Evaluation of the prognostic value of all four HER family receptors in patients with metastatic breast cancer treated with trastuzumab: A Hellenic Cooperative Oncology Group (HeCOG) study

Abstract

In the current study, we performed a complete analysis, with four different methods, of all four HER family receptors, in a series of patients with metastatic breast cancer treated with trastuzumab-based regimens and evaluated their prognostic value. Formalin-fixed paraffin-embedded tumor tissue samples were collected from 227 patients, considered to be HER2-positive when assessed at the local laboratories. We evaluated gene amplification, copy number variations (CNVs), mRNA and protein expression of all four HER family members. In addition, our analysis included the evaluation of several other factors by immunohistochemistry (IHC), such as pHER2Tyr1221/1222, pHER2Tyr877 and PTEN. Central review of HER2 status by IHC and fluorescence in situ hybridization revealed that of the 227 patients, only 139 (61.2%) were truly HER2-positive. Regarding the 191 patients treated with trastuzumab as first-line therapy, median time to progression (TTP) was 15.3 and 10.4 months for HER2-positive and HER2-negative participants, respectively, whereas median survival was 50.4 and 38.1 months, respectively. In HER2-positive patients, high HER3 mRNA expression was of favorable prognostic significance for TTP and survival (HR = 0.43, 95% CI 0.21-0.88, Wald's p = 0.022 and HR = 0.43, 95% CI 0.21-0.88, p = 0.021, respectively), while EGFR copy gain and EGFR protein expression were associated with higher risk for disease progression in HER2-negative patients (HR = 3.53, 95% CI 1.19-10.50, p = 0.023 and HR = 3.37, 95% CI 1.12-10.17, p = 0.031, respectively). Positive HER3 protein expression was a favorable factor for TTP in HER2-negative patients (HR = 0.43, 95% CI 0.22-0.84, p = 0.014). In the multivariate analysis, only EGFR copy gain retained its prognostic significance for TTP in the HER2-negative population (HR = 3.96, 95% CI 1.29-12.16, p = 0.016), while high HER3 mRNA expression retained its favorable prognostic significance for TTP in the HER2-positive subgroup (HR = 0.47, 95% CI 0.23-0.99, p = 0.048). The present study suggests that EGFR copy gain represents a negative prognostic factor for TTP in HER2-negative patients with metastatic breast cancer treated with trastuzumab. In addition, high HER3 mRNA expression appears to be of favorable prognostic significance for TTP in HER2-positive patients. Given the small number of patients included in the current analysis and the retrospective nature of the study, our findings should be validated in larger cohorts.

Fig 1. REMARK diagram.

Fig 2. Representative staining images of proteins studied in invasive breast carcinomas.

A. EGFR expression detected as moderate (2+) and strong (3+) membranous staining in neoplastic cells. B. Uniform, intense HER2 membranous staining (3+) in the majority of tumor cells. C. Moderate cytoplasmic HER3 expression in tumor cells. D. Moderate (2+) and strong (3+) cytoplasmic HER4 expression. E. Cytoplasmic and membranous expression of pHER2^Tyr1221/1222. F. Strong (3+) membranous and moderate (2+) cytoplasmic staining of tumor cells for pHER2^Tyr877. Bar: 10 μm. Magnification: x200.

Fig 3. Representative FISH photomicrographs using gene and centromere specific probes performed on TMA slides.

A. Amplification of the EGFR gene (green signals; gene probe). B. High amplification of the HER2 gene. C. Tumor cells with normal HER3 gene status. D. HER4 non-amplified invasive breast carcinoma. Magnification: x1000.

Fig 4. Kaplan-Meier curves in terms of (A) time to progression (TTP) and (B) survival, according to HER3 mRNA expression, in HER2-positive patients treated with first-line trastuzumab.