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Year : 2012  |  Volume : 55  |  Issue : 1  |  Page : 33-37
The expression of immunohistochemical markers estrogen receptor, progesterone receptor, Her-2-neu, p53 and Ki-67 in epithelial ovarian tumors and its correlation with clinicopathologic variables

1 Department of Pathology, JIPMER, Puducherry, India
2 Department of Obstetrics and Gynecology, JIPMER, Puducherry, India

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Date of Web Publication11-Apr-2012


Background: This study aims to evaluate the expression of estrogen receptor alpha (ER α), progesterone receptor A (PRA), Her-2-neu, p53, and Ki-67 in epithelial ovarian tumors and their correlation with various clinicopathologic variables. Materials and Methods: This study included 60 consecutive cases of epithelial ovarian tumors. Sections of 4 μm were taken from paraffin embedded tissue blocks for immunohistochemistry (IHC). Statistical analysis was done using Chi square test, ANOVA. Results: ER α had lower expression in benign (29%) and PRA higher expression in malignant (63.6%) tumors. ERα, PRA had higher expression in serous (72.72%, 57.14%), postmenopausal (81.8%, 71.42%), advanced stage (63.63%, 52.38%), grade 3 (45.45%, 38.09%), and tumors with ascites (90.90%, 85.7%). Her-2-neu, p53 were negative in benign and higher in malignant (21%, 57.6%), serous (71.42%, 57.89%), grade 3 (57.14%, 31.57%), and tumors with ascites (85.7%, 84.21%). Ki-67 had a significant higher expression in malignant (48.6± 26.76), serous (55.43± 27.85), and grade 3 tumors (68 ± 22). CA-125 levels were significantly higher in malignant, serous, advanced stage, grade 3 and ER α, Her-2-neu and p53 positive tumors. Conclusion: ERα, PRA expression in tumors with adverse prognostic factors support the mitogenic role of estrogen and estrogenic regulation of PR. Her-2-neu and p53 expression only in malignant tumors suggest their carcinogenic role and aid in the differentiation of borderline and malignant tumors. Higher Ki-67 in tumors with adverse prognostic factors would help in prognostication and differentiation. Lack of co-expression of markers proves the extreme heterogeneity of ovarian tumors. These markers may aid in differentiation and prognostication of ovarian tumors.

Keywords: Epithelial ovarian tumors, Her-2-neu, Ki-67, p53, steroid receptors

How to cite this article:
Sylvia MT, Kumar S, Dasari P. The expression of immunohistochemical markers estrogen receptor, progesterone receptor, Her-2-neu, p53 and Ki-67 in epithelial ovarian tumors and its correlation with clinicopathologic variables. Indian J Pathol Microbiol 2012;55:33-7

How to cite this URL:
Sylvia MT, Kumar S, Dasari P. The expression of immunohistochemical markers estrogen receptor, progesterone receptor, Her-2-neu, p53 and Ki-67 in epithelial ovarian tumors and its correlation with clinicopathologic variables. Indian J Pathol Microbiol [serial online] 2012 [cited 2023 Jun 7];55:33-7. Available from:

   Introduction Top

Each year, over 22,000 women are diagnosed worldwide with epithelial ovarian cancer and 15,000 die of it. [1] The etiology and pathogenesis are still poorly understood. The overall prognosis is poor with current treatment modalities. In the absence of definite etiologic factors and effective tools of screening, the only possible means of improving survival would be to develop effective targeted therapy. This requires a complete understanding of the pathogenesis of the tumors.

Ovarian tumors are heterogenous. Insight into their pathogenesis requires understanding of the mutations involved, overexpression of oncogenes and role of cell cycle regulators. There have been persistent efforts in the investigation of molecular markers in epithelial ovarian tumors, but the results are controversial.

The aims of this study were to evaluate the expression of five common molecular pathways namely estrogen receptor alpha (ER α), progesterone receptor A (PRA), Her-2-neu, p53, and Ki-67 by immunohistochemistry (IHC) and to compare it with clinicopathologic prognostic factors of ovarian tumors namely age, histological type, tumor grade, stage, CA-125 levels and the presence of ascites.

   Materials and Methods Top

This study included 60 consecutive cases of epithelial ovarian tumors received in the Department of Pathology from August 2009 to July 2011. The hematoxylin and eosin stained sections from the tumor specimens were studied. Representative 4 μm sections were taken from paraffin embedded tissue blocks for IHC which was performed according to heat induced epitope retrieval method with specific antibodies against ERα, PRA, Her-2-neu, p53, and Ki-67. CA-125 levels and clinical details were collected from the case records. Informed consent was obtained from all the participants. Statistical analysis was done by Chi square, Kruskal Wallis, and ANOVA (analysis of overall variance) tests using Statistical Package for Social Sciences (SPSS) software (Version 16)

   Results Top

Among the 60 cases, 33 cases were malignant 55%, 17 (28%) benign, and 10 (17%) borderline tumors. The median age of patients was higher in malignant tumors (50 years) as compared to benign and borderline tumors (40 years). Serous tumors were the most common type [Figure 1]. The tumor characteristics are shown in [Table 1] and [Table 2]. Ascites was present in 26 of the 33 malignant cases.
Figure 1: Gross specimen of papillary serous cystadenocarcinoma

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Table 1: Tumor characteristics

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Table 2: Grade and stage of malignant cases (n=33)

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Expression Profile of Immunohistochemical Markers

ERα and PRA expression

Expression of ERα was low in benign tumors (5/17cases, 29%) compared to malignant (11/33 cases, 33%) and borderline (4/10 cases, 40%). Serous tumors were the most common type in all three groups [Figure 2]. Mucinous tumors, clear cell carcinoma, and mixed tumors were negative for ERα.

PRA showed marginally higher expression in malignant cases (63.6%, 21 cases) [Figure 3] compared to borderline (60%,6 cases) and benign tumors (41.2%,7 cases). In PRA+ malignant tumors, 57.14% of the cases were serous, 14.28% were endometrioid, and 14.28% were mucinous. Clear cell carcinoma was negative.
Figure 2: Malignant serous tumor with strong ER positivity (IHC, ×100)

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Figure 3: Malignant serous tumor with strong PR positivity (IHC, ×100)

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Her-2-neu, p53 expression

Her-2-neu was negative in all benign tumors. Of the malignant tumors, 7 cases (21%) were positive (5 serous,1 mucinous, and 1 clear cell) [Figure 4]. p53 had higher positivity in malignant tumors (57.6%, 19 cases) (P=0.08, Chi square value-2.96) [Figure 5] with the majority being serous tumors (57.89%, 11 cases). Of the borderline tumors, 2 cases (20%) were positive. All the benign tumors were negative for p53. Mixed endometrioid, mucinous and clear cell carcinomas were negative for p53 and Her-2-neu.
Figure 4: Strong 3+ Her-2-neu positivity in Grade 3 serous tumor (IHC, ×400)

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Figure 5: Malignant serous tumor with strong p53 positivity (IHC, ×100)

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Ki-67 index

Proliferation index was highest in malignant tumors (mean=48.6, SD=26.76) followed by borderline tumors (23.2 ± 21.55), and the lowest in benign tumors (2.17 ± 1.38). The difference between malignant and the other two groups was statistically significant (P<0.05, F = 26.26).

In malignant group, serous tumors had high index of 55.43% followed by endometrioid (50%), and the lowest in mucinous tumors (26.12%).

Association of Expression of Markers with Clinicopathologic Variables

ERα and PRA had a statistically significant higher expression in women with age >50 years (P<0.05) as compared to other markers [Table 3]. ERα and PRA expression were similar among all three grades and stages.
Table 3: Association of marker expression with age

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Analysis of CA-125 Levels

Levels of CA-125 were available for all benign, borderline and 29 of 33 malignant tumors. With a cut off point of 35 IU/ml for detecting malignant epithelial ovarian tumors, sensitivity was 73% and specificity was 99%. The levels were significantly higher in malignant tumors (275.46 IU/ml). Serous tumors had higher median levels (379.35 IU/ml). Median CA-125 levels were significantly increased in high grade (P=0.29) and advanced tumors (P=0.21) [Table 4]. CA-125 levels did not have a significant correlation with proliferation index.
Table 4: CA 125levels in relation to tumour grade and stage

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Association Between Markers

Of the malignant tumors, 27.3% were ERα+PRA+ and 15% were ERα+p53+. Co-expression of Her-2-neu was more with PRA (4 cases) as compared to ERα (1 case). With regard to p53, PR were co-expressed in 42.42% of cases were p53+PRA+ and 18.18% of cases were p53+Her-2-neu+. There was no significant association between the markers.

Triple Negative Tumors

Of the 33 malignant tumors, 8 cases (24.24%) were triple negative tumors (ERα-, PRA- and Her-2-neu-). Among the eight cases, six were serous, and one case each in mucinous and endometrioid tumor. There were no grade 3 tumors. Advanced stage tumors consisted of three cases with the rest being in early stage. p53 was positive in four cases. The mean Ki-67 index of tumors was 51± 24. Mean CA-125 levels were lower in these tumors (39.2 IU/ ml) as compared to the non triple negative tumors (348 IU/ml).

   Discussion Top

Malignant tumors were the most common with serous carcinomas being the predominant type as previously reported.

ERα expression was higher in borderline and malignant tumors as compared to benign cases which similar to the findings of Damiao et al. [4] Agarwal et al. [5] had reported that benign tumors were negative for steroid receptors and that serous tumors had more expression as compared to mucinous tumors. Serous tumors, age >50 years, tumours with ascites and higher CA-125 levels had higher expression of ERα similar to previous studies [5] suggesting a mitogenic role for estrogen. Buchynska et al. [6] demonstrated that higher grade tumors had lower ERα expression. This is in contrast to our study which showed the similar expression in low grade and high grade tumors.

Clear cell and mucinous are genetically and epidemiologically distinct cancers and are among the least likely to express ERα and PR. [3]

In contrast to previous studies, [7] PRA expression was similar to ERα, with higher expression in malignant, serous tumors, postmenopausal age group, advanced stage, and grade 3 tumors. This is in contrast to the study by Lau et al. [8] who found a decrease in PRA expression with grade 3 and advanced stage tumors. CA-125 levels were low in PRA positive tumors. PRA expression had significant association with postmenopausal age group. This is in contrast to many of previous studies, in particular the study by Hecht et al. [7] Thus, PRA may also play a carcinogenic role or rather PR is regulated by estrogen and therefore a high PR content in conjunction with high ER expression is likely to be indicative of estrogen-regulated disease. [9],[10]

Her-2-neu was negative in all grade 1 tumors and all benign cases, higher in grade 2 and 3 tumors in concordance to previous studies. [11] Most of these tumors had higher association with ascites suggesting an aggressive tumor type and advanced stages which is similar to the study by Hellstrom et al. [11] p53 was negative in all benign tumors but positive in half of malignant cases. This is in concordance with previous studies which showed mutation in or inactivation of p53 in 46% [12] of invasive ovarian tumors, but in only 8% of borderline (low malignant potential) tumors and virtually nonexistent in benign tumors or normal ovarian epithelium. [13]

Malignant tumors, serous group, and grade 3 tumors had significant higher proliferation index similar to previous results. [14]

Though CA-125levels were maximum in malignant tumors, 27.56% cases had normal CA-125 levels which were predominantly early stage tumors. Zorn et al. [15] have showed that 7.6% of patients with malignant tumors have normal levels.

Triple negative tumors occur in advanced age and have aggressive course with poor prognosis according to literature. [16] However, in our study, these tumors were more common in younger age group, were of lower grade and stage, and were serous tumors with a lower CA-125 levels.

   Conclusion Top

ERα expression in tumors with adverse prognostic factors supports the mitogenic role of estrogen in ovarian tumors. Similar pattern of PRA expression may be related to the estrogenic regulation of PR and the complex interaction between the steroid receptors which further needs to be analyzed. The expression of steroid receptors paves way for anti hormonal therapy. Her-2-neu and p53 were expressed only in malignant tumors suggesting their carcinogenic role and help in the differentiation of borderline and malignant tumors. Ki-67 index was higher in tumors with adverse prognostic factors. Hence, it would help in prognostication and differentiation of the three morphological types. CA125 levels reflect the tumor bulk and the median levels were higher in tumors with adverse prognostic factors. There was no significant co-expression of the markers proving the extreme heterogeneity of ovarian tumors. Thus, a panel of these markers would help in the differential diagnosis of borderline and malignant cases, prognostication of ovarian tumors and the development of targeted therapy.

   Acknowledgment Top

Dr. Hari Chandra Kumar, Department of Biostatistics, JIPMER.

   References Top

1.Jernal A, Siegel R, Ward E, Hao Y, Xu J, Thun MJ, et al. Cancer statistics 2009. Cancer J Clin 2009;59:225-49.  Back to cited text no. 1
2.Reles A, Wen WH, Schmider A, Gee C, Runnebaum IB, Kilian U, et al. Correlation of p53 mutations with resistance to platinum based chemotherapy and shortened survival in ovarian cancer. Clin Cancer Res 2001;7:2984-97.  Back to cited text no. 2
3.William E, Winter, Maxwell L, Tian C, Carison JW, Ozols RF, et al. Prognostic factors for stage 3 epithelial ovarian cancer: A gynecologic oncology group study. J Clin Oncol 2007;25:3621-7.  Back to cited text no. 3
4.Damiao RD, Oshima CT, Stavale JN, Goncalves WJ. Analysis of the expression of estrogen receptor, progesterone receptor and chicken ovalbumin upstream promoter transcription factor I in ovarian epithelial cancers and normal ovaries. Oncol Rep 2007;18:25-32.  Back to cited text no. 4
5.Agarwal N, Rao DL, Murgeshan K, Verma U, Mittal S, Buckshee K. Clinical evaluation of steroid receptors in ovarian neoplasms. Int J Gynecol Obstet 1987;25:145-9.  Back to cited text no. 5
6.Buchynska LG, Iurchenko NP, Grinkevych VM, Nesina IP, Chekhun SV, Svintsitsky VS. Expression of the estrogen and progesterone receptors as prognostic factor in serous ovarian cancers. Exp Oncol 2009;31:48-51.  Back to cited text no. 6
7.Hecht JL, Kotsopoulos J, Hankinson SE, Tworoger SS. Relationship between Epidemiologic Risk Factors and Hormone Receptor Expression in Ovarian Cancer: Results from the Nurses Health Study. Cancer Epidemiol Biomarkers Prev 2009;18:1624-30.  Back to cited text no. 7
8.Lau KM, Mok SC, Ho SM. Expression of human estrogen receptor-A and -B, progesterone receptor, and androgen receptor mRNA in normal and malignant ovarian epithelial cells. Proc Natl Acad Sci 1999;96:5722-7.  Back to cited text no. 8
9.Lazennec G, Bresson D, Lucas A, Chauveau C, Vignon F. ERβ inhibits proliferation and invasion of breast cancer cells. Endocrinology 2001;142:4120-30.  Back to cited text no. 9
10.Miller WR, Anderson TJ, Dixon JM. Antitumour effects of letrozole. Cancer Invest 2002;20:15-21.  Back to cited text no. 10
11.Hellstrom I, Goodman G, Pullman J, Yang Y, Hellstrom KE. Overexpression of Her-2 in ovarian carcinomas. Cancer Res 2001;61:2420-3.  Back to cited text no. 11
12.Levesque MA, Katsaros D, Yu H, Zola P, Sismondi P, Giardiana G, et al. Mutant p53 protein expression is associated with poor outcome in patients with well or moderately differentiated ovarian carcinoma. Cancer 1995;75:1327-38.  Back to cited text no. 12
13.Berchuck A, Kohler MF, Hopkins MP, Humphrey PA, Robboy SJ, Rodriguez GC, et al. Overexpression of p53 is not a feature of benign and early-stage borderline epithelial ovarian tumours. Gynecol Oncol 1994;52:232-6.  Back to cited text no. 13
14.Huettner PC, Weinberg DS, Large JM. Assesment of proliferative activity in ovarian neoplasms by flow and static cytometry. Correlation with prognostic features. Am J Pathol 1992;141:699-706.  Back to cited text no. 14
15.Zorn KK, Tian C, McGuire WP, Hoskins WJ, Markman M, Muggia FM, et al. The prognostic value of pretreatment CA 125 in patients with advanced ovarian carcinoma. A Gynecologic Oncology Group Study. Cancer 2009;1028-35.  Back to cited text no. 15
16.Liu N, Wang X, Sheng X. The clinicopathological characteristics of triple negative epithelial ovarian cancer. J Clin Pathol 2010;63:240-3.  Back to cited text no. 16

Correspondence Address:
Surendra Kumar
Department of Pathology, JIPMER, Korimedu, Puducherry
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0377-4929.94852

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

  [Table 1], [Table 2], [Table 3], [Table 4]

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