The significance of Erb-b2 immunostaining in cervical cancer

Prevalence of HER2 overexpression and amplification in cervical cancer: A systematic review and meta-analysis

The reported rates of HER2 positivity in cervical cancer (CC) range from 0% to 87%. The importance of HER2 as an actionable target in CC would depend on HER2 positivity prevalence. Our aim was to provide precise estimates of HER2 overexpression and amplification in CC, globally and by relevant subgroups. We conducted a PRISMA compliant meta-analytic systematic review. We searched Medline, EMBASE, Cochrane database, and grey literature for articles reporting the proportion of HER2 positivity in CC. Studies assessing HER2 status by immunohistochemistry or in situ hybridization in invasive disease were eligible. We performed descriptive analyses of all 65 included studies. Out of these, we selected 26 studies that used standardized American Society of Clinical Oncology / College of American Pathologists (ASCO/CAP) Guidelines compliant methodology. We conducted several meta-analyses of proportions to estimate the pooled prevalence of HER2 positivity and subgroup analyses using geographic region, histology, tumor stage, primary antibody brand, study size, and publication year as moderators. The estimated pooled prevalence of HER2 overexpression was 5.7% (CI 95%: 1.5% to 11.7%) I2 = 87% in ASCO/CAP compliant studies and 27.0%, (CI 95%: 19.9% to 34.8%) I2 = 96% in ASCO/CAP non-compliant ones, p < 0.001. The estimated pooled prevalence of HER2 amplification was 1.2% (CI 95%: 0.0% to 5.8%) I2 = 0% and 24.9% (CI 95%: 12.6% to 39.6%) I2 = 86%, respectively, p = 0.004. No other factor was significantly associated with HER2 positivity rates. Our results suggest that a small, but still meaningful proportion of CC is expected to be HER2-positive. High heterogeneity was the main limitation of the study. Variations in previously reported HER2 positivity rates are mainly related to methodological issues.

Role of HER-2/neu in Premalignant and Malignant Lesions of Uterine Cervix

Introduction

In light of literature and controversy that exists in various cervical lesions, this prospective study was designed to explore the expression of Human Epidermal Growth Factor Receptor-2 (HER-2/neu) in the cervical lesions and its correlation with the histopathological grade and type of tumour. Immunohistochemistry (IHC) was performed to evaluate HER-2/neu expression as it is the most reliable method of detecting overexpression of HER-2/neu.

Aim

To assess the role of HER-2/neu expression in premalignant and malignant lesions of uterine cervix.

Materials and Methods

Seventy cases of premalignant and malignant cervical lesions received in our department from January 2015 to December 2016, were included in study and Polyclonal Rabbit Anti-Human c-erbB-2 oncoprotein from DAKO was used. Standard streptovidin-biotin peroxidase method of IHC was followed. A golden brown membrane and cytoplasmic staining was taken as a positive reaction and intensity of expression was graded according to the 2014 ASCO/CAP guidelines for HER-2/neu reporting.

Results

Out of total 70 cases, HER-2/neu expression scores were 0 in 64.3% {23 cases of Cervical Intraepithelial Neoplasia (CIN) and 22 of Squamous Cell Carcinoma (SCC)}, +1 in 22.9%, (04 cases of CIN and 12 of SCC) +2 in 10% (06 cases of SCC and 01 of adenosquamous carcinoma) and +3 in 2.9% (02 cases of adenocarcinoma) cases. HER-2/neu overexpression rate was significantly higher in malignant (48.8%) as compared to pre malignant (14.8%) cases (p=0.004) and expression scores were higher (+2 and +3) in 20.9% of malignant cases as compared to none of pre malignant cases (p=0.020). Significant higher HER-2/neu scores are seen (+2 and +3) in all the adenocarcinoma cases as compared to 15% cases of SCC (p<0.001). Among malignant cases, HER-2/neu expression was statistically significantly higher in {Moderately Differentiated (MD) + Poorly Differentiated (PD)} 59.09% as compared to {Well Differentiated (WD)} 38.09% cases (p=0.090).

Conclusion

Study shows that expression of HER-2/neu is relatively lower in cervical lesions. However, the results of our study show that with shift from well to poorly differentiated lesions; the HER-2/neu expression rate shows an incremental trend.

Emerging biological treatments for uterine cervical carcinoma

Cervical cancer is the third most common cancer worldwide, and the development of new diagnosis, prognostic, and treatment strategies is a major interest for public health. Cisplatin, in combination with external beam irradiation for locally advanced disease, or as monotherapy for recurrent/metastatic disease, has been the cornerstone of treatment for more than two decades. Other investigated cytotoxic therapies include paclitaxel, ifosfamide and topotecan, as single agents or in combination, revealing unsatisfactory results. In recent years, much effort has been made towards evaluating new drugs and developing innovative therapies to treat cervical cancer. Among the most investigated molecular targets are epidermal growth factor receptor and vascular endothelial growth factor (VEGF) signaling pathways, both playing a critical role in cervical cancer development. Studies with bevacizumab or VEGF receptor tyrosine kinase have given encouraging results in terms of clinical efficacy, without adding significant toxicity. A great number of other molecular agents targeting critical pathways in cervical malignant transformation are being evaluated in preclinical and clinical trials, reporting preliminary promising data.

In the current review, we discuss novel therapeutic strategies which are being investigated for the treatment of advanced cervical cancer.

Demonstration of her-2 protein in cervical carcinomas

OBJECTIVE.: Recently, an immunohistochemical test for her-2-neu has been approved by the Food and Drug Administration for evaluation of breast cancer patients who might benefit from treatment with Herceptin (HercepTest). This study was undertaken to evaluate the immunohistochemical staining patterns in cervical cancer and correlate with clinical parameters. MATERIALS AND METHODS.: A total of 24 cases of invasive squamous cell carcinoma of the cervix were evaluated. Cases were stained using the HercepTest kit according to protocol. Results were graded from 0 to 3+, using the standards set for breast lesions. RESULTS.: A total of 17 cases (70.8%) were negative, 3 cases (12.5%) showed 1+ staining, and 4 cases (16.7%) showed 2+ staining. No cases showed 3+ staining. Higher her-2 staining grade correlated strongly with vaginal margin status. A weak positive correlation was seen between her-2 staining and tumor stage. There was no correlation with tumor grade or histological lymph node status. CONCLUSIONS.: A subset of invasive squamous cell carcinomas of the cervix overexpress her-2 protein. Further studies are needed to correlate with clinical outcome and determine if overexpression of her-2 protein is a marker of cervical carcinoma aggressiveness.

Molecularly targeted therapies in cervical cancer. A systematic review

Cervical cancer represents the third most common cause of female cancer mortality. Even with the best currently available treatment, a significant proportion of patients will experience recurrence and eventually die. Evidently, there is a clear need for the development of new agents with novel mechanisms of action in this disease. A number of biological agents modulating different signal transduction pathways are currently in clinical development, inhibiting angiogenesis, targeting epidermal growth factor receptor, cell cycle, histone deacetylases, cyclooxygenase-2 (COX-2), or mammalian target of rapamycin (mTOR). This is the first systematic review of the literature to synthesize all available data emerging from trials and evaluate the efficacy and safety of molecularly targeted drugs in cervical cancer. However, it should be stressed that relatively fewer molecularly targeted agents have been tested in cervical cancer in comparison with other cancer types; of note, no related phase 3 trials have been published and consequently no agent has been approved for use in clinical practice. Nevertheless, the promising results of bevacizumab in therapeutic trials for cervical cancer have shown that targeting the VEGF pathway is an attractive therapeutic strategy. As knowledge accumulates on the molecular mechanisms underlying carcinogenesis in the cervix, the anticipated development and assessment of molecularly targeted agents may offer a promising perspective for cervical cancer.

Stromal issues in cervical cancer: a review of the role and function of basement membrane, stroma, immune response and angiogenesis in cervical cancer development

The carcinogenesis of cervical carcinoma implies an intricate interplay of neoplastic, human papillomavirus infected epithelial cells and stromal tissue, in which different factors have distinct but interacting influence. Persistent infection with an oncogenic human papillomavirus type may lead to epithelial dysplasia with progressive severity. To access the adjacent stromal tissue, tumour cells have to breach the basement membrane. The stroma partly controls tumour growth, invasion and angiogenesis. Last but not least there is considerable influence of the immune response. In this review we describe the importance of various stromal factors in carcinogenesis of cervical cancer.

Upregulation of MUC4 in cervical squamous cell carcinoma: pathologic significance

MUC4 is a transmembrane glycoprotein more highly expressed in cervical dysplasia than benign cervical epithelium. We sought to determine whether MUC4 expression differs between benign and malignant cervical tissue. Fifty-eight patients with benign, dysplastic, or malignant cervical pathology were identified retrospectively, and representative sections were stained with a mouse monoclonal anti-MUC4 antibody. Semiquantitative analysis was performed on benign, dysplastic, and malignant regions by scoring staining intensity (0: negative, 1: weak, 2: moderate, and 3: strong) and distribution (focal <10%, multifocal=10%-60%, diffuse > or =60%). In samples with benign glycogenated squamous epithelium, only the parabasal cells had MUC4 staining, and 48.5% had an intensity of 2 or 3. All samples with immature squamous metaplasia were positive through the entire epithelial thickness. Cervical intraepithelial neoplasia (CIN) 1 samples had variable staining with an intensity similar to glycogenated squamous epithelium but distribution similar to squamous metaplasia. All CIN 3 (n=21) and invasive squamous cell carcinomas (n=17) had increased MUC4 staining intensity (P<0.001 and P<0.001) and increased diffuse staining (P<0.001 and P<0.001) compared with the limited staining in glycogenated squamous epithelium. In contrast, no differences in staining were observed between benign endocervical glands, adenocarcinoma in situ, and invasive adenocarcinoma. These expression patterns suggest that MUC4 is a lineage marker in benign cervical tissue that may have aberrant expression in squamous dysplasia and carcinoma. Further studies may elucidate the role of MUC4 in the development of squamous cell cervical cancer.

EGFR and HER2 expression in primary cervical cancers and corresponding lymph node metastases: implications for targeted radiotherapy

Background

Proteins overexpressed on the surface of tumor cells can be selectively targeted. Epidermal growth factor receptor (EGFR) and human epidermal growth factor receptor 2 (HER2) are among the most often targeted proteins. The level and stability of expression in both primary tumors and corresponding metastases is crucial in the assessment of a receptor as target for imaging in nuclear medicine and for various forms of therapy. So far, the expression of EGFR and HER2 has only been determined in primary cervical cancers, and we have not found published data regarding the receptor status in corresponding metastatic lesions. The goal of this study was to evaluate whether any of these receptors are suitable as target for clinical diagnosis and therapy.

Methods

Expression of EGFR and HER2 was investigated immunohistochemically in both lymph node metastases and corresponding primary cervical cancers (n = 53). HER2 and EGFR expression was scored using HercepTest criteria (0, 1+, 2+ or 3+).

Results

EGFR overexpression (2+ or 3+) was found in 64% (35/53) of the primary cervical tumors and 60% (32/53) of the corresponding lymph node metastases. There was a good concordance between the primary tumors and the paired metastases regarding EGFR expression. Only four patients who had 2+ or 3+ in the primary tumors changed to 0 or 1+ in lymph node metastases, and another two cases changed the other way around. None of the primary tumors or the lymph node metastases expressed HER2 protein.

Conclusion

The EGFR expression seems to be common and stable during cervical cancer metastasis, which is encouraging for testing of EGFR targeted radiotherapy. HER2 appears to be of poor interest as a potential target in the treatment of cervical cancer.

Molecular targets in gynaecological cancers

The application of high throughput expression profiling and other advanced molecular biology laboratory techniques has revolutionised the management of cancers and is gaining attention in the field of gynaecological cancers. Such new approaches may help to improve our understanding of carcinogenesis and facilitate screening and early detection of gynaecological cancers and their precursors. Individualised prediction of patients' responses to therapy and design of personalised molecular targeted therapy is also possible. The studies of various molecular targets involved in the various signal pathways related to carcinogenesis are particularly relevant to such applications. At the moment, the application of detection and genotyping of human papillomavirus in management of cervical cancer is one of the most well established appliances of molecular targets in gynaecological cancers. Methylation, telomerase and clonality studies are also potentially useful, especially in assisting diagnosis of difficult clinical scenarios. This post-genomic era of clinical medicine will continue to make a significant impact in routine pathology practice. The contribution of pathologists is indispensable in analysis involving tissue microarray. On the other hand, both pathologists and bedside clinicians should be aware of the limitation of these molecular targets. Interpretation must be integrated with clinical and histopathological context to avoid misleading judgement. The importance of quality assurance of all such molecular techniques and their ethical implications cannot be over-emphasised.

Overexpression/Amplification of HER-2/neu is Uncommon in Invasive Carcinoma of the Uterine Cervix

The aim of this study was to investigate HER-2/neu (c-erbB2) overexpression/amplification in carcinoma of the uterine cervix using immunohistochemistry and fluorescent in situ hybridization (FISH) to assess whether anti-p185c-erbB2 therapy might have potential benefits in patients with advanced invasive cervical carcinoma. The authors used a protocol for p185c-erbB2 immunohistochemistry (clone CB11) that has been previously calibrated using FISH as the gold standard, showing a 98% accuracy rate in a large series of breast carcinomas. Immunolabeling for p185c-erbB2 was present in 24 of 82 (29%) of the tumors, but only 2 tumors (2%) with a labeling of more than 60% of the cells were considered positive for overexpression. FISH analysis did not find HER-2/neu gene amplification in these cases, although five other tumors showed weak and/or focal immunolabeling. There was no correlation between the presence of immunolabeling and age, histologic type, or clinical stage. Overexpression/amplification of HER-2/neu is uncommon in invasive cervical carcinoma, suggesting that there is little indication for using anti-p185c-erbB2 therapy in the treatment of these patients.

Microinvasive squamous cell carcinoma of the cervix: immunohistochemically detected prognostic factors in a case with poor clinical outcome

BACKGROUND

Established prognostic factors for cervical cancer are tumor stage, vascular space invasion, tumor size/volume, depth of invasion, and lymph node status. Although patients with superficially invasive lesions have a very good prognosis, cases are still reported which have a poor clinical outcome.

CASE

We report a case of a 41-year-old woman with very early stromal invasion (0.6 mm deep and <1 mm wide) who presented with a pelvic recurrence at 3 years and then developed an anterior abdominal wall and disseminated peritoneal recurrence 4 years after extrafascial hysterectomy. Archival tissue of the cone biopsy was stained immunohistochemically for CD44v6, Her2-neu, p53, bcl-2, MMP-1, and VEGF and showed positive staining for CD44v6 and MMP-1.

CONCLUSION

The identification of new prognostic factors may enhance our understanding of the biologic behavior of early invasive cancer of the cervix. Our findings suggest that CD44v6 and MMP-1 may be markers worth further investigation in patients with microinvasive cervical cancer.

Symposium part IV: investigative approaches to endocervical pathology

There is continuing interest in the study of adenocarcinoma of the cervix and its precursors because of its increase in incidence, both absolute and relative, to squamous neoplasia and the complexity of benign glandular lesions with which endocervical neoplasia may be confused. Investigative techniques may be applied as aids to diagnosis, as prognostic markers, and to further our understanding of etiopathogenesis. This article focuses on recent developments in the four areas of epithelial glycoproteins, molecular markers, cell proliferation markers, and human papillomaviruses as applied to endocervical pathology. Although immunohistochemistry remains dominant, a wide range of other techniques is discussed.

CD44 mediates constitutive type I receptor signaling in cervical carcinoma cells

OBJECTIVE

The CD44 transmembrane glycoprotein family has been implicated in the growth and metastasis of numerous human cancers. CD44 may function in some cells through interactions with type I receptor tyrosine kinases, including erbB2. Here, we tested whether CD44 interacts with erbB2 and another type I receptor, the epidermal growth factor receptor (EGFR), in human cervical carcinoma tissues and cell lines and whether these interactions influence erbB2 signaling.

METHODS

CD44, EGFR, and erbB2 colocalization were examined in 36 pT1b-pT2b cervical cancer cases and in the CaSki and SiHa cervical carcinoma cell lines by immunohistochemistry and laser scanning confocal microscopy. The role of CD44-EGFR-erbB2 interactions in erbB2 signaling was examined by immunoprecipitation and using antisense CD44 oligonucleotides.

RESULTS

CD44, erbB2, and EGFR coexpression and colocalization were observed in 42% (15/36) of cervical carcinoma cases and in both cervical carcinoma cell lines. Colocalization occurred to an equivalent extent in all tumor grades examined. CD44 coimmunoprecipitated with erbB2 and EGFR in cervical carcinoma cell lysates, indicating that these proteins interact with each other. Reduction of CD44 expression inhibited constitutive erbB2 activity. High CD44 expression was linked to EGFR activity using dominant negative EGFR, suggesting that type I receptors may autoregulate their activity in these cells.

CONCLUSIONS

Our data indicate that CD44 can mediate type I receptor function in cervical carcinoma cells that overexpress both CD44 and either erbB2 or EGFR and suggest a novel mechanism by which these proteins may contribute to cervical carcinoma tumor growth and metastasis.