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\title{Her2/Neu Overexpression in Gastric Cancer and its Correlation with Histopathological Grade and Subtype}
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             \author[1]{Dr. Kuldeep  Kaur}

             \author[2]{Dr. Molly  Joseph}

             \author[3]{Dr. Jagriti  Yadav}

             \author[4]{Dr. Hema  Goyal}

             \author[5]{Dr. Richa  Jindal}

             \affil[1]{  St. Stephen?s Hospital, Delhi}

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\date{\small \em Received: 6 December 2019 Accepted: 31 December 2019 Published: 15 January 2020}

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\begin{abstract}
        


Gastric cancer is one of the leading causes of cancer mortality in the world. At advanced stage majority of cases are diagnosed. The survival rate of patients with advanced unresectable gastric cancers remains poor despite new treatment strategies, such as perioperative chemotherapy or adjuvant chemoradiation [1]. In certain gastric tumors added therapy gives superior survival benefits. One such targeted protein of interest is HER2 /neu. We have undertaken this study to evaluate the overexpression of HER-2/Neu gene in gastric cancer and its correlation with several pathological features.

\end{abstract}


\keywords{gastric adenocarcinoma, grade a n d subtype, her2/neu overexpression, immunohistochemistry, her 2 scoring in gastric cancer, trastuzumab.}

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\let\tabcellsep& 	 	 		 
\section[{Her2/Neu Overexpression in Gastric Cancer and its Correlation with Histopathological Grade and Subtype}]{Her2/Neu Overexpression in Gastric Cancer and its Correlation with Histopathological Grade and Subtype}\par
Keywords: gastric adenocarcinoma, grade and subtype, her2/neu overexpression, immunohistochemistry, her 2 scoring in gastric cancer, trastuzumab.\par
HER2/neu gene. Amplification of HER2/neu gene is seen at different sites like breast, stomach, colon, etc. and its overexpression is associated with poor prognosis.\par
Recently published data, from the randomised, prospective phase III clinical trial TOGA provided first documentation of the clinical benefit of Trastuzumab, anti-HER2/neu an antibody, when used in combination with chemotherapy in the setting of advanced gastric carcinoma  {\ref [4]}. The Stage is the most important prognostic factor for gastric carcinoma followed by the histological subtype and since there is limited data available on HER2/neu overexpression in gastric cancer and its correlation to histopathological stage, grade and subtype, we propose to conduct this study to evaluate the same since an accurate assessment of HER2/neu overexpression in gastric cancer patients is of great utility in the optimal selection of patients for Trastuzumab therapy. 
\section[{II.}]{II.}\par
Material and Methods III. 
\section[{Statistical Analysis}]{Statistical Analysis}\par
Qualitative variables are expressed as frequencies/percentages and compared between groups using Chi-square Test. Quantitative variables are expressed as mean±sd and compared across groups using ANOVA and unpaired t-test. A p-value < 0.05 is considered statistically significant. The data is analysed using Statistical Package for Social Sciences (SPSS) version 16.0 software. 
\section[{Study Design: Cross-sectional study}]{Study Design: Cross-sectional study} 
\section[{Sample size determination:}]{Sample size determination:}\par
The formula used for sample size estimation is:n = z2 P(1 -P)/d2\par
Introduction astric cancer is one of the leading causes of cancer mortality in the world, with the majority of cases presenting at an advanced stage. Gastric cancer is the fifth most common cancer overall and it is the third most common cause tumor-related deaths globally  {\ref [1]}.The incidence of gastric cancer in India is 10.6 per 100000 population  {\ref [2]}.\par
Human epidermal growth factor receptor 2 (HER2/neu) protein is a cellular target for the added therapy. It is a growth factor of EGFR family with intrinsic protein tyrosine kinase activity and is associated with tumor proliferation, migration and differentiation. The production of HER2/neu protein, is regulated by the G The mainstay of treatment is surgical resection and can cure patients with early-stage cancer. The survival rate of patients with advanced resectable gastric or gastroesophageal junction (GEJ) tumors, however, remains poor despite new treatment strategies, such as perioperative chemotherapy or adjuvant chemoradiation  {\ref [3]}. Improvements in the treatment modality of gastric cancer, including combination chemotherapy, have resulted in improved overall survival. In certain gastric tumors added therapy gives superior survival benefits.\par
A total of 49 patients, with gastric carcinoma, were included in this study period of seven years (Jan 2011 to May 2018) in the Department of Pathology, St.\par
Stephen's Hospital, New Delhi, India. The detailed clinical history and results of relevant investigations were obtained from the patient's case files. The method of study was immunohistochemistry, using the HER-2/Neu antibody.\par
IV. 
\section[{Result and discussion}]{Result and discussion} 
\section[{a) Demographic data in our study}]{a) Demographic data in our study}\par
Our study included 50 cases. The age of the patients varied from 24 years to 85 years, with a mean age of 57.69 years. In our study, the incidence of gastric carcinoma in males and females were 77.1\% and 22.9\% respectively (male: female ratio =3:1) 
\section[{b) Clinical manifestations}]{b) Clinical manifestations}\par
In our study, chief complaints of patients were dysphagia (43.7\%) followed by loss of appetite (35.4\%), pain abdomen (33.3\%), vomiting (29.2\%), weight loss (22.9\%), hematemesis (6.2\%) and melena (4.2\%). Gastric carcinoma often produces no specific symptoms when it is superficial and can be removed surgically, although up to 50\% of patients may have nonspecific gastrointestinal complaints such as dysphagia, anorexia, nausea, vomiting, weight loss as well as abdominal pain that is vague and insidious. 
\section[{Site}]{Site}\par
The most common site of gastric carcinoma in our study was the antral region. 
\section[{Table 1: Comparison of Location of Gastric Carcinoma: c) Histopathological subtype}]{Table 1: Comparison of Location of Gastric Carcinoma: c) Histopathological subtype}\par
In our study, poorly cohesive carcinoma (66\%) was the most common subtype followed by tubular carcinoma (26\%). However, intestinal-type was the most common subtype (Lauren's classification) according to studies done by Raziee et al.(  {\ref 5}) and ToGA trial (4). This difference could be explained by the low sample size in our study and heterogeneity of pathological classifications. The increase in the proportion of poorly cohesive carcinoma can be explained by changes in the pathological classification systems used to characterise these cancers. Since the publication of the WHO classification of gastric cancers in 1990, signet ring cell adenocarcinoma constitutes one specific histotype and therefore can be better identified among gastric cancers. WHO 2010 further classified Signet ring cell and diffuse variety into a single group of poorly cohesive carcinoma. Previously, signet-ring cell adenocarcinoma was classified as "diffuse-type" according to Lauren's classification  {\ref [8]} and "infiltrative type" by Ming[9]. During January 2011 to May 2018, a total of 50 samples (from 49 patients) reported as gastric adenocarcinoma on histopathological examination at St.Stephen's hospital, Delhi were included in the study. 
\section[{d) Histopathological grade}]{d) Histopathological grade}\par
Among 49 patients, gastric carcinoma had a peak incidence in the age group of 50 to 60 years. The oldest age of presentation was 85 years and the youngest was 24 years.\par
In our study, poorly differentiated grade tumors were more common than other grades accounting for 54\% of cases, which is similar to observations made by Lazar et al.(64\%) and Fondevila et al. (49\%) in their studies. 
\section[{Depth of Infiltration}]{Depth of Infiltration}\par
In our study, a higher proportion of tumours belonged to T4 subtype 63.6\% which is similar to the observation made by Lazar et al  {\ref [8]} (approximately 50\%).This is explained by later presentation of gastric carcinoma due to nonspecific symptoms and hence delayed diagnosis. 
\section[{HER2 Overexpression}]{HER2 Overexpression}\par
In our study, HER2 overexpression is noted in 20\% of cases, which is similar to observations made worldwide by  {\ref Marx et al.(19\%)}    \begin{figure}[htbp]
\noindent\textbf{}\includegraphics[]{image-2.png}
\caption{\label{fig_0}}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.85\textwidth}}
Year 2020\\
16\end{longtable} \par
 
\caption{\label{tab_0}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{3} \par 
\begin{longtable}{P{0.39107981220657273\textwidth}P{0.11732394366197184\textwidth}P{0.011173708920187793\textwidth}P{0.1660093896713615\textwidth}P{0.01835680751173709\textwidth}P{0.07821596244131455\textwidth}P{0.06784037558685446\textwidth}}
\multicolumn{6}{l}{Her2/Neu Overexpression in Gastric Cancer and its Correlation with Histopathological Grade and}\\
\tabcellsep \tabcellsep \multicolumn{2}{l}{Subtype}\tabcellsep \tabcellsep \\
Authors Raziee et al. [5] Hofmann et al. [11]\tabcellsep \multicolumn{4}{l}{Year Population studied No of patients 2007 Iranians 100 2007}\tabcellsep 26 \% HER2 positivity 10.7 \%\tabcellsep Year 2020\\
Marx et al. [12]\tabcellsep 2009\tabcellsep \multicolumn{2}{l}{Germans}\tabcellsep 166\tabcellsep 19 \%\tabcellsep 17\\
Xie et al. [13] Lee et al. [14] Sekaran et al. [2] Lakshmi V et al. [15] Yoshida et al. [16] Our study\tabcellsep \multicolumn{3}{l}{2009 2010 Australians Chinese 2011 Indians 2014 Indians 2014 Japanese 2018 Indians}\tabcellsep 218 178 52 78 207 48\tabcellsep 18.8 \% 17.4 \% 44.2 \% 35.9 \% 17 \% 20\%\tabcellsep Volume XX Issue II Version I\\
\multicolumn{3}{l}{In our study, there is no correlation between HER-2/neu overexpression and various}\tabcellsep \multicolumn{3}{l}{overexpression was associated with elderly age, male gender, poorly cohesive carcinoma (according to WHO}\tabcellsep ( D D D D ) C\\
\multicolumn{3}{l}{clinicopathological factors such as age, gender, complaints, site or gross appearance in gastrectomy specimens. Increased frequency of HER-2/neu IMAGES}\tabcellsep \multicolumn{3}{l}{subtype), moderately differentiated grade and T4 level of infiltration, but statistically insignificant.}\tabcellsep Medical Research\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep Global Journal of\\
\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep © 2020 Global Journals\end{longtable} \par
  {\small\itshape [Note: [MODERATELY DIFFERENTIATED][POORLY DIFFERENTIATED ADENOCARCINOMA]]} 
\caption{\label{tab_1}Table 3 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.021399297423887586\textwidth}P{0.48621194379391103\textwidth}P{0.3423887587822014\textwidth}}
\tabcellsep \multicolumn{2}{l}{Her2/Neu Overexpression in Gastric Cancer and its Correlation with Histopathological Grade and}\\
\tabcellsep \multicolumn{2}{l}{Subtype}\\
\tabcellsep independent predictors of tumour recurrence and\tabcellsep \\
\tabcellsep survival following curative resection of gastric\tabcellsep \\
\tabcellsep cancer. Br J Cancer. 2004; 90(1): 206-215.\tabcellsep \\
\tabcellsep 7. Czyzewska J, Guzi?ska-Ustymowicz K, Lebelt A,\tabcellsep \\
\tabcellsep Zalewski B, Kemona A. Evaluation of proliferating\tabcellsep \\
\tabcellsep markers Ki-67, PCNA in gastric cancers. Roczniki\tabcellsep \\
\tabcellsep Akademii Medycznej wBialymstoku (1995). 2004;\tabcellsep \\
\tabcellsep 49: 64-6.\tabcellsep \\
\tabcellsep 8. Lauren P. The two histological main types of gastric\tabcellsep \\
\tabcellsep carcinoma: diffuse and so-called intestinal-type\tabcellsep \\
Year 2020\tabcellsep carcinoma: an attempt at a histo-clinical classification. Acta Pathologica Microbiologica Scandinavica. 1965; 64(1):31-49. 9. Ming SC. Gastric carcinoma: a pathobiological\tabcellsep \\
20\tabcellsep classification. Cancer. 1977 Jun; 39(6): 2475-85.\tabcellsep \\
Volume XX Issue II Version I\tabcellsep {}[ 10. 10.Lazar D, Taban S, Sporea I, Dema A, Cornianu M, Lazar E, et al. The immunohistochemical expression of the p53-protein in gastric carcinomas. Correlation with clinicopathological factors and survival of patients. Rom J Morphol Embryol. 2010; 51(2): 249-57. 11. Hofmann M,\tabcellsep References Références Referencias 1. Macdonald JS, Smalley SR, Benedetti J, Hundahl SA, Estes NC, Stemmermann GN, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach A\\
( D D D D ) C\tabcellsep \tabcellsep or gastroesophageal junction. N Engl J of Med. 2001; 345(10):725-30.\\
Global Journal of Medical Research\tabcellsep VI. 1. Larger sample size and follow up might shed more Recommendation Increasing the sample size in future studies, and designing prospective studies with close observation of survival, the utility of HER2/neu overexpression as an important prognostic marker can be enhanced. 2. Geographical differences, tumor heterogeneity, molecular target therapy. tumor progression besides avoiding the failure of assessment of its role in gastric carcinogenesis and staining and scoring methods for accurate proteins. It is mandatory to standardize Her2/neu the current therapeutic approaches targeting those and progression need to be detected to modulate 3. The precise role of Her2/neu in cancer development 2/neu positivity rates between the studies. expertise may have caused the variations in HER-differences in scoring systems, and pathologist light on the role of HER 2/neu in gastric carcinoma.\tabcellsep Basic Med Sci. 2007; 10(2):139-145. histolopathologic subtype , grade and stage. Iran J resectable gastric cancer and its relationship with T, Ghavamnasiri MR. HER-2/neu expression in 5. Raziee HR, Kermani TA, Ghaffarzadegan K, Shakeri controlled trial. Lancet. 2010; 8; 376(9742):687-97. cancer (ToGA): a phase 3, openlabel, randomised advanced gastric or gastro-oesophageal junction chemotherapy alone for treatment of HER2-positive combination with chemotherapy versus SA, Estes NC, Stemmermann GN, et al. Chemoradiotherapy after surgery compared with surgery alone for adenocarcinoma of the stomach or gastroesophageal junction. N Engl J of Med. 2001; 345(10):725-30. 4. Bang YJ, Van Cutsem E, Feyereislova A, Chung HC, Shen L, Sawaki A, et al. Trastuzumab in 2. Sekaran A, Kandagaddala RS, Darisetty S, Lakhtakia S, Ayyagari S, Rao GV, et al. HER2 expression in gastric cancer in Indian population-an immunohistochemistry and fluorescence in situ hybridization study. Indian J of Gastroenterol. 2012; 31(3):106-110. 3. Macdonald JS, Smalley SR, Benedetti J, Hundahl\\
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  {\small\itshape [Note: Conclusion 1. The present work reported that advanced age, especially in male patients is a risk factor for gastric carcinoma. 2. The percentage of HER2/neu overexpression in gastric adenocarcinoma is correlating with other studies. 3. Correlation between HER2/neu overexpression and clinico-pathological variables like age, gender, site, gross, subtype, grade and depth of tumor infiltration is statistically insignificant. 4. Majority of cases overexpressing HER 2/neu were of poorly cohesive subtype (according to WHO classification, 2010), but results were statistically insignificant. cknowledgements I am highly thankful to the department of pathology,]} 
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