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Journal of Clinical Oncology, Vol 24, No 15 (May 20), 2006: pp. 2376-2385 © 2006 American Society of Clinical Oncology. DOI: 10.1200/JCO.2005.03.4827 HER-2 Is an Independent Prognostic Factor in Endometrial Cancer: Association With Outcome in a Large Cohort of Surgically Staged Patients
From the Department of Pathology, Division of Gynecologic Oncology Center for Biostatistics, The Arthur James Cancer Hospital, and the Richard Solove Research Institute, The Ohio State University Medical School Columbus, OH; and the Division of Gynecologic Oncology, Walter Reed Army Medical Center, Washington, DC. Address reprint requests to Carl Morrison, MD, DVM, Pathology Core Facility, 418-M SL 320 W 10th Ave, Columbus, OH 43210; e-mail: morrison4{at}medctr.osu.edu
Purpose To evaluate HER-2 expression and amplification in a large cohort of endometrial cancer with complete surgical staging and outcome data. Patients and Methods A tissue microarray was constructed of 483 patients with endometrial cancer of diverse histologic type and stage and tested for HER-2 expression and amplification using current standards of practice. There was outcome data for 83% of all patients and 81% with complete surgical staging. Results Both expression and amplification of HER-2 was associated with high-grade (P = .0001) and high stage (P = .0001) endometrial cancer. The highest rate of HER-2 expression and amplification was seen in serous carcinoma (43% and 29%), while grade 1 endometrioid adenocarcinoma showed the lowest levels (3% and 1%). For all histologic types, the rate of HER-2 expression and amplification was remarkably different (P < .0001) for grade 3 cancers (31% and 15%) versus grade 2 (7% and 3%) and grade 1 cancers (3% and 1%), with similar results for endometrioid type (P < .0001). Both HER-2 expression and amplification correlated with disease-specific survival and progression-free survival in univariate analyses. By multivariate analysis HER-2 expression in the presence of amplification (P = .012) correlated with overall survival, but not expression in the absence of amplification. Overall survival was significantly shorter (P = .0001) in patients who overexpressed (median, 5.2 years) and/or showed amplification of HER-2 (median, 3.5 years) versus those that did not (median of all cases, 13 years). Conclusion Our results would suggest that HER-2 is an important oncogene in high grade and stage endometrial cancer, but plays only a minor role in the much more common low grade and stage tumors that encompass the majority of clinical practice.
An extensive body of literature exists regarding the prognostic value and clinical utility of HER-2 (ERBB2; v-erb-b2 erythroblastic leukemia viral oncogene homolog 2; alias NEU, HER-2) biomarker expression for patients with breast cancer. In virtually all of these studies, HER-2 overexpression in the background of gene amplification, as opposed to overexpression without gene amplification, appears to have a stronger association with an adverse outcome.1-5 A recent meta-analysis6 of the literature concerning HER-2 and breast cancer (> 27,000 patients) has clearly shown that HER-2 overexpression with gene amplification is an independent prognostic marker by multivariate analysis and strongly correlates with other independent prognostic markers in breast cancer including tumor grade and type. HER-2 expression and amplification have been studied in endometrial cancer,7-25 but there are conflicting results in both the incidence and clinical importance of this finding. Many of these studies have been limited by the methodology employed, as well as the number of patients and histologic types represented for analysis. With the exception of recent reports,22-25 the previous studies evaluating HER-2 expression evaluated an overabundance of low grade and stage endometrial cancer. In this study we have evaluated a broad spectrum of histologic type, grade, and stage of endometrial cancer. Analysis of a large number of individual tumor specimens is necessary to establish the prognostic significance and potential therapeutic value of a biologic marker, such as HER-2, in endometrial carcinoma. The objective of this study was to assess the prevalence of HER-2 expression and amplification and compare that status to well-defined, traditional, clinicopathologic prognostic factors in a large group of women diagnosed with endometrial cancer where the great majority underwent surgical staging and had clinical follow-up.
Patients All of the patients in this study were diagnosed with uterine malignancy and treated between January 1, 1980 and July 31, 2003 at the Arthur James Cancer Hospital of the Ohio State University Medical School (OSU; Columbus, OH). The OSU institutional review board gave approval for this study. More than 81% of the patients in this study underwent comprehensive surgical staging including total abdominal hysterectomy bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection. Lymphadenectomy was not performed in some patients who had either high surgical risk, gross intraperitoneal disease, or minimal risk intrauterine features at the time of intraoperative frozen section analysis. Patients without lymphadenectomy and with no gross intraperitoneal disease were staged by uterine factors. Platinum-based chemotherapy (with either doxorubicin or paclitaxel) was given at the discretion of the attending physician to patients with advanced disease. Alternatively, patients with advanced disease or those at risk for pelvic failure were given pelvic radiation (with or without coverage of the aortic lymph nodes). A small subset of patients was treated with either concurrent or sequential cisplatin-based chemoradiotherapy. Two pathologists (C.M., N.R.) independently reviewed all cases for the evaluation of standard pathologic factors including histologic type, grade, FIGO stage, and depth of myometrial invasion. Cases for which there were discordant results were then reviewed concurrently and a consensus agreement reached.
Immunohistochemistry and Fluorescent In Situ Hybridization
Fluorescent in situ hybridization (FISH) for HER-2 amplification using the PathVysion HER-2 DNA Probe kit (Vysis, Dover, IL) was done in accordance with the manufacturer's guidelines and performed manually. Specimens were evaluated with the Olympus BX51 microscope (Olympus Optical Company LTD, Tokyo, Japan) under oil immersion at x100 magnification using the recommended filters. For each case the ratio of HER-2 to CEP17 signals in at least 60 interphase nuclei with non-overlapping nuclei in the tumor cells was determined. Cells with no signals or with signals of only one color were disregarded. Tumors cells displaying at least two centromeric chromosome 17 signals and multiple HER-2 signals, with a HER-2/CEP17 ratio
Tissue Microarrays
Statistical Analysis
Patients For the 483 patients in this study there was an average patient age of 62 years (range, 17 to 89), with a total of 42 patients younger than 45 years of age at the initial diagnosis of endometrial cancer. Just slightly more than 90% of the patients were white, with the remainder of patients consisting predominantly of black women. Follow-up was available for 83% of all patients with a median follow-up time of 33 months (average, 41; range, 1 to 229). Seventy-five patient deaths occurred, 51 related to endometrial cancer and 24 related to other causes. Seventy adverse events were recorded, which included recurrent disease as well as deaths related to endometrial cancer. Of patients who received follow-up, 8% received external-beam radiation therapy (EBRT) alone, 31% received chemotherapy alone, 9% received EBRT plus chemotherapy, and 52% received no additional therapy beyond surgical resection.
Rates of HER-2 Expression and Amplification
HER-2 Association With Standard Staging Parameters and Survival Univariate analyses involving Cox proportional hazards model (Table 3) showed a number of standard histopathologic features correlated with shorter DSS and PFS. Not unexpectedly these features included high-grade (G3) histology, nonendometrioid histology, advanced stage (stage III and IV), positive nodal status, and more than 50% myometrial invasion (P < .0001 for all). Likewise, DSS and PFS showed statistically significant correlation with both HER-2 expression (P = .07 and P = .008, respectively) and amplification (P < .0001 for both). Multivariate models included age, grade, stage, and status of HER-2 expression and amplification (Table 4). Stage III (P = .009), stage IV (P < .001), and high grade (P < .001) were associated with DSS, as well as HER-2 expression in the presence of amplification (P = .010). HER-2 expression in the absence of amplification did not show a statistically significant correlation with DSS (P = .976). Similar results occurred for PFS, with a significant correlation for stage III (P = .013), stage IV (P < .001), high grade (P < .001), and HER-2 expression in the presence of amplification (P = .002). As with DSS, HER-2 expression in the absence of amplification did not show a statistically significant correlation with PFS by multivariate analysis (P = .233). Results for OS were similar to those for DSS and PFS (data not shown).
Kaplan-Meier survival curves for DSS, OS, and PFS for all groups of endometrial cancer patients were significantly different (log-rank P = .0001 for all) for cases that overexpressed and/or showed amplification of HER-2 (Fig 2). For 116 cases of high-stage (IIIA to IVB) endometrial cancer there was a significant difference in PFS, DSS, and OS (Fig 3) for cases that overexpressed and/or showed amplification of HER-2 (log-rank P < .05 for all). For 145 patients with grade 3 endometrial cancer there was a significant difference in PFS (log-rank P = .0059) and OS (log-rank P = .0271) for cases that overexpressed and/or showed amplification of HER-2, with DSS showing a similar trend but not quite reaching statistical significance (log-rank P = .1132; Fig 4).
Undoubtedly, the overall results of this study indicate that HER-2 expression and amplification is much more common in nonendometrioid than endometrioid endometrial cancer (EEC), but the survival results are similar even at this lower rate of incidence (Fig 5). For 315 cases of EEC with follow-up, there was a significant difference in DSS (log-rank P = .0002) and PFS (log-rank P = .0001) for cases that overexpressed and/or showed amplification of HER-2. For cases of EEC with stage IA and IB of any grade and follow-up there were few cases with HER-2 expression and amplification (224 patients; 6% IHC+, 1.3% amplified). Survival curves for this group of patients (Fig 6) showed a significant difference in DSS (log-rank P = .00001) and PFS (log-rank P = .00001) that overexpressed and/or showed amplification of HER-2, although these results should be viewed with caution due to the limited number of total events.
HER-2 Association With Treatment In regard to potential interactions of HER-2 and EBRT and chemotherapy, the overall number of patients treated with the former was too small for a meaningful analysis. Of the 160 patients (40%) of all patients given chemotherapy with follow-up (123 patients received chemotherapy alone, 37 patients received chemotherapy plus EBRT), there was a statistically significant difference between those patients alive with no disease or who died due to another cause versus those patients either alive with disease or who died of disease (P = .0000024). For the 120 patients alive with no disease or who died due to another cause, there was a 11.7% rate of HER-2 expression, versus a 46.3% rate for those patients either alive with disease or who died of disease. This finding is confounded by the fact that those patients with an adverse outcome related to disease showed a statistically significant difference compared with the other group for all the standard staging parameters, including high grade and stage, nonendometrioid type, and positive lymph node status (all P values < .01).
There have been few prior studies of this size to address HER-2 overexpression and gene amplification in endometrial cancer. Our overall results would suggest that HER-2 is an independent prognostic marker for survival by multivariate analysis and important in a small subset of patients. In this study HER-2 overexpression without gene amplification was not found to be an independent prognostic marker for survival by multivariate analysis. Undoubtedly other studies are needed to confirm and refine these results. It is not that surprising that HER-2 overexpression with or without gene amplification is strongly correlated with other independent prognostic markers, including tumor grade and stage, based on our knowledge of this biomarker in breast cancer. This association with other known prognostic clinicopathologic markers complicates the issue of response to chemotherapy in HER-2 positive endometrial cancer. It should also be noted that the survival curves for both high-stage and high-grade endometrial cancers showed a decline in survival for cases with HER-2 overexpression, irrespective of the presence or absence of amplification. This would suggest that 2+ levels of staining without increased copy numbers of the HER-2 genes is a group that needs additional study. Prognostic implications of HER-2 expression and amplification in endometrial cancer are controversial. Part of the confusion regarding the incidence of HER-2 protein expression and gene amplification in endometrial cancer can be explained in part by the methodologies of prior studies, which used no standardized method of scoring results7-18 and the predominance of type I low-stage tumors.19-21 The current standard of practice for positive scoring of HER-2 expression in breast cancer is based on membranous staining that must be completely circumferential in at least 10% of the tumor cells and with a disregard for cytoplasmic staining. Whether a patient is scored as 2+ (moderately positive and possibly amplified) or 3+ (strongly positive and usually amplified) are based on the intensity of this particular pattern of membranous staining. In this study we scored HER-2 expression by the criteria that currently exists for breast cancer and used a reasonable proportion of type II and high-stage tumors. The highest level of HER-2 expression, particularly that associated with gene amplification, in this study was seen in the group of uterine serous papillary carcinoma. Two recent papers have looked at HER-2 in this group of tumors with discordant results.22,24,26 One of these studies22 included cases of mixed epithelial type with serous differentiation, although Slomovitz et al22 did not disclose the percentage of such cases. In our study, we divided such cases and included only cases with essentially 100% serous differentiation as uterine serous papillary carcinoma. Our cases of mixed epithelial type with serous differentiation showed a similar rate of HER-2 expression, but a significantly lower rate of amplification than uterine serous papillary carcinoma. This most likely explains some of the recent discrepancies concerning HER-2 in uterine serous papillary carcinoma and underscores the need for ancillary techniques in the classification of endometrial cancer as we move toward specific gene targeted therapies. Considering the body of literature that currently exists, it is safe to say there are no current accepted guidelines for HER-2 testing in endometrial cancer. For breast cancer the guidelines are simple—all cases of invasive carcinoma irrespective of type, grade, or stage are tested for HER-2 expression by immunohistochemical staining with subsequent FISH analysis for intermediate expressing (2+) cases. Our results would suggest that grade 3 endometrial cancer, regardless of stage, and all patients with stage greater than IIIA should be tested for HER-2 expression and amplification. For both of these groups, HER-2 expression (2+ or greater) would identify almost 50% of the adverse events in a prospective fashion. This apparent enthusiasm for HER-2 testing in high grade and stage endometrial cancer should be tempered by the relatively low incidence of these types of cases. For the vast majority of endometrial cancer, which are endometrioid in type and stage IC or less, the low incidence of HER-2 expression and/or gene amplification in this group would suggest that global testing as done in breast cancer would not be warranted. Trastuzumab (Herceptin; Genentech, San Francisco, CA) is now standard therapy for appropriately selected patients with breast cancer. It is logical to assume that targeted therapies directed against HER-2 would be effective in a segment of the population of patients with endometrial cancer; however, little information exists in the literature. The Gynecologic Oncology Group reported its experience with trastuzumab given to 23 patients with recurrent disease with 2+ or 3+ staining or amplification by FISH.27 Unfortunately, no objective response was observed. While this study did not rule out the use of trastuzumab in endometrial cancer, it did illustrate the importance of defining a population where targeted therapies are considered as only 13% of the patients in this study were documented to have tumors positive for amplification by FISH analysis. An additional clinical trial (Gynecologic Oncology Group 229D) involving GW572016 (lapatinib, GlaxoSmithKline, Parsippany, NJ), a dual inhibitor of epidermal growth factor receptor and HER-2, is currently accruing patients with endometrial cancer, but no results are currently available. At this time it might be appropriate to state that continued investigation of HER-2 inhibition in high grade or stage endometrial cancer is appropriate before discounting the use of HER-2 blocking agents in endometrial cancer. In summary, to date this study—the largest study of HER-2 in endometrial cancer—suggests that HER-2 is an important factor in at least a small subset of cases, particularly high-risk tumors. Unfortunately the role that HER-2 plays in the vast majority of endometrial cancer may be diminished in comparison with breast cancer due to the relatively low incidence of expression and/or amplification in low grade and stage endometrial cancer.
The authors indicated no potential conflicts of interest.
Supported by Grant No. BAA051 from the Department of Defense Health Systems/US Army Medical Research and Material Command Gynecologic Cancer Center for the Study of Racial Disparities of the Uniformed Services University of the Health Sciences. Presented in part in abstract form at the 36th Annual Meeting of the Society of Gynecologic Oncologists, Miami, FL, March 19-22, 2005. Authors' disclosures of potential conflicts of interest and author contributions are found at the end of this article.
1. Slamon DJ, Godolphin W, Jones LA, et al: Studies of the HER-2/neu proto-oncogene in human breast and ovarian cancer. Science 244:707-712, 1989 2. Borg A, Tandon AK, Sigurdsson H, et al: HER-2/neu amplification predicts poor survival in node-positive breast cancer. Cancer Res 50:4332-4337, 1990 3. Wright C, Angus B, Nicholson S, et al: Expression of c-erbB-2 oncoprotein: A prognostic indicator in human breast cancer. Cancer Res 49:2087-2090, 1989 4. Hayes DF, Thor AD: C-erbB-2 in breast cancer: Development of a clinically useful marker. Semin Oncol 29:231-245, 2002[CrossRef][Medline] 5. Andrulis IL, Bull SB, Blackstein ME, et al: Neu/erbB-2 amplification identifies a poor-prognosis group of women with node-negative breast cancer: Toronto Breast Cancer Study Group. J Clin Oncol 16:1340-1349, 1998 6. Ross JS, Fletcher JA, Linette GP, et al: The Her-2/neu gene and protein in breast cancer 2003: Biomarker and target of therapy. Oncologist 8:307-325, 2003 7. Hetzel DJ, Wilson TO, Keeney GL, et al: HER-2/neu expression: A major prognostic factor in endometrial cancer. Gynecol Oncol 47:179-185, 1992[CrossRef][Medline] 8. Khalifa MA, Mannel RS, Haraway SD, et al: Expression of EGFR, HER-2/neu, P53, and PCNA in endometrioid, serous papillary, and clear cell endometrial adenocarcinomas. Gynecol Oncol 53:84-92, 1994[CrossRef][Medline] 9. Lukes AS, Kohler MF, Pieper CF, et al: Multivariable analysis of DNA ploidy, p53, and HER-2/neu as prognostic factors in endometrial cancer. Cancer 73:2380-2385, 1994[CrossRef][Medline] 10. Pisani AL, Barbuto DA, Chen D, et al: HER-2/neu, p53, and DNA analyses as prognosticators for survival in endometrial carcinoma. Obstet Gynecol 85:729-734, 1995[CrossRef][Medline] 11. Nazeer T, Ballouk F, Malfetano JH, et al: Multivariate survival analysis of clinicopathologic features in surgical stage I endometrioid carcinoma including analysis of HER-2/neu expression. Am J Obstet Gynecol 173:1829-1834, 1995[CrossRef][Medline] 12. Kohlberger P, Loesch A, Koelbl H, et al: Prognostic value of immunohistochemically detected HER-2/neu oncoprotein in endometrial cancer. Cancer Lett 98:151-155, 1996[Medline] 13. Backe J, Gassel AM, Krebs S, et al: Immunohistochemically detected HER-2/neu-expression and prognosis in endometrial carcinoma. Arch Gynecol Obstet 259:189-195, 1997[CrossRef][Medline] 14. Rasty G, Murray R, Lu L, et al: Expression of HER-2/neu oncogene in normal, hyperplastic, and malignant endometrium. Ann Clin Lab Sci 28:138-143, 1998[Abstract] 15. Mariani A, Sebo TJ, Webb MJ, et al: Molecular and histopathologic predictors of distant failure in endometrial cancer. Cancer Detect Prev 27:434-441, 2003[CrossRef][Medline] 16. Macwhinnie N, Monaghan H: The use of P53, PTEN, and C-erbB-2 to differentiate uterine serous papillary carcinoma from endometrioid endometrial carcinoma. Int J Gynecol Cancer 14:938-946, 2004[CrossRef][Medline] 17. Saffari B, Jones LA, el-Naggar A, et al: Amplification and overexpression of HER-2/neu (c-erbB2) in endometrial cancers: Correlation with overall survival. Cancer Res 55:5693-5698, 1995 18. Riben MW, Malfetano JH, Nazeer T, et al: Identification of HER-2/neu oncogene amplification by fluorescence in situ hybridization in stage I endometrial carcinoma. Mod Pathol 10:823-831, 1997[Medline] 19. Rolitsky CD, Theil KS, McGaughy VR, et al: HER-2/neu amplification and overexpression in endometrial carcinoma. Int J Gynecol Pathol 18:138-143, 1999[Medline] 20. Cianciulli AM, Guadagni F, Marzano R, et al: HER-2/neu oncogene amplification and chromosome 17 aneusomy in endometrial carcinoma: Correlation with oncoprotein expression and conventional pathological parameters. J Exp Clin Cancer Res 22:265-271, 2003[Medline] 21. Konopka B, Janiec-Jankowska A, Paszko Z, et al: The coexistence of ERBB2, INT2, and CMYC oncogene amplifications and PTEN gene mutations in endometrial carcinoma. J Cancer Res Clin Oncol 130:114-121, 2004[CrossRef][Medline] 22. Slomovitz BM, Broaddus RR, Burke TW, et al: Her-2/neu overexpression and amplification in uterine papillary serous carcinoma. J Clin Oncol 22:3126-3132, 2004 23. Amant F, Vloeberghs V, Woestenborghs H, et al: ERBB-2 gene overexpression and amplification in uterine sarcomas. Gynecol Oncol 95:583-587, 2004[CrossRef][Medline] 24. Santin AD, Bellone S, Siegel ER, et al: Racial differences in the overexpression of epidermal growth factor type II receptor (HER2/neu): A major prognostic indicator in uterine serous papillary cancer. Am J Obstet Gynecol 192:813-818, 2005[CrossRef][Medline] 25. Santin AD, Bellone S, Van Stedum S, et al: Determination of HER2/neu status in uterine serous papillary carcinoma: Comparative analysis of immunohistochemistry and fluorescence in situ hybridization. Gynecol Oncol 98:24-30, 2005[CrossRef][Medline] 26. Rubin MA, Dunn R, Strawderman M, et al: Tissue microarray sampling strategy for prostate cancer biomarker analysis. Am J Surg Pathol 26:312-319, 2002[CrossRef][Medline] 27. Fleming GF, Sill MA, Thigpen JT, et al: Phase II evaluation of trastuzumab in patients with advanced or recurrent endometrial carcinoma: A report on GOG 181B. Proc Am Soc Clin Oncol 22:453, 2003 (abstr 1821) Submitted August 2, 2005; accepted March 1, 2006.
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Copyright © 2006 by the American Society of Clinical Oncology, Online ISSN: 1527-7755. Print ISSN: 0732-183X
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ABSTRACT
INTRODUCTION
2.2 were considered consistent with amplification of HER-2. Tumors cells displaying at least two centromeric chromosome 17 signals and an equal number of HER-2 signals, with a HER-2/CEP17 ratio less than 2.2 were considered consistent with no amplification of HER-2. 
2 analysis was used for comparison of individual surgical-pathologic variables and HER-2 expression and amplification. Both univariate and multivariate logistic regression analysis were done to investigate relationships between surgical-pathologic variables and outcome. Kaplan-Meier survival curves for progression-free survival (PFS), overall survival (OS), and disease-specific survival (DSS) were evaluated with a log-rank test. Deaths due to cause other than disease were listed as censored events and not as adverse events for DSS or PFS. For statistical purposes, stage and grade were each reduced to two categories: stage I and II versus stage III and IV, grade 1 and 2 versus grade 3, respectively. HER-2 expression and amplification were consolidated into one variable with three categories: no expression and no amplification, expression but no amplification, and both expression and amplification. 
