INTRODUCTION
Breast cancer, due to its diverse genetic makeup, is a heterogeneous disease with variable biological and clinical features. India has a population of 1.3 billion in 29 states and seven union territories, and many of the states are as large as other nations with differing degrees of growth, population genetics, environment, and behaviors, contributing to a heterogeneous distribution of the burden of disease and health loss.[1]
The study of tumour molecular characteristics has improved our understanding of the risk of breast cancer recurrence, and treatment response.[2] To determine the trajectory of malignancies, molecular biomarkers are important. Several molecular markers that are significant in the clinical aspect of malignancies have been found, particularly in breast cancer. In forecasting the outcome of disease and decision-making for effective care, the evaluation of these biomarkers is valuable.[3] In breast cancer, overexpression of Her2 and p53 may have prognostic importance.
Her2 (c-erbB2) encodes a membrane protein (p185) that, after interaction with its ligands, is phosphorylated by tyrosine. Overexpression of Her2 occurs by either gene amplification or by overexpression of mRNA. p53 is involved in regulating cell proliferation-inducing apoptosis and enhancing chromosomal stability. In carcinogenesis, disturbance of these roles tends to play a significant role. There is evidence that overexpression of Her2 and p53 is implicated in the development of breast cancer.[4] This argument is grounded on the elevated overexpression level of Her2 and p53 in invasive, noninvasive breast cancer and over-and among benign breast diseases.[5,6] This implies that in the early stages of breast tumorigenesis, Her2 and p53 play important roles.
The purpose of this study was to observe any possible association between the expression of p53 and Her2/neu with other prognostic factors in histologically confirmed breast cancer patients.
MATERIALS AND METHODS
This study was approved by the institutional ethical committee before the commencement of the study. A total of fifty consecutive diagnosed cases of infiltrating duct carcinoma over a period of 2 years were reviewed from archived pathology records. Relevant clinical and pathological data, such as age, gender, dimensions of the tumors, and the presence of lymph node metastases, were obtained from the clinical documents, gross records, and pathological reports of these patients. Follow-up data of these patients were done from hospital information system, from the department of radiotherapy, and the records of the cancer registry. This study analyzed de-identified patient data as far as possible.
Representative sections from breast cancer patients diagnosed with infiltrating duct carcinoma in histopathological specimens were obtained.
Cases where full clinical details and/or follow-up were not available, and those with insufficient representative tissue for immunohistochemistry were excluded from the study.
To obtain the best section for immunohistochemistry, hematoxylin and eosin-stained slides were retrieved and screened, and as far as possible, sections showing both normal and tumor were selected to provide internal control. Evaluation of p53 and Her2/neu staining was done, and staining was scored as 0, 1, 2, 3, and 0, 1±, 2±, or 3±, respectively. Overexpression of p53 and Her2/neu was considered positive when the scoring was 1, 2, or 3 and 2 ± or 3±, respectively. Due to less number of cases in some of the subgroups, staining for p53 and Her2/neu overexpression was only considered positive and negative.
RESULTS
In the present study, we examined clinicopathological parameters separately and also in association with each other to find a possible relation.
The age of the patients ranged from 28 to 75 years old (51.44 ± 11.02). Most of the cases presented as lumps in the left breast. Only one patient presented with a retracted nipple while all others presented with lumps in breast. Most of the patients in the current study were Grade III tumors, regardless of size of primary tumor.
We had only one case of tumor <2 cm which did not show lymph node involvement. Tumor size between 2 and 5 cm and more than 5 cm had almost the same number of lymph node involvement.
The other baseline information of all the patients with breast cancer enrolled in this study is presented in Table 1.
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Table 1: Baseline information of the cases
In 7 and 12 cases, respectively, p53 and Her2/neu were positive and negative. p53 positivity was found in 26 cases with Her2/neu negativity, whereas p53 negativity was found in 5 cases with Her2/neu positivity (P = 0.5) [Table 2].
Table 2: Correlation of p53 with Her2/neu status
One case with a tumor size <2 cm was Grade III tumor. Grade III tumors accounted for 18 cases of tumors with a size of 2–5 cm and 9 cases of tumors with a size more than 5 cm. Lymph node involvement was seen in 23 cases with tumor sizes ranging from 2 to 5 cm and 10 cases with tumor sizes >5 cm. One patient with tumor size <2 cm was positive for p53 expression, while 22 cases with tumor size between 2 and 5 cm and 10 cases with tumor size more than 5 cm were positive for p53 expression. A single case of Her2/neu overexpression in tumor <2 cm was found to be negative. Six cases with a size of 2–5 cm and six cases with a size of more than 5 cm had Her2/neu overexpression [Table 3].
Table 3: Distribution of various clinicopathological parameters in relation to size of tumor
Thirteen cases of Grade II tumor and 19 cases of Grade III tumors had lymph node involvement, while in only 1 case of Grade I tumors, lymph nodes were involved. p53 was positive in 3 cases out of 4 cases of Grade I tumor, 9 cases of Grade II tumors, and 21 cases of Grade III tumors. Her2/neu was positive in 1 out of 4 cases of Grade I tumors, 7 out of 18 cases of Grade II tumors, and 4 out of 28 cases of Grade III tumors [Table 4].
Table 4: Distribution of various clinicopathological parameters in relation to grade of tumor
We were able to do follow-up on 21 cases till the completion of the study. Six patients with tumor size more than 5 cm expired as compared to 1 alive case and 9 cases of Grade III patients expired as compared to 4 and 1 cases of Grade II and Grade I tumors. Nine and five patients who had overexpression of p53 and negative p53, respectively, died during follow-up. The same percentage of cases with overexpression of Her2/neu and Her2/neu negativity were either expired or alive. Survival of patients according to other clinicopathological parameters is shown in Table 5.
Table 5: Survival of patients according to various clinicopathological parameters
DISCUSSION
In low-income and middle-income countries, including India, cancer patients typically have a worse prognosis because of comparatively low cancer awareness, delayed diagnosis, and lack of or inadequate access to affordable curative care compared to patients in high-income countries.[7,8]
Breast cancer is the second most common neoplasm among women in India, and its incidence is growing. In patients with breast cancer, many molecular cancer biomarkers have been linked with poor prognosis, and the existence of these markers is also considered to provide information on the biological activity of the malignant breast tumor. The tumor suppressor gene p53 has recently been the subject of much attention. Mutations or alterations of this gene lead to lack of negative regulation of growth and thus accelerate the proliferation of cells.[9]
As most of them have lymph node involvement by the time they report to the health services, most patients from India and other low-income countries have a higher stage of illness. The higher the grade of tumor, bigger is the tumor size which indicates a correlation between grade of tumor and stage of disease; as higher the tumor size, higher will be the tumor stage. The findings of our study suggest that breast cancer is more prominent among old age, which is in agreement with other studies.[10–12]
In their analysis, González-Sistal etal.[13] observed that increased tumor size correlated significantly with histological Grade III.
In our study, Grade III tumors were observed in most patients with tumor size >5 cm compared to those with tumor size between 2 and 5 cm, although this result was not statistically significant.
However, it indicates a pattern that a tumor with a higher grade has a bigger tumor size, which is in sync with the findings of other authors.[13,14] Our study results agree with other authors that the high tumor grade was substantially associated with a higher risk of lymph node involvement.[15,16]
Due to less number of cases in some of the subgroups, overexpression was considered positive or negative for p53 and Her2/neu overexpression. Nearly two-third of the patients were shown to have p53 positivity in the tumor cells. There was, however, no connection between the extent of the tumor and p53 positivity. There was also no connection between p53 overexpression and histological grade and lymph node involvement.
There is no clear correlation between p53 overexpression and tumor size and p53 overexpression with lymph node activity in the results of the present study as well as most of the other studies.[17–20] While p53 expression has been related to poor outcomes in patients with breast cancer, its usefulness as a prognostic marker has been contentious.
However, by taking a cutoff point of 50%, Kikuchi etal.[21] found that p53 overexpression was a major prognostic factor. We took a cutoff of more than 10% as positive in the present analysis. Much of the other contributors had a 5%–25% cutoff. Therefore, evaluating different cutoffs and then correlating p53 expression with other prognostic markers such as Her2/neu and estrogen receptors, progesterone receptor status would be beneficial.
In 24% of the cases, Her2/neu was positive in the present analysis. No association was found between tumor size and overexpression of Her2/neu. However, we observed that more number of patients had lymph node involvement when the tumor was Her2/neu positive (overexpression), and there was no association between grade of tumor and Her2/neu positivity.
In deciding cancer staging and treatment choice, lymph node status is important. There have been studies that have found substantial correlations. Most of the studies[20,22,23] have not observed any relationship between tumor size and Her2/neu overexpression. Most of the authors,[24,25] however, found a significant correlation between lymph node involvement and Her2/neu overexpression. All authors in the literature had observed a significant association with grade of tumor and Her2/neu overexpression.[20,22–26]
There were only four cases of Grade I tumor in our study and this may explain as to why no significant correlation between histologic grade and overexpression of Her2/neu was found. As with other studies, we found a correlation between lymph node activity and Her2/neu overexpression.
Her2/neu overexpression has been shown to predict poorer survival in patients with lymph node-positive breast cancer, and as a trastuzumab therapeutic target in patients with Her2/neu overexpressed breast cancer.[27] Therefore, its detection is important in the management of breast cancer patients.
There was also no substantial correlation between p53 expression and Her2/neu overexpression was observed by most authors in literature,[15,20] but our study indicates that Her2/neu-negative lesions are more likely to be p53 positive as found by Payandeh etal.[25]
Follow-up was possible in only 21 patients, and there was no clear correlation between tumor size, tumor grade, and Her2/neu expression with patient survival. However, compared to those patients who did not have lymph nodes involvement, patients who had lymph node involvement had a greater risk of mortality. Likewise, as opposed to p53-positive patients, p53-negative patients had greater mortality rates.
Our results differed with most of the authors[6,14,20,22] and no significant correlation was found between tumor size, tumor grade, and Her2/neu expression with patient survival.
Lymph node involvement and negative p53 were, however, associated with survival of patient.
The survival outcomes of the present study are not comparable with other authors because we had follow-up available in <50% of our cases.
A larger study with improved survival analysis, complete details of cancer-directed treatment and follow-up over a longer period would aid in ascertaining the role of p53 and Her2/neu as a prognostic marker in the rural population of India.
CONCLUSION
Studies using various cutoff figures to label p53 overexpression need to be undertaken to ascertain the role of p53 as a prognostic marker. Her2/neu overexpression is associated with lymph node involvement and it also acts as a therapeutic target. Therefore, its detection is important in the management of breast cancer patients. A study with a larger sample size should be undertaken with complete detail of cancer-directed treatment and regular follow-up over a longer duration to ascertain the role of p53 and Her2/neu as a prognostic marker in the rural population of India.
Financial support and sponsorship
Financially aided by Research Grant committee of institute.
Conflicts of interest
There are no conflicts of interest.
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