|Year : 2017 | Volume
| Issue : 2 | Page : 82-85
Clinicopathological significance of epidermal growth factor receptor and vascular endothelial growth factor expression in biliary tract malignancies
S Viswanath1, Reena Bharadwaj2, Amul Kapoor1
1 Department of Medical Oncology, Army Hospital (Research and Referral), New Delhi, India
2 Department of Pathology, Armed Forces Medical College, Pune, Maharashtra, India
|Date of Web Publication||13-Jun-2017|
Department of Medical Oncology, Army Hospital (Research and Referral), Delhi Cantt - 110 010, New Delhi
Source of Support: None, Conflict of Interest: None
Background: Biliary tract malignancies consists of gall bladder malignancies and intrahepatic and extrahepatic cholangiocarcinoma. Among these, the most common is gall bladder malignancies. The incidence of gall bladder carcinoma in India ranges from 1.01 per 100,000 for males and 10.1 per 100,000 for females.
Aims and Objectives: This study was conducted to assess the incidence of epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF) in biliary tract malignancies in Indian population, and to correlate the same with histological features as well as clinical staging and treatment outcomes.
Materials and Methods: Fifty cases of proven biliary tract malignancy were immunohistochemically stained for EGFR and VEGF, and scoring was done as per the standard recommendations.
Results: In our study, the expression of EGFR was significantly higher in advanced stage disease as well as in poorly differentiated adenocarcinomas.
Conclusion: Our study shows that advanced biliary tract malignancies show increased expression of EGFR.
Keywords: Biliary tract malignancies, EGFR, VEGF
|How to cite this article:|
Viswanath S, Bharadwaj R, Kapoor A. Clinicopathological significance of epidermal growth factor receptor and vascular endothelial growth factor expression in biliary tract malignancies. J NTR Univ Health Sci 2017;6:82-5
|How to cite this URL:|
Viswanath S, Bharadwaj R, Kapoor A. Clinicopathological significance of epidermal growth factor receptor and vascular endothelial growth factor expression in biliary tract malignancies. J NTR Univ Health Sci [serial online] 2017 [cited 2017 Sep 26];6:82-5. Available from: http://www.jdrntruhs.org/text.asp?2017/6/2/82/208000
| Introduction|| |
Biliary tract malignancies consist of gall bladder malignancies and intrahepatic and extrahepatic cholangiocarcinoma. Among these, the most common is gall bladder malignancies. The incidence of gall bladder carcinoma in India ranges 1.01 per 100,000 for males and 10.1 per 100,000 for females, however, the actual number may be much more in the endemic zones of western Bihar and eastern Uttar Pradesh where it is the third most common malignancy of the alimentary tract. The clinical and biological behavior of biliary tract malignancies not only depends on the size and extent of the disease but also on some molecular markers. The biological behavior of carcinoma gallbladder is based on certain well-established morphological features such as tumor size, site, grade, type, invasion, and metastatic state, as well as molecular markers that can be determinants of the prognosis of the disease. Limited studies have been conducted so far in the Indian subcontinent on the expression of EGFR and VEGF expression in biliary tract malignancies. In this study, we have tried to evaluate the expression of molecular markers, epidermal growth factor receptor (EGFR) and vascular endothelial growth factor (VEGF), in biliary tract malignancies.
Aim and objectives
To assess the incidence of EGFR and VEGF in biliary tract malignancies in Indian population and to correlate the same with histological features as well as clinical staging.
| Materials and Methods|| |
This study was approved by Institutional Review Board. This study included 50 cases of proven biliary tract malignancies (gall bladder cancers and cholangiocarcinoma), who attended our oncology department from October 2012 to June 2014. Surgical/trucut biopsy specimens from tumor/metastatic sites were submitted to the Department of Pathology for histopathology (HPE) and immunohistochemistry (IHC) analysis of EGFR and VEGF expression.
Rabbit antihuman VEGF (polyclonal) antibody and mouse antihuman EGFR (monoclonal) antibodies were used for the detection of expression on formalin-fixed, paraffin-embedded tissue sections. IHC is a method of identifying substances in the tissue using antigen-antibody reactions, which can be made visible microscopically using a suitable label. The primary antibody binds to specific tissue antigens. The biotinylated secondary antibody is directed at the primary antibody. The Streptavidin/Horse radish peroxidase (HRP) complex is then applied. Streptavidin binds to the biotin on the secondary antibody, and HRP acts as an indicator enzyme. On addition of diaminobenzidine (DAB) substrate, free oxygen radicals are released that oxidize DAB to a brown-colored precipitate. The precipitate gets deposited on the site and can be detected by microscopy.
VEGF was considered positive when more than 10% of the tumor cells showed unequivocal staining of cell membrane/cytoplasm. EGFR staining was evaluated as described by Kaufmann et al. as score 0 – no staining, 1+ – faint membrane staining in more than 1% of tumor cells in part of membrane, 2+ – weak-to-moderate incomplete staining in more than 1% of tumor cells, score 3+ – weak-to-moderate complete membrane staining in more than 1% of tumor cells.
| Results|| |
In our study, out of the 50 cases, 36 (72%) were extrahepatic cholangiocarcinoma which included extrahepatic biliary and gall bladder tumors, and 14 (28%) were intrahepatic cholangiocarcinoma [Figure 1].
Most of the cases were advanced stage, and the stage distribution is shown in [Table 1]. Well-differentiated adenocarcinoma was seen in 10 (20%) of the cases, moderately differentiated adenocarcinoma was seen in another 10 (20%) of the cases, and poorly differentiated adenocarcinoma was seen in 30 (60%) of the cases [Figure 2].
As far as the expression of EGFR and VEGF were concerned, there was no significant difference in the expression of these markers between extrahepatic cholangiocarcinoma and intrahepatic cholangiocarcinoma. In extrahepatic cholangiocarcinoma, the EGFR was expressed in 28% of the cases and VEGF in 55% of the cases [Figure 3]a. In intrahepatic cholangiocarcinoma, EGFR was expressed in 28% of the cases and VEGF in 59% of the cases [Figure 3]b,[Figure 3]c,[Figure 3]d.
|Figure 3: (a) Molecular expression in EHCC; (b) molecular expression in IHCC; (c) EGFR cytoplasmic positive; (d) expression of VEGF|
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The tumor types in stage (stages I and II) disease were well differentiated, and 8 expressed VEGF; only one among them expressed EGFR. In advanced stage (stages III and IV), 75% of the tumors were poorly differentiated, 20% were moderately differentiated, and only 5% were well differentiated. In our study, VEGF was expressed in 62% of all cases of early stage and 56% of advanced stage disease, whereas EGFR was expressed in 7% of early stage disease and 23% of advanced stage disease.
| Discussion|| |
Biliary tract cancer is rather common in Latin America and Asia, including Japan, while being relatively rare in European countries and United States; approximately 16000 patients in Japan and 5000 patients in the United States are newly diagnosed as having this type of cancer each year. The varied geographic distribution of the risk factors for biliary tract cancer, including primary sclerosing cholangitis, hepatolithiasis, congenital biliary cystic diseases, chemical agents, and hepatitis virus infections, appears to contribute to the differences in the incidence rates among ethnic groups.,,,
In general, gall bladder cancer carries a worse prognosis than cholangiocarcinoma; however, gall bladder cancer tends to exhibit a greater response rate (RR) to chemotherapy. No significant strides have been made in the management of locally advanced and metastatic biliary tract malignancies.,
In this study, we have considered 50 consecutive cases of biliary tract malignancies. Periampullary carcinomas and carcinomas of the ampula of vater were not considered. This study was a pilot study to assess the expression of EGFR and VEGF in Indian popula'tion and attempted to correlate the clinical profile of the disease mainly the location (intrahepatic cholangiocarcinoma or extrahepatic cholangiocarcinoma) and the stage of the disease.
We have not attempted to change the treatment protocol based on the expression pattern as the scope of this study was to assess the expression pattern of EGFR and VEGF in our population and to correlate most of the patients were in the advanced stage at the time of presentation, which is consistent with most of the clinical studies internationally., In higher in the advanced stage disease as well as in poorly differentiated adenocarcinomas. There was no significant difference in the expression of VEGF in early stage or advanced stage and also between well-differentiated, moderately-differentiated, and poorly-differentiated tumors.
After surgery, gall bladder cancer is more likely to recur distantly than extrahepatic cholangiocarcinoma, for which local recurrence is an appreciable risk.
Preclinical studies have shown that EGFR and VEGF have a crucial role in the pathogenesis of these tumors. In addition, EGFR signaling regulates the expression of VEGF. Some studies have demonstrated overexpression of EGFR and VEGFR, or mutations of their signalling pathways in biliary tract cancer.
As has been already stated in the study, there was a correlation with the stage of the disease and EGFR expression. This being a small pilot study in the Indian population, there is a requirement of further larger studies to map the expression patterns in Indian population and thereafter consider using targeted therapies in further studies. This is further supported by the increased incidence of biliary tract malignancies when compared to other parts of the world with more cases of gall bladder malignancy.,,, VEGF expression has been shown to be associated with intrahepatic metastasis in cases of intrahepatic cholangiocarcinoma.,
Some preclinical experiences show that VEGF or EGFR inhibitors administered alone might be effective in the treatment of biliary tract cancer. In many patients, with progressive disease receiving firstline chemotherapy with the relatively toxic regimen of cisplatin plus gemcitabine, the general condition is poor, and serious cholangitis can easily develop. Less toxic therapy, such as monotherapy with a targeted agent, may be useful in such patients.
| Conclusion|| |
Our study shows that advanced biliary tract malignancies show increased expression of EGFR. As our study was a pilot study, further studies are required. The question whether the expression of EGFR in the early stage portends a tendency towards progressive disease needs to be assessed in larger studies with more years of follow-up. As the incidence of biliary malignancies is high in our targeted therapy in biliary malignancies need to be undertaken.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Randi G, Malvezzi M, Levi F, Ferlay J, Negri E, Franceschi S, La Vecchia C. Epidemiology of biliary tract cancers: An update. Ann Oncol 2009;20:146-59.
Lazaridis KN, Gores GJ. Cholangiocarciinoma. Gastroenterology 2005;128:1655-67.
Aljiffry M, Walsh MJ, Molinari M. Advances in diagnosis, treatment and palliation of cholangiocarcinoma: 1990-2009. World J Gastroenterol 2009;15:4240-62.
Ben-Menachem T. Risk factors for cholangiocarcinoma. Eur J Gastroenterol Hepatol 2007;19:615-7.
Eckel F, Schmid RM. Chemotherapy in advanced biliary tract carcinoma: A pooled analysis of clinical trails. Br J Cancer 2007;96:896-902.
Hezel AF, Zhu AX. Systemic therapy for biliary tract cancers. Oncologist 2008;13:415-23.
Nakeeb A, Pitt HA, Sohn TA, Coleman J, Abrams R, Piantodosi S, et al
. Cholangiocarcinoma. A spectrum of intrahepatic, perihilar and distal tumors. Ann Surg 1996;224:463-73.
Malhi H, Gores GJ. Cholangiocarcinoma: Modern advances in understanding a deadly old disease. J Hepatol 2006;45:856-67.
Jarnagin WR, Ruo L, Little SA, Klimstra D, D'Angelica M, DeMatteo RP, et al
. Patterns of initial disease recurrence after resection of gallbladder carcinoma and hilar cholangiocarcinoma: Implications for adjuvant therapeutic strategies. Cancer. 2003;98:1689-700.
Aaronson SA. Growth factors and cancer. Science 1991;254:1146-53.
De Luca A, Carotenuto A, Rachiglio A, Gallo M, Maillo MR, Aldinucci D, et al
. The role of the EGFR signaling in tumour microenvironment. J Cell Physiol 2008;214:559-67.
Thomas MB. Biological characteristics of cancers in the gallbladder and biliary tract and targeted therapy. Crit Rev Oncol Hematol 2007;61:44-51.
Nonomura A, Ohta G, Nakanuma Y, Izumi R, Mizukami Y, Matsubara F, et al
. Simultaneous detection of epidermal growth factor receptor (EGF-R), epidermal growth factor (EGF) and ras p21 in cholangiocarcinoma by an immunocytochemical method. Liver 1988;8:157-66.
Yoshikawa D, Ojima H, Iwasaki M, Hiraoka N, Kosuge T, Kasai S, et al
. Clinicopathological and prognostic significance of EGFR, VEGF, and HER2 expression in cholangiocarcinoma. Br J Cancer 2008;98:418-25.
Feruse J, Okasaka T. Targeted therapy for biliary tract cancers. Cancers 2011;3:2243-54.
[Figure 1], [Figure 2], [Figure 3]