Keywords:
Endometrial carcinoma - Renal clear cell carcinoma - EGFR family - p53
Descritores:
Carcinoma Endometrial - Carcinoma renal de células claras - Família EGFR - p53
INTRODUCTION
When patients have more than one tumor in the same or different organs/tissues, it
is expected a hereditary predisposition to multiple tumors. Overall, based on an analysis
of several studies, the incidence of multiple primary tumors is reported to be around
0.73-5.2 %.([1]) In patients diagnosed with two malignancies simultaneously, a major challenge is
to find an anticancer therapy strategy to treat both cancer types without increasing
toxicity or pharmacological interactions, and without negative impact on overall outcome.([2]
[3]) Caucasian ancestry, cancer diagnostic at younger age, lower grade with indolent
clinical behavior with longer survival, and cancer family history are reported as
risk factors for multiple primary tumors.([1])
Human epidermal growth factor receptor (HER) family members have been shown to be
involved in oncogenesis in a number of human cancers.([4]) In endometrial cancer, the expression of EGFR has been noted in 43-67% of cases
and is associated with a decrease in disease-free and overall Survival.([4]) In renal cell carcinoma (RCC) EGFR expression is higher in primary RCC specimens
compared with benign renal parenchyma, indicating its possible role in tumor development
and progression.([5]) EGFR expression is often heterogeneous within clear cell RCC, where it has been
described as negative, weakly positive, and strongly positive staining.([6])
Normal endometrium had a mild HER-2 protein expression regardless of the phase of
the menstrual cycle.([7]) In endometrial cancer the HER-2 expression directly correlates with disease stage,
grade, and non-endometrioid tumor subtype, suggesting that HER-2 has potential use
as a biomarker for predicting disease stage, tumor aggressiveness and prognosis.([7])
Normal endometrial glands and stroma show weak to moderate expression of HER-4. HER-4
and its ligands have also been noted to be more highly expressed during the secretory
phase versus the proliferative phase of the menstrual cycle, suggesting a possible
involvement in maturation and anti-proliferative effects in the endometrium. HER-4
is expressed at a lower level in endometrial cancer and is overexpressed in approximately
15% of cases.([8]) Furthermore, Thomasson et al.([9]) evaluated HER-4 gene and protein expression in normal kidney parenchyma compared
to renal carcinomas from 31 patients and observed that HER-4 mRNA expression in RCC
tumor tissue was significantly reduced compared with normal matched kidney cortex.([9])
Therefore, the aim of the present study it was to correlate synchronous immunohistochemistry
expression of the EGFR family and p53 in a synchronous endometrial and renal primary
tumor, and also correlate with tumors grade and histological characteristics.
Case description
The patient was a 69 year-old, non-obese, post-menopausal woman, with no vaginal bleeding,
abdominal pain or urinary symptoms. She was diagnosed with synchronous endometrial
adenocarcinoma and clear cells renal cell carcinoma (RCC), and anatomopathological
characteristics of tumors are describe on[Table 1]
. Of note in her medical history, she regularly took medications with paracetamol
for back pain. She has a sister with a history of breast cancer at age 54, diagnosed
as invasive ductal carcinoma grade II (cancer-free for sixteen years), and a brother
who died at age 83 with grade 2 follicular lymphoma. The patient in the present study
has been cancer-free since surgery 4 years ago; no other treatment was advised besides
regular follow up imaging.
Table 1
Anatomopathological characteristics of tumors.
|
|
Endometrium
|
Kidney
|
|
Histological type
|
Endometrioid adenocarcinoma
|
Clear cells renal cell carcinoma
|
|
Histological grade
|
Well differentiated
|
Grade 1
|
|
Nuclear grade
|
Grade 2
|
Fuhrman grade 2
|
|
Mitotic index
|
Moderated
|
Not describe
|
|
Necrosis
|
Absent
|
Present
|
|
Hemorrhage
|
Not describe
|
Present
|
|
Invasion/Infiltration
|
Vascular infiltration - not observed
Myometrium invasion - superficial and focal
Endocervical infiltration - absent
|
Kidney capsule - absent
Perirenal fat - absent
Renal pelvis - absent
|
|
TNM
|
pTa pNO pMX - Stage I
|
pT1b pNO pMX - Stage I
|
Protein expression analysis was performed in both tumors of this patient, and fixed
paraffin-embedded tissue sections were processed for immunohistochemistry (IHC) staining
using the ABC (avidin-biotin complex) method, following the protocol shown in[Table 2]
. As a positive IHC control for EGFR, HER-2, HER-3 and HER-4, canine mammary specimens
were used ([Figure 1]), in a well-established routine protocol in collaboration with the Comparative Pathology
Laboratory at UFMG (Laboratório de Patologia Comparada - LPC) ([Figure 1]).
Results from endometrial adenocarcinoma IHC staining confirmed a well-differentiated
tumor (FIGO grade 1), with an epithelial growth pattern, areas of budding and branching
of glands forming papillary structures, endometrioid type, nuclear grade 2, and with
moderate mitotic index. Results from the renal cell carcinoma confirmed a clear cell
type, solid tumor, Fuhrman nuclear grade 2, with areas of necrosis and hemorrhage.
In the present investigation HER-2, HER-4 and EGFR expression was present in both
primary tumors. HER-2 was weakly expressed in both endometrioid and renal cell carcinomas.
However, HER-4 was localized in nuclei of the renal cell carcinoma ([Figure 3]), with 50% positive staining of the tubules and glomerulus ([Figure 3]), although the endometrioid adenocarcinoma revealed an intense membrane staining
([Figure 3]). EGFR expression in clear cells RCC was positive, with moderate membranous staining
in 90% of the cells ([Figure 2]), and in the endometrioid adenocarcinoma EGFR stained weakly in epithelial cells
([Figure 2]).
No HER-3 expression was evident, and p53 was detected only in the papillary areas
of the endometrioid adenocarcinoma ([Figures 2] and [3]).
Table 2
IHC parameters for polyclonal EGFR, HER-2, HER-3, HER-4 and p53 antibody.
|
Antibody
|
Antigen Retrieval
|
Dilution
|
Incubation
|
Source
|
|
EGFR
|
Pepsin + 37°C
|
1:50
|
ON
|
Dako
|
|
HER2
|
Citrate buffer + WB
|
1:200
|
ON
|
Dako
|
|
HER3
|
EDTA + WB
|
1:100
|
30′
|
Dako
|
|
HER4
|
Citrate buffer + Pascal
|
1:100
|
ON
|
Dako
|
|
p53
|
Citrate buffer + Pascal
|
1:400
|
ON
|
Dako
|
* WB - Water bath; ON - Overnight, Pascal - pressure cooker.
Figure 1 Immunohistochemistry (IHC) positive protocol for EGFR, HER-2, HER-3 and HER-4. Canine
mammary specimens.
Figure 2 Immunohistochemistry (IHC) for EGFR, HER-2 and p53 in endometrial carcinoma and clear
cell renal carcinoma.
A: H&E - endometrial carcinoma glandular area.
B: EGFR IHC - Intense staining of EGFR in stromal area, and weak staining in glandular
area of endometrial carcinoma.
C: HER-2 IHC - Weak staining of HER-2 in endometrial carcinoma glandular area.
D: p53 IHC - negative staining of p53 in endometrial carcinoma glandular area.
E: H&E - endometrial carcinoma papillary area.
F: EGFR IHC - Moderate staining of EGFR in stromal area, and negative staining in epithelial
cells of endometrial carcinoma papillary area.
G: HER-2 IHC - Negative staining of HER-2 in endometrial carcinoma papillary area.
H: p53 IHC - Intense staining of p53 in endometrial carcinoma papillary area.
I: H&E - Clear cells renal carcinoma.
J: EGFR IHC - moderate staining of EGFR in CCR.
L: HER-2 IHC - Weak staining of HER-2 in CCR.
M: p53 IHC - negative staining of p53 in CCR.
Figure 3 Immunohistochemistry (IHC) for HER-3 and HER-4 in endometrial carcinoma and clear-cell
renal carcinoma.
A: H&E - endometrial carcinoma glandular area.
B: HER-3 IHC - negative staining of HER-3 in stromal area of endometrial carcinoma glandular
area.
C: HER-4 IHC - Intense staining of HER-4 in endometrial carcinoma glandular area.
D: H&E - Clear cells renal carcinoma.
E: HER-3 IHC - negative staining of HER-3 in CCR.
F: HER-4 IHC - Nuclear positive staining of HER-4 in CCR.
DISCUSSION
HER-2 expression is associated with high grade endometrioid adenocarcinoma, and HER-2
overexpression is linked to poor prognostics because of a more aggressive tumor behavior.([10]
[11]) In the present investigation HER-2 was weakly expressed in endometrioid adenocarcinoma,
and this IHC result is in accordance to the patient good prognosis, since she has
been cancer-free for 4 years, and with patient's tumor histological grade. With regard
to the RCC, our results showed that HER-2 expression is rare in clear cells renal
cell carcinoma, in accordance to Wang et al. (2012) that showed a reduced HER-2 expression
during the development, oncogenesis and progression of RCC.([12])
According to Thomasson et al. (2004),([9]) HER-4 is a tumor suppressor in most RCCs, and it is related with a good prognosis.
In addition, Srinivasan et al. (1999)([8]) showed HER-4 overexpression in endometrioid adenocarcinoma compared to normal endometrium.
In clear cell RCC evaluated in the present study, HER4 was localized in nuclei of
the clear cells RCC, and endometrioid adenocarcinoma revealed an intense HER-4 membrane
staining ([Figure 3]).
EGFR receptor overexpression is related to initiation and tumor progression in RCC,([13]) and in the present patient it was observed 90% of clear cells RCC with EGFR moderate
staining, indicating its relation to tumor initiation. EGFR protein is normally expressed
in normal glandular endometrium, and EGFR could play a dual role in endometrial carcinoma,
such that high EGFR expression in type I carcinoma is associated with low grade and
favorable outcomes, but in contrast, EGFR expression in type II carcinoma was associated
with high grade and adverse clinical outcome.([14]
[15]
[16]
[17])
The p53 mutation in endometrial carcinoma is related to tumor survival and metastasis
risk,([18]) however, in the endometrioid adenocarcinoma it was observed p53 immunostaining
only in papillary area of the tumor. At the present investigation in clear cells RCC
p53 expression was negative ([Figure 2]), but nevertheless p53 expression is considered rare in clear cells RCC, in relation
to other types of renal carcinomas.([19])
In conclusion, HER-2, HER-4 and EGFR proteins were found synchronously expressed in
both primary tumors, and their expression in the present study is consistent with
their histological grade and patient cancer-free status, and it is also in accordance
to literature on the HER-2, HER-4 and EGFR proteins expression behavior in both tumors.
Future studies to investigate genetic instability in EGFR family DNA sequence may
clarify if the synchronous proteins expression in both primary tumors it is an important
trigger for cancer in those cases.
Bibliographical Record
Priscila Fernanda da Silva Martins, Izabella Cristina Alves Souza, Enio Ferreira,
Emerson Soares Veloso, Tatiany L Silveira, Adam Underwood, Fabiano Conde Araujo, Helen
Lima Del-Puerto. Expression of EGFR family and p53 in a patient with Synchronous Primary
Endometrial Adenocarcinoma and Clear Cell Renal Carcinoma: a Case Report. Brazilian
Journal of Oncology 2019; 15: e-20190011.
DOI: 10.5935/2526-8732.20190011
