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 Table of Contents  
Year : 2018  |  Volume : 1  |  Issue : 1  |  Page : 25-29

Role of human epidermal growth factor receptor 2 antagonist (Trastuzumab) in the management of nonmuscle-invasive urinary bladder carcinoma

1 Department of Pathology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
2 Department of Anatomy, Faculty of Medicine, Zagazig University, Zagazig, Egypt
3 Department of Urology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
4 Department of Medical Oncology, Faculty of Medicine, Zagazig University, Zagazig, Egypt
5 Department of Radiotherapy, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Web Publication30-Jan-2018

Correspondence Address:
Dr. Raafat Hegazy
Department of Pathology, Zagazig University, Zagazig
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tme.tme_15_17

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Background: Superficial bladder cancers (nonmuscle invasive) are commonly faced by urologists and represent a major challenge for urologists and oncologists, especially Grade III carcinomas, whether conservative treatment is sufficient alone or with radical cystectomy is essential. Aim of the Study: We aimed to find a way to avoid recurrences in the nonmuscle-invasive bladder cancer and in the same time avoid radical cystectomy. Patient and Methods: We selected 42 patients with nonmuscle-invasive bladder cancers from those attending to Urology Department, Zagazig University Hospitals, from December 2011 to January 2015. After complete transurethral resection (TUR) bladder resection, diagnosis of biopsy was based on H and E-stained sections. Then, human epidermal growth factor receptor 2 (Her2) immunostaining was performed for all paraffin blocks derived from the patients. Trastuzumab was given to all cases that were positive to Her2, and only one case of them did not receive trastuzumab and left as a control. All cases then underwent follow-up for 20 months. Results: We found a significant relationship (P = 0.05) between Her2 immunostaining positivity and tumor stage, grade, multifocality, and recurrences/progression. Most cases who received trastuzumab did not undergo recurrences (19/22) (P = 0.005). We found also decrease in the immunostaining in cases of recurrences, indicating the presence of other factors affecting the occurrence or recurrences/progression. Conclusions: We concluded that administration of anti-Her2 therapy (like trastuzumab) may be essential for Her2-positive superficial bladder cancer to avoid recurrences after complete TUR bladder (TURB). Recommendation: We recommend for other studies on the significances of recurrences and how to avoid them.

Keywords: Bladder carcinoma, human epidermal growth factor receptor 2 antagonist, nonmuscle invasive bladder cancer

How to cite this article:
Hegazy R, Hegazy A, Kamel M, El-Farargy O, Nawar N, El-Atar A. Role of human epidermal growth factor receptor 2 antagonist (Trastuzumab) in the management of nonmuscle-invasive urinary bladder carcinoma. Tumor Microenviron 2018;1:25-9

How to cite this URL:
Hegazy R, Hegazy A, Kamel M, El-Farargy O, Nawar N, El-Atar A. Role of human epidermal growth factor receptor 2 antagonist (Trastuzumab) in the management of nonmuscle-invasive urinary bladder carcinoma. Tumor Microenviron [serial online] 2018 [cited 2023 Dec 9];1:25-9. Available from: http://www.TMEResearch.org/text.asp?2018/1/1/25/224339

  Introduction Top

Most bladder cancers are diagnosed as superficial bladder carcinoma, i.e., noninvasive including that confined to the mucosa and those invading the lamina propria but not reaching the muscle layer, the so-called nonmuscle invasive. The diagnosis of bladder cancer depends on cystoscopy and histopathologic diagnosis. The complete, correct transurethral resection (TUR) is essential in proper management of the patient.[1] Recurrences represent a major challenge to urologists and oncologists; not only it means failure of management protocol, but also the recurrences are more aggressive. The risk of recurrence and progression may be estimated using the scoring system and risk tables.[2] In cases of superficial (pT1), high-grade (G3) tumors, there is still controversy about the best line of treatment; whether conservative treatment (TUR-B/instillation of BCG vaccine or chemotherapy) is enough or radical cystectomy must be done is still unclear. More than half of these patients (treated with conservative measures) do not progress. In addition, radical cystectomy from the beginning represents overtreatment.[3] In a previous research,[4] we recommended to perform another study to investigate the relation between human epidermal growth factor receptor 2 (Her2) immunohistochemical staining marker and treatment with anti-Her2 chemotherapy. Anti-Her2 is one of the promising therapies of cancers. Her2 gene is related to the epidermal growth factor receptor family. Her2 gene activates intracellular pathways that promote cell proliferation, hence promoting tumor cell survival, mobility, and invasiveness.[5],[6] In breast cancers, gene amplification is the primary mechanism for Her2 overexpression. Anti-Her2 therapies (e.g., trastuzumab) have become a standard treatment in breast cancers.[6],[7] Utilization of ant-Her2 in the management of muscle-invasive bladder cancer was previously performed.[8]

  Patient and Methods Top

Specimen selection was as follows: 42 patients suffering from nonmuscle-invasive bladder cancer were selected from those attending the urology, pathology, and/or oncology departments, Faculty of Medicine, Zagazig University, between January 2013 and December 2014. Diagnostic TUR bladder (TURB) was done first, hematoxylin and eosin-stained slides were prepared, histopathological diagnosis was done using Binuclear Olympus microscope (CX31), and classification was done according to tumor-node-metastasis and Mostofi classification.[9],[10] Forty-two cases of nonmuscle-invasive bladder cancer were selected, and written concepts were taken. Cases of/or associated with carcinoma in situ (Cis) were excluded from this study.

Immunohistochemical staining

Immunostaining was performed according to previous works,[11] with some modifications. Briefly, (1) the paraffin blocks were obtained after histopathological diagnosis. (2) the paraffin blocks were cut into 4 um thick sections, (3) Then, placed on positively charged glass slides (obtained from BioGenex). (4) Sections were deparaffinized and cleared in three instances of changes of xylene, 10 min each. (5) Endogenous peroxidase activity was blocked by a 3% solution of hydrogen peroxide and methanol for 30 min. (6) Sections were then hydrated in descending grades of alcohol (2 instances of changes of absolute alcohol, then 95%, 80%, 70%, and 50% for 10 min each) to distilled water. (7) Antigen retrieval was performed in citrate-buffered solution (pH: 6), heating in a microwave at 100°C for 4 min. (8) Slides were then cooled to room temperature and placed in a humidified chamber. (9) Addition of blocking antiserum: 10% normal horse serum (Vector Laboratories, Burlingame, CA) was applied for 20 min, and then blotting the blocking antiserum. (10) The primary antibody (c-erb B2; BioGenex; 1:50 dilution) was applied and incubated overnight at 4°C. (11) They were placed in phosphate-buffered saline (PBS) for 20 min. (12) Application of the biotinylated secondary antibody: horse-antimouse biotinylated antibody (Vector Laboratories) was applied at a dilution of 1:800 and incubated for 60 min at room temperature. (13) Two PBS rinses were performed (14) Then, it was followed by a 30-min incubation with avidin-biotin complex (Vector Laboratories). (15) Color development was achieved by application of the chromagen 3,3 diaminobenzidine tetrahydrochloride (Vector Laboratories) and careful monitoring of staining by direct light microscopy visualization. The slides were then rinsed thoroughly in running tap water. (16) The slides were counterstained in Mayer's hematoxylin, dehydrated, cleared, and cover slipped by DPX. Negative control sections were achieved by subjection to all steps of staining except for the primary antibody. Positive controls were paraffin-embedded sections of breast carcinoma that had been identified as positive for Her2/neu by immunohistochemistry analysis.

Sections were examined by Binuclear Olympus light microscopy (CX31). Sections were scored as positive only if membrane staining was uniform, complete around 20% or more of 400 examined malignant cells (we examined 100 cells in four slides for each time). Less than 20% of cells taking the stain uniformly were considered negative.

Cases that showed positivity (>20% of cells showed uniform clear cytoplasmic/membranous reactivity) were 24 cases, 22 of them underwent treatment with trastuzumab while two cases were left without treatment with trasuzumab as a control.

Dosage and duration of trastuzumab treatment

The initial dosage of 8 mg/kg bodyweight was administered, and the maintenance dose at 6 mg/kg body weight at 3 weeks' interval, beginning 3 weeks after the initial dose. We did not use adjuvant chemotherapy. We utilized trastuzumab for 20 months or until appearance of recurrence.

Frame of follow-up

All the 42 cases underwent clinical examination every 3 months, ultrasound and MRI evaluation every 6 months, and transurethral endoscopy and biopsy for suspected cases. Immunohistochemical staining of Her2 was done for the cases of recurrences. The process of follow-up was continuous for 20 months at urology, oncology, and pathology departments.

Statistical analysis

The relation of age of patients at the time of cancer diagnosis is studied with the sex (male or female). The relationship of Her2 immunohistochemical reactivity to tumor stage, grade, multifocality, recurrences/progression were analyzed. We analyze, also, the relationship of trastuzumab administration and the occurence or absence of recurrences. All these were studied with Chi-square test with significance of P = 0.05 or less, using SPSS 16.0 for Windows (SPSS Inc. Chicago, Illinois, USA).

  Results Top

In this study, age of patients ranged from 59 to 83 years, with a median age of 71 years. The male:female ratio was 2:1 [Table 1]. Patients <70 years old were more in male category (23 males and 4 females), while older patients (>70 years) were more in female category (5 males and 10 females), with significant relationship (P = 0.05) [Table 2]. Cases which were positive for Her2 (>20% of malignant cells showed uniform complete membranous staining) were 24 cases [Figure 1] and [Figure 2]. We found significant increase of Her2 staining positivity (P = 0.05) with tumor stage, tumor grade, multifocality, and recurrences and/or progression. Twenty-two cases were treated with trastuzumab [Table 3]. Cases of multifocality were excluded from the assay of recurrences. Recurrences occurred only in four cases; three of them were previously treated with trastuzumab while one case did not take Trastuzumab. A significant relation of treatment with trastuzumab and absence of recurrences (P = 0.05) was found [Table 4]. We found decrease in the scoring of Her2 immunostaining in the three cases of recurrences [Figure 3].
Table 1: Summary of clinical data, tumor stage, grade, trastuzumab, multiplicity, and recurrences/progressions

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Table 2: Age of patients in relation to sex

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Figure 1: Human epidermal growth factor receptor 2 positive immunostaining in a case of papillary transitional cell carcinoma (T1 gIII), and small area of submucosal infiltration, ×400

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Figure 2: Human epidermal growth factor receptor 2 positive immunostaining in a case of papillary transitional cell carcinoma (Ta gIII), ×400

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Table 3: Relationship of human epidermal growth factor receptor 2 immunohistochemical reactivity to tumor stage, grade, multifocality, and recurrences/progression

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Table 4: Relationship of trastuzumab and absence of recurrences

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Figure 3: Human epidermal growth factor receptor 2 immunostaining, posttreatment of case of previous strong reactivity; low reaction of human epidermal growth factor receptor 2 is noticed

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  Discussion Top

In this study, we found that nonmuscle-invasive bladder cancer occurred mainly in males below 70 years old (23 cases) and mainly in females above 70 years old (10 cases), with a significant relationship (P = 0.05). This may be attributed to the exposure to irritants and carcinogens that affect males earlier. This result agreed with that of other authors.[12] In regard to Her2 immunohistochemical staining, we found increase in the expression of Her2 immunostaining with the higher grade, stage, multifocality, and recurrences/progression (P = 0.05). This result agreed with other authors.[13],[14] In our previous study,[4] we found significant relation of Her2 immunohistochemical expression with tumor grading and recurrences but insignificant with tumor staging and multifocality. The introduction of Her2-directed therapies has dramatically given excellent results in patients with Her2-positive breast cancers, but bad results have been noticed in other Her2-overexpressing cancers.[15] In cases of advanced muscle-invasive urothelial carcinoma, Her2 antagonists (like trastuzumab) give better results and better prognosis.[16] Trastuzumab binds with subdomain IV, a juxtamembrane region of Her2's extracellular domain. Binding of trastuzumab with Her2 inhibits ligand-independent Her2 signaling and prevents the proteolytic cleavage of its extracellular domain, an activation mechanism of Her2. As a result, trastuzumab inhibits the proliferation of human tumor cells that overexpress Her2. Additionally, trastuzumab is a potent mediator of antibody-dependent cell-mediated cytotoxicity.[17]

To our knowledge, no researches performed studies on the relation of anti-Her2 chemotherapy with nonmuscle-invasive bladder cancer. We administrated trastuzumab (anti-Her2) for all cases that express positivity for immunohistochemical staining of Her2 (23 cases) except for only two cases as a control. Only three cases from 21 cases given trastuzumab underwent recurrence/progression (P = 0.05). This result gives an idea about the importance of trastuzumab to avoid recurrences in the Her2-positive nonmuscle-invasive bladder cancer. Immunostaining of Her2 in cases of recurrences showed decrease in the intensity despite the recurrences. This result may be due to the effect of other controllers of tumor recurrences and/or progression. We did not give trastuzumab to two cases that showed positivity for Her2, one of them showed recurrence; this result also shows the importance of other controllers of tumor progression.

  Conclusions Top

We suggest to perform Her2 for nonmuscle-invasive bladder cancer and prescribe anti-Her2 (e.g., trastuzumab) after TURB to avoid tumor recurrences.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kamat AM, Gee JR, Dinney CP, Grossman HB, Swanson DA, Millikan RE, et al. The case for early cystectomy in the treatment of nonmuscle invasive micropapillary bladder carcinoma. J Urol 2006;175:881-5.  Back to cited text no. 1
Babjuk M, Oosterlinck W, Sylvester R, Kaasinen E, Böhle A, Palou-Redorta J, et al. EAU guidelines on non-muscle-invasive urothelial carcinoma of the bladder. Eur Urol 2008;54:303-14.  Back to cited text no. 2
Pham HT, Soloway MS. High-risk superficial bladder cancer: Intravesical therapy for T1G3 transitional cell carcinoma of the urinary bladder. Semin Urol Oncol 1997;15:147-53.  Back to cited text no. 3
Hegazy R, Kamel M, Salem EA, Salem NA, Fawzy A, Sakr A, et al. The prognostic significance of P53, P63 and Her2 expression in non-muscle-invasive bladder cancer in relation to treatment with Bacille Calmette-Guerin. Arab J Urol 2015;13:225-30.  Back to cited text no. 4
Harris L, Fritsche H, Mennel R, Norton L, Ravdin P, Taube S, et al. American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer. J Clin Oncol 2007;25:5287-312.  Back to cited text no. 5
Begnami MD, Fukuda E, Fregnani JH, Nonogaki S, Montagnini AL, da Costa WL Jr., et al. Prognostic implications of altered human epidermal growth factor receptors (HERs) in gastric carcinomas: HER2 and HER3 are predictors of poor outcome. J Clin Oncol 2011;29:3030-6.  Back to cited text no. 6
Bang YJ, Van Cutsem E, Feyereislova A, Chung HC, Shen L, Sawaki A, et al. Trastuzumab in combination with chemotherapy versus chemotherapy alone for treatment of HER2-positive advanced gastric or gastro-oesophageal junction cancer (ToGA): A phase 3, open-label, randomised controlled trial. Lancet 2010;376:687-97.  Back to cited text no. 7
Kiss B, Wyatt AW, Douglas J, Skuginna V, Mo F, Anderson S, et al. Her2 alterations in muscle-invasive bladder cancer: Patient selection beyond protein expression for targeted therapy. Sci Rep 2017;7:42713.  Back to cited text no. 8
Eble JN, Sauter G, Epstein JI, Sesterhenn IA. Pathology and Genetics of Tumours of the Urinary System and Male Genital Organs. Lyon: IARC; 2004.  Back to cited text no. 9
Sobin LH, Gospodarowicz MK, Wittekind C. TNM Classification of Malignant Tumours. 7th ed. Weinheim: Wiley; 2009.  Back to cited text no. 10
Boenisch T, Farmilo AJ, Stead R, editors. Hand Book Immunochemical Staining Methods. California USA: DAKO Corporation Carpinteria; 2001. p. 1-62.  Back to cited text no. 11
Horstmann M, Witthuhn R, Falk M, Stenzl A. Gender-specific differences in bladder cancer: A retrospective analysis. Gend Med 2008;5:385-94.  Back to cited text no. 12
Alexa A, Baderca F, Zăhoi DE, Lighezan R, Izvernariu D, Raica M, et al. Clinical significance of Her2/neu overexpression in urothelial carcinomas. Rom J Morphol Embryol 2010;51:277-82.  Back to cited text no. 13
Charfia S, Khabira A, Mnifa H, Ellouzea S, Mhirib M, Sellamia T. Immunohistochemical expression of HER2 in urothelial bladder carcinoma and its correlation with p53 and p63 expression. J Microsc Ultrastruct 2013;1:17-21.  Back to cited text no. 14
Iqbal N, Iqbal N. Human epidermal growth factor receptor 2 (HER2) in cancers: Overexpression and therapeutic implications. Mol Biol Int 2014;2014:852748.  Back to cited text no. 15
Gandour-Edwards R, Lara PN Jr., Folkins AK, LaSalle JM, Beckett L, Li Y, et al. Does HER2/neu expression provide prognostic information in patients with advanced urothelial carcinoma? Cancer 2002;95:1009-15.  Back to cited text no. 16
American Cancer Society: Breast Cancer Facts & [Figure 2015], [Figure 2016]. 2016. Available from: http://www.cancer. Org/acs/groups/content/@research/documents/documents/acspc-046381.pdf. [Last accessed on 2016 Apr 06].  Back to cited text no. 17


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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