11.||Berchuck A, Kamel A,Whitaker R, Olt G, Kinney R, Soper JT, et al.Overexpression of HER-2/neu is associated with poor survival in advanced epithelial ovarian cancer. Cancer Res 1990;50:4087-91. |
|12.||Helzel DJ, Wilson TO, Keeney GL, Roche PC, Cha SS. HER-2/neu expression. A major prognostic factor in endometrial cancer. Gynecol Oncol 1992;47:179-85. |
|13.||Rosen PP, Lesser ML, Arroyo CD, Cranor M, Borgen P, Norton L. Immunohistochemical detection of HER-2/neu in patients with axillary lymph mode negative breast carcinoma.A study of epidemiologic risk factors,histlogic features,and prognosis. Cancer 1995;75:1320-6. |
|14.||Tetu B, Brisson J. Prognostic significance of HER-2/neu oncoprotein expression in node positive breast cancer. The influence of the pattern of immunostaining and adjuvant therapy. Cancer 1994;73:2359-65. |
|15.||Ravdin PM. Should HER-2 status be routinely measured for all breast cancer patients ?. Semin Oncol 1999;26:117-23. |
|16.||Hung MC, Lau YK. Basic science of HER-2/neu: A review. Semin Oncol 1999;26:57-9. |
|17.||Bαnkfalvi A. HER-2 diagnostics. Magy Onkol 2002;46:11-5. |
|18.||Mandai M, Konishi I, Koshiyama M, Komatsu T, Yamamoto S, Nanbu K, et al. Altered expression of nm23-H1 and c-erb B-2 proteins have prognostic significance in adenocarcinoma but not in squamous cell carcinoma of the uterine cervix. Cancer 1995;75:2523-9. |
|19.||Mitra AB, Murty VV, Pratap M, Sodhani P, Chaganti RS. EBBB2 (HER-2/neu) oncogene is frequently amplified in squamous cell carcinoma of uterine cervix. Cancer Res 1999;54:637-9. |
|20.||Berchuck A, Rodriguez G, Kamel A, Soper JT, Clarke-Pearson DL, Bast RC Jr. Expression of epidermal growth factor receptor and HER-2/neu in normal and neoplastic cervix, vulva and vagina. Obstet Gynecol 1990;76:381-7. |
|21.||Nakano T, Oka K, Ishikawa A, Morita S. Correlation of cervical carcinoma C-erb B-2 oncogene with cell proliferation parameters in patients treated with radiation therapy on cervical carcinoma. Cancer 1997;79:513-20. |
|22.||Niibe Y, Nakano T, Ohno T, Suzuki Y, Oka K, Tsujii H. Prognostic significance of C-erb B-2/HER2 expression in advanced uterine cervical carcinoma with para-aortic lymph node metastasis treated with radiation therapy. Int J Gynecol Cancer 2003;13:849-55. |
|23.||Rosty C, Couturier J, Vincent-Salomon A, Genin P, Frιneaux P, Sigal-Zafrani B, et al. Overexpression/amplification of HER-2/neu is uncommon in invasive carcinoma of the uterine cervix. Int J Gynecol Pathol 2004;23:13-7. |
|24.||Califano D, Losito S, Pisano C, Santelli G, Greggi S, Iodice F, et al. Significance of erb-B2 immunoreactivity in cervical cancer. Front Biosci 2006;1:2071-6. |
|25.||Cirisano FD, Karlan BY. The role of HER-2/neu oncogene in gynecologic cancers. J Soc Gynecol Investig 1996;3:99-105. |
|26.||Scott GK, Robles R, Park JW, Montgomery PA, Daniel J, Holmes WE, et al. A truncated intracellular HER-2/neu receptor produced by alternative RNA processing affects growth of human carcinoma cells. Mol Cel Biol 1990;3:2247-57. |
|27.||Bosher JM, Williams T, Hurst HC. The developmentally regulated transcription factor AP-2 is involved in C-erb B-2 overexpression in human mammary carcinoma. Proc Natl Acad USA 1995;92:744-7. |
4\9J, Medical Enclave, PGIMS, Rohtak-124 001, Haryana
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]