Histopathological Patterns of Ovarian Tumours and HER2 Expression in Epithelial Ovarian Carcinoma
*Barua M,1 Hossain MI,2 Bini UH,3 Nasreen S,4 Ahamad MU,5 Bhattecharjee P,6 RahmanM Z7
- * Mitasree Barua, Lecturer, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh. firstname.lastname@example.org
- Mohammad Ismail Hossain, Lecturer, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh
- Umme Habiba Bini, Assistant Professor, Department of Pathology, Pabna Medical College, Pabna, Bangladesh.
- Sayeeda Nasreen, Assistant Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
- M. Sahab Uddin Ahamad, Associate Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
- Pradip Bhattacharjee, Associate Professor, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
- Md. Zillur Rahman, Professor & Head, Department of Pathology, Chittagong Medical College, Chattogram, Bangladesh.
Background: Ovarian tumours are a heterogenous group of neoplasm of epithelial, stromal and germ cell origin. The management of which depends on the histological type of the tumour. Neoadjuvant chemotherapy is limited by toxicity and resistance. Hence targeted therapy is now being proposed to overcome these hurdle.
Objectives: To find out the histopathological patterns of ovarian tumours and to evaluate HER2 overexpression in epithelial ovarian carcinoma.
Methods: This study was carried out in the Department of Pathology, Chittagong Medical College, Chattogram, received from Department of Gynaecology and Obstetrics, Chittagong Medical College Hospital, Chattogram during the period from January 2016 to December 2016. A total of 92 cases of ovarian tumours were selected consecutively. The age range was 12-80 years. Histopathological sections were stained with Hematoxylin and Eosin stain and epithelial ovarian carcinoma were subjected to HER2/neu immunohistochemical stain. Histopathological patterns of ovarian neoplasm, histopathological subtyping and grading of epithelial ovarian tumours and the expression of HER2/neu among epithelial ovarian carcinomas on immunohistochemistry was analyzed.
Results: Out of total 92 cases, histopathological diagnosis showed 65 (70.7%) were benign tumours and 27 (29.3%) were malignant tumours. Histologically, surface epithelial tumours were the most common (74%) followed by germ cell tumours (21.7%) and sex cord stromal tumours (4.3%). Age incidence of benign tumour was age group of 21-40 yrs and malignant 41-60 years. One in 23 epithelial ovarian carcinoma cases (4.3%) exhibits HER2 overexpression. Only one HER2 positive case was mucinous cystadenocarcinoma grade II.
Conclusion: Surface epithelial tumours were most common followed by germ cell tumours. Serous cystadenocarcinoma were most common epithelial ovarian carcinoma.
[Journal of Histopathology and Cytopathology, 2020 Jan; 4 (1):23-32]
Keywords: Ovarian tumour, Epithelial Carcinoma, HER2/neu.
Ovarian tumours account for 3% of all cancers in females, being the second most common cancer of the female genital tract, next only to uterine cancer.1 Ovarian cancer, traditionally known as the silent killer, is a dreaded disease because of its vague, nonspecific symptoms and late presentation. Worldwide, it is the seventh most common cause of cancer and eighth most common cause of cancer-related death among women.2 It is be a disease of developed and industrialized countries where parity of women is low. As the standard of living increases and resources for a medical infrastructure improve in Bangladesh, there will be an increased need to address less common but highly lethal cancers such as ovarian cancer. Globocan predicts a change in the reported incidence of ovarian cancer from 2912 in year 2012 to 3132 in year 2015.3
Risk factors for ovarian cancer are not well defined. However, there is general agreement on two: nulliparity and family history. Women 40 to 59 years of age who have taken oral contraceptives or undergone tubal ligation have a reduced risk of developing ovarian cancer.4 Two treatment options, available for ovarian cancers in advanced stage, are either a primary surgical cytoreduction/debulking or chemotherapy in an attempt to downstage the tumor followed by surgery. Though platinum-based therapy has produced an impressive result, chemoresistance and toxicity are creating hurdles. To overcome this, monoclonal antibodies targeting HER2/neu, a transmembrane protein homologous to epidermal growth factor receptor, has been introduced recently that might bring a new era of management.5
HER2/neu protein expression is commonly measured using immunohistochemistry (IHC).6 Overexpression of HER2/neu is seen in 20–30% patients with ovarian cancer. Some of these differences are likely to be attributable to the diagnostic technique used to measure HER2 expression. HER2/neu overexpression in epithelial ovarian carcinomas has not been studied as extensively as it has been studied in case of breast carcinomas, especially in Bangladesh scenario.
The aim of my study was to determine histopathological patterns of ovarian tumor and to evaluate the frequency of the expression of HER2 among epithelial ovarian carcinomas.
It was a cross-sectional descriptive study carried out in the Department of Pathology of Chittagong Medical College, Chattogram, Bangladesh. Study period was for one year from 1st January, 2016 to 31st December, 2016. All female patients clinically diagnosed as ovarian neoplasm received at the Department of Pathology of Chittagong Medical College, Chattogram referred from Department of Gynaecology and Obstetrics, Chittagong Medical College Hospital (CMCH) during the specified time duration. Finally, 92 consecutive patients were selected according to time frame.
Patient with clinically diagnosed as ovarian tumours who underwent intervention like diagnostic laparoscopy or laparotomy; at least for biopsy in Chittagong Medical College Hospital, Chattogram. Patient with histopathologically diagnosed ovarian tumour in the Department of Pathology, Chittagong Medical College.
Previously diagnosed case of ovarian tumour who already has got treatment. Patient unwilling to give written consent.
Protocol was ethically reviewed and approved by the Ethical review Committee of Chittagong Medical College, Chattogram. All the patients included in the study were informed and explained about the nature of study. Informed written consent was taken from all the subjects after full explanation of nature, purpose and potential risks of all the procedures.
A brief clinical history was taken from each patient with particular reference to the age, occupation, marital history, parity, menstrual history, family history, history of breast feeding, use of contraceptives etc. Clinical history, questionnaire, thorough physical examination, and relevant investigations were recorded in details in all cases.Routine histopathology with H & E stain and Immunohistochemistry for ovarian carcinoma were done.
H&E stained slides were examined under light microscope to get a definitive diagnosis of the ovarian tumour and its type. Histological classification was based on the 2003 World Health Organization classification of ovarian tumours. The Shimizu-Silverberg three-grade histological grading system was used in epithelial ovarian carcinoma (EOC).
The most representative tumor tissue was chosen from each epithelial ovarian carcinoma case and 4 μm sections were taken to poly-L-lysine coated slides for immunohistochemical staining. For immunohistochemistry, epitope retrieval was done with a polymer-based detection system (Envision; Dako) using a Herceptin kit (HercepTest; Dako) according to the manufacturer’s instructions.Antigen retrieval for HER2 using Hercep Test was performed by immersing and incubating the slides in 10 mmol/L citrate buffer in calibrated water bath (95- 99°C) for 40 minutes. After decanting the epitope-retrieval solution, the sections was rinsed in the wash buffer and later, soaked in the buffer for 5 to 20 minutes before staining. Then the slides were rinsed, placed in 200 μL peroxidase-blocking reagent for 5 minutes, rinsed, placed in 200 μL primary anti-HER2 protein (or negative control reagent) for 30 minutes, rinsed twice, and finally immersed in 200 μL substrate chromogen solution (3,3´-diaminobenzidinetetrahydrochloride, DAB) for 10 minutes. The slides were counter stained with hematoxylin and finally were cover slipped.
In this study the age range of 92 ovarian tumours was 12-80 years, were divided into seven age groups and it was observed that maximum number of benign lesions 19 (20.6%) were in age groups 21-30 years. Maximum number of malignant tumours were found 9 (9.8%) in age group 41-50 years. Among 92 ovarian lesions, 68 (74%) were surface epithelial tumour, 20 (21.7%) were germ cell tumour, 4 (4.3%) were sex cord stromal tumours .
Current study was carried out in Departmant of pathology, Chittagong Medical College to see the histopathological patterns of ovarian tumours and HER2 expression in epithelial ovarian carcinoma (EOC).Total number of the patients in this study was 92. The age range was 12-80 years. The mean age was 34.64 years. Patients were divided into seven groups consisting of each decade as a single group and maximum number patients 23 (25%) were in 21 – 30 years group, followed by 21 (22.8%) were in 41-50 years age group. Study done in Nepal by Vaidya et al.(2014) showed highest number of patients (58%) were in 21-40 years age group which is similar to present study.7 In this study in 21-40 years age group total number of patients were 42 (45.65%). Study done in India by Bhagyalakshmi et al (2014)) patients age ranged from 11-70 years, majority of benign cases and malignant cases were between 21 to 40 years and 41 to 60 years respectively.8 Agrawal et al. (2015) also showed age ranged from 12 to 80 years with most common benign and malignant lesions cases were 21 to 40 years and 41 to 60 years respectively which was consistent with this study.9
In this study, among 92 cases, 72 (78.3%) were married and 20 (21.7%) cases were unmarried women. This is probably due to more married women presented to the outpatient department than unmarried ones. Among 72 married women 08 (11.1%) were nulliparous, 03(4.2%) were primiparous and 64 (84.7%) were multiparous.Study done in Dhaka by Dhar et al (2015) showed 8% were unmarried and 92% were married, of whom 12% were nulliparous and 80% was parous.10
Regarding socio-economic status 68 (73.9%) cases were from average socioeconomic condition, 23 (25%) were from poor and only 1 (1.1%) cases from high socioeconomic family. Among the malignant cases maximum 13 (48.1%) cases were from average socioeconomic condition. This is similar to the finding of Dhar et al (2015).10This may be due to the fact that patients attended at a government hospital and most of the people of average and poor socioeconomic conditions usually come here to get treatment.
In this study, it was seen that, 19 (20.7%) had history of hormonal contraceptive use and 49 (53.3%) had no history. Among 27 malignant cases 3 (11.1%) had history of contraceptive use. Ness et al (2011) had reported that oral contraceptives reduce the risk of developing ovarian cancer.11
In this study 75 (81.5%) patients presented with lower abdominal pain 74 (80.4%) with lower abdominal mass. Study done by Jaffar et al (2013) showed, abdominal pain was in 90% cases, abdominal mass was present in 24% of the patients with benign tumours and in 66% with malignant tumours.12
In the present study, among 65 benign lesions 20 (21.7%) cases had increased level of CA-125 and among 27 malignant lesions 3(3.3%) cases were found within normal level.Miralles et al. (2003) suggested that variety of malignancies and benign conditions courses with increased CA-125 level and it is observed that CA-125 is very important as tumour marker for malignancy.13
In the present study, out of 65 benign tumours 62(95.3%) were unilateral and 3(4.6%) were bilateral. Out of 27 malignant tumours 5(18.51%) were bilateral and 22(81.48%) were unilateral. Modepalli et al (2016) reported 93.8% of the neoplasms were unilateral and remaining 6.2% of the lesions were bilateral.14 Benign tumours were more unilateral than malignant tumours. In this present study, out of 92 cases, maximum number of lesions were 48 (52.2%) in the right side of abdomen which is similar to the study done by Modepalli et al (2016).14
Among 92 cases 43 (46.7%) were solid and cystic lesion, 41 (44.6%) were cystic lesions and 8 (8.7%) were solid. Similar study done by Agrawal et al (2017) showed 83.3% benign tumours were cystic whereas 65.3% malignant tumours were solid and cystic.9 Benign tumors were more often cystic in consistency in this study and malignant tumors were solid consistency which was comparable to the study of Kanthikar et al. (2014).15
In this study of the 92 cases of ovarian tumours, 67 (70.7%) were benign and 27 (29.3%) were malignant. Similar studies in India carried out by GG swamy et al. (2010) showed 86 (71.6%) benign tumours, 30 (25.1%) malignant and 4 (3.3%) borderline tumors.16 In Nepal R Jha et al reported 83.9% benign, 16.1% malignant and 2.8% borderilne ovarian tumour.17 In Pakistan a similar study by Ahmed et al showed 59.18% benign and 40.81% malignant tumour. In this study there was no borderline malignancy which were similar to the study done by Yasmine et al. (2008).18
Among the histologic types, in the present study, surface epithelial tumours were most common 68 (74%), germ cell tumour was 20 (21.7%), and sex cord stromal tumour was 4 (4.3%).Similar observation made by Pilli et al.(2002) showed 70.9% surface epithelial tumours, 21.2% germ cell tumours and 6.7% sex cord stromal tumours.19
In this present study Among 92 cases the most common benign surface epithelial tumour was mucinous cystadenoma 26 (28.3%) followed by serous cyst adenoma 18 (19.6%) and benign brenner tumour 1(1.1%). The most common benign germ cell tumour was mature cystic teratoma 18 (19.6%).In this study benign sexcord stromal tumour was fibroma 2(2.2%). Studies done by Bhagyalakshmi et al (2014)8 and Mondol et al (2011)20 showed serous cystadenoma was the most common benign tumour. Study done by Ahmed et al (2000) however found the most common benign tumour to be benign cystic teratoma.21
The commonest malignant tumour was serous cyst adenocarcinoma 13 (14.1%), followed by mucinous cystadenocarcinoma 8 (8.7%), malignant brenner tumour 1 (1.1%) and clear cell carcinoma 1 (1.1%). Similar results were shown in studies by Mondol et al (2011) and Yogambal et al (2014).22
In this present study 23 cases of epithelial ovarian carcinoma (EOC) were evaluated for HER2/neu protein expression using immunohistochemistry.The positive expression rate of HER2/neu in this study was 1(4.3%).This is comparable to the rate of HER2/neu positivity in EOC reported in the literature,which ranges from 7-50%Verri et al (2005),23 Berchuck et al (1990),24 Mayr et al (2006).25 The variation in HER2/neu protein expression rate in different studies may be early stage and 17% of patients with advanced stage disease in the study by Kacinsky et al (1992). However, multiple factor may be involved in producing a wide range of positivity, such as sample size, the detection technique and type of monoclonal antibody used, staining intensity and the tissue where analysis is performed. Studies with populations smaller than 100 patients reported a frequency of 1.8-76%,(Serrano-Olvera et al., 2006).26
In this study among 8 mucinous cystadenocarcinoma, HER2 expression was positive in 1 (12.5%) case and was in Grade-II. In the study done by Missaoui et al (2014),27 HER2 expression was described in 14.3% of mucinous carcinoma. Study in Nijeria done by Ajani et al.(2015) 28 observed that a higher proportion of serous carcinoma (as opposed to mucinous carcinoma) was HER2/neu positive. Sarkar et al (2015)2 also showed that HER2 expression was more intense for high grade serous carcinoma.
In this study HER2 expression is relatively common in mucinous epithelial carcinoma of the ovary and trastuzumab therapy would be an option for patients with mucinous carcinoma when the tumour has HER2 overexpression.
The study also has some limitations. This study was severely constrained by the limited duration that led to have small population size and this study was done in patient who underwent surgery and samples were collected from Chittagong Medical College and Hospital only. In spite of these reason the present study showed more or less acceptable findings with consideration of the observations by others.
Ovarian cancer presents a tremendous clinical challenge to gynecologists, medical oncologists and radiotherapists. It is a silent menace and is not associated with significant symptoms. Surface Epithelial Tumours were the commonest group followed by Germ Cell Tumours. Most common Germ cell tumours were mature cystic teratoma occured in much younger women. Malignant ovarian neoplasms were more common in patients above 40 years. Sex Cord Stromal Tumours were also common with Fibroma and Granulosa cell tumour. Unilateral involvement of ovarian neoplasms was more common than bilateral and involvement of right ovary was more than the left. Mucinous cystadenoma was the commonest benign ovarian neoplasm while the commonest malignant tumour was serous cystadenocarcinoma. Mucinous epithelial carcinoma have expressed HER2.
- Lora EH, & Edyta PC. The Female Genital Tract. 8 ed. Philadelphia; Saunders; 2010.1040p.
- SarkarM, JhaT, Das TK, SauV et al. Spectrum of Epithelial ovarian tumors with HER2/new expression by the carcinomas among patients admitted in a tertiary care hospital in Eastern India.J Med Sci Public Health. 2015; 4(10):1388-1392.
- Pervin S, Islam F, Hall T, & Goodman A. The management of ovarian cancer in Bangladesh: A report of a long-term survivor.Austin Journal of obstetrics and Gynecology. 2015;2(4):1047.
- Ness RB, Dodge RC, Edwards RP, et al. Contraception Methods, beyond Oral Contraceptives and Tubal. Ann Epidemiology. 2001;21(3):188–196.
- Ray-Coquard I, Gaustalla JP, Allouache D, Combe M, et al. HER2 Overexpression / amplification and trastuzumab treatment in advanced ovarian cancer: a GINECO Phase II study. Clin Ovarian Cancer. 2008;1(1):54-59.
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- Vaidya S, Sharma P, KC S,Vaidya SA . Spectrum of ovarian tumour in a referral hospital in Nepal. Journal of Pathology Nepal. 2014; l4: 539-543.
- BhagyalakshmiA, SreelekhaA, Sridevi S, Chandralekha J, Parvathi G,Venkatalaksmi A Prospective study of histopathological patterns of ovarian tumours in a tertiary care centre. International Journal of Research in Medical Sciences. 2014;2(2):448-456.
- Agrawal P, Kulkarni DG, Chakrabarti PR, Chourasia S, Dixit M, Gupta K. Clinicipathological Spectrum of Ovarian Tumors: A 5 Year Experience in a Tertiary Health Care Center. Journal of Basic and Clinical Reproductive Science. 2015;4(2), 90-96.
- Dhar SR, Begum S, Zabin F, Akter S. Socio-demographic Characteristics of Ovarian Tumor Patients attended at a tertiary care hospital in Dhaka city. Journal of Current and Advance Medical Research. 2015;2(2):39-41.
- Ness RB, Dodge RC, Edwards RP, et al. Contraception Methods, beyond Oral Contraceptives and Tubal. Ann Epidemiology. 2001;21(3):188–196.
- Jaffer Y, Ehsan N, Ambreen. Clinical presentation of ovarian tumors. Journal of Surgery Pakistan (International). 2013;18(2):82-86.
- Miralles C, Orea M, España P, Provencio M, Sánchez,A, Cantos B,etal.Cancer Antigen 125 Associated With Multiple Benign and Malignant Pathologies. Annals of Surgical Oncology. 2003;10(2):150–154 DOI: 10.1245/ASO.2003.05.015
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