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(C-Erbb-2) and Epidermal Growth Factor Receptor in Cervical Cancer

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(C-Erbb-2) and Epidermal Growth Factor Receptor in Cervical Cancer Gynecologic Oncology 93 (2004) 209–214 www.elsevier.com/locate/ygyno Expression of HER2neu (c-erbB-2) and epidermal growth factor receptor in cervical cancer: prognostic correlation with clinical characteristics, and comparison of manual and automated imaging analysis$ Christopher M. Lee,a R. Jeffrey Lee,b Elizabeth Hammond,c Alexander Tsodikov,d Mark Dodson,e Karen Zempolich,e and David K. Gaffneya,* a Department of Radiation Oncology, University of Utah, Salt Lake City, UT 84132, USA b Department of Radiation Oncology, LDS Hospital, Salt Lake City, UT, USA c Department of Pathology, LDS Hospital, Salt Lake City, UT, USA d Department of Biostatistics, Huntsman Cancer Institute, Salt Lake City, UT, USA e Department of Gynecologic Oncology, University of Utah, Salt Lake City, UT, USA Received 8 October 2003 Abstract Objectives. To evaluate HER2neu and epidermal growth factor receptor (EGFR) expression with respect to overall survival and disease- free survival (DFS), and correlate expression with pretreatment factors. Comparative evaluations of manual and automated immunohistochemical imaging systems for HER2neu and EGFR expression were made. Methods. Fifty-five patients with stages I–IVA carcinoma of the cervix were treated with definitive radiation therapy. Immunohistochemistry was performed for HER2neu and EGFR, and scored by both manual and automated methods. Univariate and multivariate analyses were performed with disease-free survival (DFS) and overall survival (OS) as primary endpoints, and biomarkers were evaluated for correlation between prognostic factors. Results. Strong correlations in HER2neu and EGFR protein expression were observed between digitally and manually analyzed staining ( P V 0.0001). Increased FIGO stage and decreased HER2neu expression were significant for reduced DFS on univariate analysis ( P V 0.001 and P = 0.03, respectively). Increased FIGO stage, decreased HER2neu expression, and increased membranous staining of EGFR were significant for diminished OS on univariate analysis ( P V 0.0001, P = 0.002, and P = 0.043, respectively). Multivariate analysis revealed only increased membranous staining of EGFR associated with diminished DFS and OS ( P = 0.046 and P = 0.012, respectively). Overexpression of HER2neu correlated significantly with adenocarcinoma, and overexpression of EGFR correlated significantly with squamous cell carcinoma histology ( P = 0.038 and P = 0.035). Inverse correlations were observed between HER2neu expression and clinical stage, EGFR membranous staining, and EGFR distribution ( P = 0.007, P = 0.006, and P = 0.034, respectively). Conclusions. Increased expression of HER2neu and decreased EGFR membranous staining identified patients with improved DFS and OS on univariate analysis, although only decreased EGFR membranous staining was significant on multivariate analysis. We also found strong correlation of results between manually and automated imaging methods. D 2004 Elsevier Inc. All rights reserved. Keywords: HER2neu; c-erbB-2; EGFR; HER1; Cervix cancer; Immunohistochemistry Introduction $ Presented at the 45th Annual Meeting of the American Society for The epidermal growth factor receptor (EGFR) family Therapeutic Radiology and Oncology, October 19–23, 2003, Salt Lake comprises four structurally related transmembrane recep- City, UT. tors: EGFR (HER1 or erbB-1), HER2neu (c-erbB-2), HER3, * Corresponding author. Department of Radiation Oncology, University of Utah, 50 North Medical Drive, Salt Lake City, UT 84132. Fax: +1-801- and HER4 [1–4]. In response to ligand specific binding, 585-3502. these receptors act by forming hetero- or homodimers and E-mail address: [email protected] (D.K. Gaffney). thereby initiate tyrosine kinase activity in the intracellular 0090-8258/$ - see front matter D 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.ygyno.2004.01.006 210 C.M. Lee et al. / Gynecologic Oncology 93 (2004) 209–214 domain. This amplification of tyrosine kinase activity results performed for HER2neu and EGFR, and the expression of in the phosphorylation of several tyrosine residues in the C- both biomarkers were quantitatively scored by ChromaVi- terminus. These phosphorylated tyrosines then serve as sion cellular imaging technology for each patient (intensity binding sites for signal transducers and adapter molecules scale based on pixel density, 0–4 for HER2neu and 0– that initiate signaling pathways resulting in cell prolifera- 16000 for EGFR). Overexpression of HER2neu and tion, differentiation, migration, adhesion, protection from EGFR were defined as >2.0 and >8000 (intensity scale), apoptosis, and transformation [1,2,4]. respectively. In addition, HER2neu and EGFR were man- The oncogenic pathway of some cells is thought to be ually scored for percent of positive cells (distribution): 0 = initiated as a result of HER2neu and/or EGFR mutation, none, 1 V 10%, 2 = 10–50%, 3 z 50%; and for the overexpression, structural rearrangements, and/or relief of intensity of staining with a subjective score of 0–3: 0 = normal regulatory or inhibitory pathways. The presence of no expression, 1 = minimal staining, 2 = moderate EGFR and HER2neu receptors have also been associated staining, 3 = heavy staining. The product of intensity with accelerated tumor progression and resistance to and distribution (mean intensity) of staining was utilized therapy for multiple types of malignancies [1,2,4]. The for further statistical analyses. The location of EGFR causal relationship of this receptor network to disease staining was further described as membranous or cyto- progression and resistance to therapy provides a rationale plasmic for each specimen. for targeting this signaling system with tumor-selective strategies. Immunohistochemistry HER2neu and EGFR expression have been investigated in the past by multiple methods. These include radioimmu- Formalin-fixed, paraffin-embedded, 5-Am-thick sections noassays, immunohistochemical stains, enzyme immuno- were prepared from biopsy specimens. Immunohistochem- assays, and flow cytometry. Due to the inherent subjective ical stains were individually assessed without knowledge of nature of manual immunohistochemical stain interpretation, patient outcome. Each slide was first deparaffinized and recently developed cellular imaging systems have been heated in citrate buffer. After cooling, immunohistochemical utilized to more objectively quantify staining intensity and staining was performed with an automated immunohisto- distribution [5,6]. chemical autostainer. Few studies have evaluated the prognostic utility of Detection for EGFR was performed with a secondary multiple biomarkers in carcinoma of the cervix for patients mouse anti-immunoglobulin linked to biotin following in- treated in a homogeneous fashion (such as definitive radio- therapy alone). To our knowledge, this study is also the first comparative analysis of manual techniques and automated Table 1 cellular imaging system techniques for the evaluation of Patient and tumor characteristics (N = 55) HER2neu and EGFR immunohistochemical staining in Characteristics N Median SEM carcinoma of the cervix. The goals of this study were to FIGO stage evaluate the correlation of HER2neu and EGFR expression IB 12 with disease-free survival (DFS) and overall survival by II 22 both univariate and multivariate analysis, and secondarily to III 17 IVA 4 evaluate differences between manual interpretation and recently developed automated cellular imaging system Histology (Chromavision Medical System). Squamous 48 Adenocarcinoma 5 Adenosquamous 2 Total dose to point A (cGy) 8038 250 Materials and methods Total treatment time (days) 44 1.6 Fifty-five patients with FIGO stage IB–IVA carcinoma # Brachytherapy insertions of the cervix on whom tumor tissue blocks were available 06 were included in this study. Approval for this study was 136 213 obtained from the LDS Hospital Institutional Review Board. Patients that received radiotherapy with definitive intent Follow-up interval (months) from 1981 to 1996 were included. Patients who received All patients 24 7 concurrent chemotherapy were also excluded from the Alive patients 69 15 analysis to provide a more homogenous population for Grade analysis. Medical charts and the hospital registry were also 12 reviewed for clinical parameters and disease status. 234 The presence of tumor and histopathologic grade were 319 verified by one pathologist. Immunohistochemistry was SEM indicates standard error of the mean. C.M. Lee et al. / Gynecologic Oncology 93 (2004) 209–214 211 Table 2 Correlations between clinical characteristics and biomarkers Spearman’s rPvalue EGFR automated Clinical characteristics Histology À 0.29 0.035 Stage 0.15 0.28 Grade À 0.021 0.88 Biomarkers EGFR manual 0.64 < 0.0001 EGFR membranous 0.41 0.002 EGFR cytoplasmic À 0.026 0.85 EGFR distribution 0.65 < 0.0001 EGFR intensity 0.61 < 0.0001 HER2neu automated À 0.23 0.089 HER2neu manual À 0.21 0.12 Fig. 1. Comparison of manual and automated methods for analysis of HER2neu expression in carcinoma of the cervix. HER2neu automated Clinical characteristics Histology 0.28 0.038 cubation with streptavidin linked to horseradish peroxidase. Stage À 0.36 0.007 Color development was accomplished with diaminobenzi- Grade À 0.12 0.40 dine as the chromagen. The EGFR detection kit was Biomarkers obtained from Dako (M3563) and was used in a concentra- EGFR manual À 0.28 0.04 EGFR membranous 0.37 0.006 tion of 1:200. Detection for HER2neu was performed with a À EGFR cytoplasmic 0.38 0.004 secondary
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