I HC HU

TRNG I HC Y DC
**********************

L VIT NHO

NGHIN CU S BIU L CA EGFR, HER2

V MI LIN QUAN VI LM SNG,
NI SOI, M BNH HC
BNH NHN UNG TH BIU M D DY

Chuyn ngnh: Ni Tiu ha

M s: 62.72.01.43

TM TT LUN N TIN S Y HC

HU - 2014

Cng trnh c hon thnh ti:

I HC HU - TRNG I HC Y DC
Ngi hng dn khoa hc:
PGS. TS. TRN VN HUY
Phn bin 1:

Phn bin 2:

Phn bin 3:

Lun n s c bo v ti Hi ng chm lun n cp i hc Hu,

ti:

C th tm hiu lun n ti:

-

Th vin Quc gia Vit Nam

Th vin Khoa hc Tng hp Hu

Th vin i hc Y Dc Hu

1
M U
1. t vn :
Ung th d dy (UTDD), vi ch yu l ung th biu m d dy
(UTBMDD),l mt bnh ung th thng gp. Tin lng UTDD vn
cn xu, vi t l sng thm 5 nm khong 28%. Ha tr liu l mt
iu tr cn thitnhngch ci thin tin lng mt s bnh nhn c
chn lc v c tnh cao. Hin nay, cha c du n sinh hc no gip
la chn bnh nhn vo cc liu php ha tr.
Bng cc k thut nghin cu t bo ung th mc phn t,
trong c k thut nhum ha m min dch (HMMD), ngi ta
xc nh nhiu yu t phn t rt lin quan vi qu trnh pht sinh v
tin trin UTDD, trong c EGFR (Epidermal Growth Factor
Receptor) v HER2(Human EpidermalGrowth Factor Receptor 2).
Cc thuc iu tr chc ch EGFR v/hoc HER2ang mang li
nhiu ha hn trong iu tr UTDD. Kt qu th nghim ToGA cho
thy cc bnh nhn UTDD tin trin HER2 dng tnh,thuc khng
HER2trastuzumab lm gim nguy c t vong, ko di thi gian sng
thm v dung np tt.iu ny gi cn phi chn la i tng vo
cc iu tr ch thng qua cc du n phn t EGFR, HER2. Ti
Vit Nam, cha c nhiu nghin cu v s biu l ca EGFR, HER2
trong UTDD.
2. Mc tiu ti ny l:
- Kho st mt s c im lm sng, hnh nh ni soi, m bnh
hc v tn sut biu l ca EGFR, HER2 bnh nhn UTBMDD.
- nh gi mi lin quan gia s biu l ca EGFR, HER2 vi
cc c im lm sng, hnh nh ni soi v m bnh hc.

2
3. ngha khoa hc:
ng dng k thut mi l HMMD xc nh t l biu l
caEGFR, HER2 trong UTDD trn mu m sinh thit d dy, lm c
s xy dng phn loi mi UTDD mc phn t
Xc nh mi lin quan gia biu l EGFR, HER2 vi c im
lm sng, hnh nh i th v m bnh hc UTDD nhm gip hiu
bit tt hn v cu trc mc phn t ca UTDD.
4. ngha thc tin:
Cung cp cho bc s lm sng thm mt cng c mi l nhng
yu t mc phn t EGFR v HER2 la chn bnh nhn vo iu
tr bng trastuzumab, mt liu php iu tr ch mi c hiu qu i
vi UTDD tin trin HER2 dng tnh.Kt qu biu l EGFR v
HER2 c th gip cho cc thy thuc la chn phc ha tr ph
hp cng nh tin lng bnh.
5. ng gp mi ca Lun n
ng dng k thut mi HMMD xc nh t l biu l ca EGFR,
HER2 trong UTDDln lt l 25,6% v 21,1% nhm chn la chnh
xc cc bnh nhn UTDD vo iu trch vi trastuzumab.
Xc nh s biu l EGFR, HER2 khng lin quan vi tui, gii
tnh, nhng c lin quan vi c im hnh nh ni soi, m bnh hc.
6. B cc lun n:
Lun n gm 118 trang. Bao gm phn m u 2 trang, tng quan
ti liu 32 trang, i tng v phng php nghin cu 18 trang, kt
qu nghin cu 26 trang, bn lun 37 trang, kt lun v kin ngh 3
trang. C 37 bng, 9 biu , s , 25 hnh minh ha v 124 ti liu
tham kho (25 ting Vit v 99 ting Anh).

3
CHNG 1:TNG QUAN TI LIU
1.1.DCH T HC V CC YU T NGUY C UTDD
1.1.1.Dch t hc UTDD: UTDD l loi ung th thng gp. Vit
Nam thuc khu vc c t l mc UTDD trung bnhmc cao.
1.1.2.Cc yu t nguy c ca UTDD: UTDD l hu qu ca tng
tc gia yu t vt ch, mi trng v c bit l nhim H. pylori.
1.2.GII PHU BNHUTDD
1.2.1.V tr: gm ung th tm v v UTDD khng thuc tm v.
1.2.2.Hnh nh i th: Borrmann phn loi hnh nh i th UTDD
thnh 4 tp l: tp I (dng polyp), tp II (dng nm), tp III (dng
lot) v tp IV (dng thm nhim).
1.2.3.Vi th: UTBM l loi UTDD thng gp nht.
1.2.3.1. Phn loi m bnh hc UTDD ca Lauren: Laurenchia
UTBMT thnh 2 th chnh l th rut v th lan ta.
1.2.3.2. Phn loi m bnh hc UTDD ca TCYTTG: TCYTTG chia
UTBMDD thnh 9 th:ng nh, th nh, th nhy,th t bo nhn.
Cc th m bnh hc khc thng t gp.
1.2.3.3. bit ha ca UTDD: c 3 mc : tt, va v km.
1.2.4.nh gi giai on UTDD: Hin naynh gi giai on UTDD
thng da trn cch nh gi khi u (Tumor), hch vng (Node) v
tnh trng di cn xa (Metastasis), gi tt l cch nh gi TNM.
1.3.CHN ON, IU TR V TIN LNG UTDD
1.3.1.Triu chng lm sng: Triu chng c nng v ton thn khng
c hiu. Triu chng thc thxut hin mun. Bnh nhn khi c cc
triu chng ny th bnh giai on tin trin, khng th phu
thut trit c.

4
1.3.2.Triu chng cn lm sng
1.3.2.1.Ni soi v chp d dy c baryt: Ni soi kt hp sinh thit l
tiu chun vng trong chn on UTDD. nhy v c hiu ca
ni soi u cao hn so vi chp d dy c baryt.
1.3.2.2.Dn n huyt thanh: Cha du n huyt thanh no c xc
nh nhy v c hiu chn on xc nh UTDD.
1.3.2.3.Chn on hnh nh, siu m ni soi v soi bng: Vai tr
chnh l chn on giai on UTDD trc khi iu tr.
1.3.3.iu tr v tin lng UTDD
1.3.3.1.iu tr UTDD: Ha tr liugi vai tr kh quan trng. Tuy
nhin, hiu qu thp,c tnh cao.Cc thuc iu tr ch hng n
h HER(Human Epidermal Growth Factor Receptor) cho kt qu kh
tt, c bit l trastuzumab. y l hng iu tr mi ha hn.
1.3.3.2.Tin lng UTDD: UTDD cng sm tin lng cng tt. Tuy
nhin, trong nhiu trng hp, cng mt giai on TNM nhng din
bin lm sng cng khc nhau ng k. Ngy nay, c nhiu cng
b v vai tr ca cc yu t phn t trong tin lng UTDD.
1.4.EGFR V HER2 TRONG UTDD
1.4.1.Vi nt v h HER
H HER gm 4 th th l EGFR, HER2, HER3v HER4 c lin
quan cht ch vi nhau.EGFR v HER2 thng qu biu l trong
nhiu t bo ung th, k c UTDD. Hot ha EGFR sai lch l yu t
quan trng ca qu trnh pht sinh ung th ng thi cng l yu t
kch thch s tng trng c tnh ca t bo ung th. HER2 l i tc
d nh trng ha ca EGFR. Do vy, HER2 l du n phn t c
dng lm ch s tin lng cng vi EGFR trong nhiu loi ung th,
k c UTDD.

5
1.4.2.Cc k thut nh gi EGFR v HER2 trong UTDD
C kh nhiu k thut nh gi tnh trng EGFR, HER2. Hin
nay,k thut thng c s dngl lai ti ch v HMMD.
1.4.3.Vai tr ca EGFR v HER2 trong tin lng UTDD
S biu l EGFR v/hoc HER2 l nhng yu t tin lng c
lp trong UTDD. Nhng cng c mt t nghin cu c kt qu khc.
EGFR v/hoc HER2 thng c ng biu l vi nhiu du n phn
t khc nn c th tn ti nhiu yu t phn t v con ng khc
nhau cng nh hng ln pht sinh v tin trin UTDD.
1.4.4.Vai tr ca EGFR v HER2 trong d on p ng iu tr
UTDD
- EGFR: Han bo co 7 bnh nhn c biu l EGFR + EGF v
TGF-a huyt thanh thp cho thy u p ng vi cetixumab, trong
khi t l p ng ca 27 bnh nhn cn li ch c 37% (p <0,001).
- HER2:thuc khng HER2 trastuzumab lm gim nguy c t
vong 26%, ko di thi gian sng thm bnh nhn UTDD tin trin
HER2 dng tnh. Mc p ng i vi trastuzumab lin quan
vi mc biu l HER2. Nhng bnh nhn c mc biu
lHER2 cng cao th thi gian sng thm cng ko di. V vy,
trastuzumab tr thnh thuc iu tr ch u tin c cp php iu
tr UTDD tin trin HER2 dng tnh.
T , nh gi EGFR v HER2 bng nhum HMMD l hng
nghin cu c la chn trong UTDD v n gip iu tr v tin
lng.

6
CHNG 2:
I TNG V PHNG PHP NGHIN CU
2.1.I TNG NGHIN CU
Cc bnh nhn n ni soi d dy ti Khoa ni soi Bnh vin
Trng i hc Y Dc Hu v Khoa ni soi Bnh vin Trung ng
Hu t thng 01/2010 n thng 12/2011 c pht hin c hnh nh
tn thng UTDD.
2.1.1.Tiu chun chn mu
- Kt qu m bnh hc:UTBMDD.
- Mu m cn s lng t bo ung th nhum HMMD.
2.1.2.Tiu chun loi tr: UTDD di cn,phi hpung th khc,
c iu tr bng ha trhoc mu m khng cn s lng t bo
ung th nhum HMMD.
2.2.PHNG PHP NGHIN CU
2.2.1.Thit k nghin cu: m t ct ngang.
2.2.2.C mu: 90
2.2.3.Ccbctinhnh: Cc bnh nhn c hi tin s, thm khm
lm sng, nh gi v v tr, c im hnh nh trn ni soi, sinh
thit, nhum HE xc nhn chn on, phn loi m bnh hc v
nhum EGFR, HER2, ghi nhn kt qu phn loi TNM.
2.2.4.Thu thp cc d liu lm sng
2.2.5.Thu thp kt qu xt nghim Hemoglobin mu
2.2.6.Thu thp d liu ni soi
- V tr tn thng: Tm v v khng thuc tm v.
- Phn loi hnh nh i ththeo Borrmann gm 4 th: dng plip, dng nm, dng lot v dng thm nhim.
- Sinh thit tn thng

7
+ Dng c: kim sinh thit FB-25K-1, ng knh2mm.
+ K thut sinh thit: Sinh thit kp.
+ S mu sinh thit: 6 mnh kch thc 2mm.
2.2.7.Thu thp d liu m bnh hc
2.2.7.1.Ni thc hin k thut
- Khoa Gii phu bnh Bnh vin i hc Y Dc v Bnh vin
Trung ng Hu c nh, chuyn c v vi nn mu m sinh thit
- Khoa Gii phu bnh t bo Bnh vin K: nhum HE
2.2.7.2.K thut: Phng php HE thng quy.
2.2.7.3.c kt qu:
- Chn on xc nh UTBM d dy
- Phn loi m bnh hc
+ Theo phn loi Lauren: gm th rut v th lan ta.
+ Theo TCYTTG: gm th nh, th ng nh, th nhy, th t
bo nhn, th tuyn vy, th t bo vy, th t bo nh, th khng
bit ha, ung th biu m khc.
+ Mc bit ha:bit ha tt, va v km.
2.2.8.Thu thp cc d liu nhum EGFR, HER2
2.2.8.1.Ni thc hin k thut
Khoa Gii phu bnh T bo, Bnh vin K (H Ni).
2.2.8.2.Dng c v ha cht
- Dng c nhum HMMD: cn, ni p sut.
- Ha cht: b kit EGFR PharmDx v Herpestest hng Dako.
2.2.8.3.K thut nhum HMMD: Nhum EGFR, HER2 theo phng
php phc hp Avidin Biotin tiu chun.
2.2.8.4.c kt qu nhum HMMD: c kt qu nhum HMMD
di knh hin vi quang hc c phng i 10 x 40 ln.
- Chng dng: Tiu bn chc chn l dng tnh 3+.

8
- Chng m: Tiu bn khng c ph khng th th nht.Ni
chng l cc t bo lnh trong m u.
- Kt qu dng tnh EGFR, HER2 nh sau:
+ EGFR: dng tnh khi > 10% t bo u c mng bt mu nu.
0: Cc t bo u khng nhum mng hoc nhum mng khng c hiu.
1+: Nhum mng yu v khng hon ton >10% t bo u.
2+: Nhum mng va v hon ton >10% t bo u.
3+: Nhum mng mnh v hon ton > 10% t bo u.
+ HER2:gm 4 mc im 0 n 3+:
0: Khng phn ng hoc nhum mng bo tng trn bt k t
bo u no.
1+: Cc m t bo u bt mu nht, bt chp t l (tuy nhin, mt
m phi c t nht 5 t bo).
2+: C m t bo u bt mu hon ton t yu n va mng t
bo mt y - bn hoc mt bn bt chp t l.
3+: C m t bo u bt mu m hon ton mng t bo mt
y - bn hoc mt bn bt chp t l.
Ch HER2 2+ v 3+ mi c coi l dng tnh.
2.2.10.Phng php x l s liu
S dng phn mm SPSS 19.0.So snh trung bnh: kim nh Ttest. So snh t l bng kim nh Khibnh phng. ngha thng
k:p< 0,05.

9
CHNG 3: KT QU
3.1.c im lm sng, cn lm sng, hnh nh ni soi, m bnh
hc v s biu l ca EGFR, HER2 trong UTBMDD
3.1.1.c im gii tnh: Trong s 90 bnh nhn c tip nhn vo
nghin cu, c 66 nam v 24 n. T l nam/n: 2,75/1.
3.1.2.c im v tui: Tui ca bnh nhnUTBMDDt 26- 92,
trung bnh l 58,9 13,8. Bnh nhn > 50 tui chim 75,6%.
3.1.3.c im lm sng
- au bng thng v, st cn,thiu mul nhng triu chng c
nng thng gp, vi t l ln lt l 98,9%, 70,0%, 47,8%. Nn ra
mu v/hoc i cu phn en, kh nut v vng da, vng mt l cc
triu chng t gp, vi t l ln lt l 11,1%, 3,3% v 1,1%.
- Triu chng thc th thng gp l s c khi thng
v(13,3%), hch thng n (3,3%) v bng (2,2%).
3.1.5.c im hnh nh ni soi
UTBMDD khng thuc tm v chim s lng ch yu (93,3%).
UTBMDD dng nm thng gp nht (41,1%), tip theo l dng
lot (36,7%).
3.1.6.c im m bnh hc
Theo phn loi Lauren, th rut gp nhiu hn th lan ta khng
ng k.Theo phn loi TCYTTG, UTDD th ng nh chim t l
cao nht (53,3%); th bit ha km chim t l cao nht.
3.1.7.Phn giai on UTDD
Trong s 90 bnh nhn, c 44 bnh nhn c phu thut v chn
on giai on TNM. a s bnh nhn c phu thut c khi u
xm ln T2 n T4 (97,7%), di cn hch t N1 n N3 (63,6%), mt

10
s c di cn xa (27,3%), ngha l bnh giai on tin trin: II
n IV (88,6%).
3.1.8.S biu l ca EGFR v HER2 trong UTBMDD
C23 (25,6%) bnh nhn nhumEGFR dng tnh v19 (21,1%)
bnh nhn nhum HER2 dng tnh v 10 bnh nhn (11,1%) bnh
nhn ng biu l EGFR v HER2.
Cckhi uEGFR m tnhc t l biu l HER2 dng tnh thp
hn so vi cc khi u EGFR dng tnh(p < 0,01).
3.2.Mi lin quan gia s biu l EGFR v HER2 vi c im
lm sng, hnh nh ni soi v m bnh hc
3.2.1.Mi lin quan gia s biu l EGFR, HER2 vi gii tnh
- S biu l EGFR nam l 27,3% v n l 20,8%. S khc
bit khng c ngha thng k (p > 0,05).
- S biu l HER2 nam l 24,2% v n l 12,5%. S khc
bit khng c ngha thng k (p > 0,05).
3.2.2.Mi lin quan gia s biu l EGFR, HER2 vi tui
- S biu l EGFR khng khc nhau gia cc nhmtui ca
bnh nhn (p > 0,05).
- S biu l HER2cng khng khc nhau gia cc nhm tui
ca bnh nhn(p > 0,05).
3.2.3.Mi lin quan gia s biu l EGFR, HER2 vi tng trng ca
bnh nhn
Tng trng ca bnh nhn khng c lin quan vi s biu l
EGFR (p > 0,05) cng nhHER2 (p > 0,05).

11
3.2.4.Mi lin quan gia s biu l EGFR, HER2 vi c im hnh
nh ni soi
3.2.4.1.Mi lin quan gia s biu l EGFR vi v tr khi u
Bng 3.24: Mi lin quan gia s biu l EGFR vi v tr khi u
V tr khi u

Biu l

lng

EGFR

n
Tm v

33,3

Khng thuc tm v

84

21

25,0

90

23

25,6

Tng cng

> 0,05

Nhn xt: Cc khi u tm v c t l biu l EGFR cao hn cc

khi u khng thuc tm v (33,3% so vi 25,0%). Tuy nhin s khc
bit cha c ngha thng k (p > 0,05).
3.2.4.2.Mi lin quan gia s biu l HER2 vi v tr khi u
Bng 3.25: Mi lin quan gia s biu l HER2
vi v tr khi u
V tr khi u

Biu l

lng

HER2

n
Tm v

50,0

Khng thuc tm v

84

16

19,0

90

19

21,1

Tng cng

> 0,05

Nhn xt: Cc khi u tm v c t l biu l HER2 cao hn cc

khi u khng thuc tm v. Tuy nhin s khc bit cha c ngha
thng k (p > 0,05).

12
3.2.4.3.Mi lin quan gia s biu l EGFR vi c im i th
Bng 3.26: Mi lin quan gia s biu l EGFRvi c im i th
Phn loi Borrmann

Biu l

lng

EGFR

n
Dng polyp

10

50,0

Dng nm

36

11

30,6

Dng lot

38

10,5

Dng thm nhim

50,0

90

23

25,6

Tng cng

<0,05

Nhn xt:T l biu l EGFR ca khi u dng lot thp nht so

vi cc khi u khc (p < 0,05).
3.2.4.4.Mi lin quan gia s biu l HER2 vi c im i th
Bng 3.27: Mi lin quan gia s biu l HER2
vi c im i th
Phn loi Borrmann

Biu l

lng

HER2

n
Dng polyp

10

50,0

Dng nm

36

25,0

Dng lot

38

13,2

Dng thm nhim

90

19

21,1

Tng cng

<0,05

Nhn xt:T l biu l HER2 ca khi u dng polyp(50,0%),

dng nm (25,0%), cao hn cc khi u dng lot (13,2%) v dng
thm nhim khng biu l HER2. S khc bit c ngha thng k.

13
3.2.5.Mi lin quan gia s biu l EGFR, HER2 vi c im m
bnh hc
Bng 3.28: Mi lin quan gia s biu l EGFR
vi c im m bnh hc
c im m bnh hc

Biu

lng

EGFR

Th rut

46

19

41,3

<0,01

Th lan ta

44

9,1

Th ng nh

48

19

39,6

Th nhy

14,3

Th t bo nhn

14

14,3

Th khng bit ha

21

4,8

Tt

29

12

41,4

Va

14

50,0

Km

47

8,5

Tng cng

90

23

25,6

Phn loi Lauren

Phn loi TCYTTG

<0,05

bit ha
<0,001

Nhn xt:Theo phn loi Lauren, th rut biu l EGFR cao hn

th lan ta (p < 0,01). Theo phn loi ca TCYTTG, s biu l
EGFR trong th ng nh l cao nht, tip theo l th nhy, th t bo
nhn, th khng bit ha (p < 0,05); s biu l EGFR cc khi u
bit ha tt v va cao hn cc khi u bit ha km (p < 0,001).

14
Bng 3.29: Mi lin quan gia s biu l HER2
vi c im m bnh hc
c im m bnh hc

Biu

lng

HER2

Th rut

46

15

32,6

<0,01

Th lan ta

44

9,1

Th ng nh

48

14

29,2

Th nhy

14,3

Th t bo nhn

14

7,1

Th khng bit ha

21

14,3

Tt

29

27,6

Va

14

42,9

Km

47

10,6

Tng cng

90

19

21,1

Phn loi Lauren

Phn loi TCYTTG

>0,05

bit ha
<0,05

Nhn xt:Theo phn loi Lauren, th rut biu l HER2 cao hn

th lan ta (p < 0,01). Theo phn loi ca TCYTTG, s biu l
HER2 gia cc th m hc cha c s khc bit c ngha thng k
(p > 0,05).Theo mc bit ha, cc khi u bit ha tt v va biu
l HER2cao hn cc khi u bit ha km (p < 0,05).

15
CHNG 4: BN LUN
4.1.c im lm sng, hnh nh ni soi, m bnh hc v s biu
l EGFR, HER2 trong UTBMDD
4.1.1.Gii tnh: UTBMDD c lin quan vi gii tnh.Trong nghin
cu, t l nam/n l 2,75/1. Cc ni tit t sinh dc n c vai tr bo
v, lm cho n mc UTDD thp hn so vi nam.
4.1.2.Tui: UTBMDD c lin quan kh cht ch vi tui.Tui trung
bnh ca cc bnh nhn:58,9 13,8, vi 75,6% bnh nhn nhm
tuitrn 50 tui.
4.1.3.c im lm sng
4.1.4.c im hnh nh ni soi
4.1.5.c im m bnh hc
4.1.6. c im giai on UTBMDD
4.1.7.S biu l ca EGFR v HER2 trong UTBMDD
4.1.7.1.T l biu l EGFR: 25,6%.T l biu l EGFR 25,6% gn
tng t vi kt qu ca Song (25,4%) v Yasui (27,9%).
4.1.7.2.T l biu l HER2 l 21,1%.T l biu l HER2 tng t
Lee S.(20,2%), Yano (21,5%), Hofmann (19%) v Zhang (18,6%),
nghin cu ToGA(22,3%), tng phn tch ca Chua (18%).
Mt s tc gi ghi nhnkt qu khc. Thm ch, mt s nghin
cu cho kt qukh khc bit. Cc nguyn nhn gii thch gm:
- Khng th s dng trong nghin cu
- Nguyn tc tnh im v nh gi kt qu khc nhau ng k:
+ c im nhum mng
+ Ngng t l phn trm t bo nhum mng khc nhau.
+ Xc nh tiu bn dng tnh

16
- Cc yu tlin quan n k thut nhum HMMDcng c th
nh hng ln kt qu nhum HMMD.
- Mum nghin cu: Mt s tc gi thc hin trn mu m
phu thut. Tuy nhin, khi u d dy thng khng ng nht, nn t
l biu l HER2 trn mu m sinh thit khng hon ton ng nht
vi mu m phu thut v mu sinh thit kh nh 2-3mm.
V vy, xy dng tiu chun nh gi ring kt qu nhum
HMMD mu m sinh thit l cn thit vi c EGFR ln HER2. Bn
cnh , c im ca i tng nghin cu, nht l c im m
bnh hc, cng c th nh hng ln kt qu nhum HER2.
4.1.7.3.ng biu l EGFR v HER2
T l ng biu l EGFR v HER2 l 11,1%. C mi lin quan c
ngha thng k gia s biu l EGFR v HER2 (p < 0,01).
Matsubara ghi nhn t l ng biu l EGFR v HER2 l
15%.Czyzewska xc nh s biu l EGFR c lin quan vi s biu
l HER2 trn mu khi u tin pht ln trn mu hch di cn.
C nhiu yu t phn t h HER c lin quan vi UTDD. C th
y l mt nguyn nhn lm cho mt s bnh nhn UTDD khng
p ng vi iu tr n ch EGFR hoc HER2. V vy, tip cn a
ch l mt trong nhng hng la chn mi hin nay.
4.2.Mi lin quan gia s biu l EGFR, HER2 vi cc c im
lm sng, hnh nh ni soi v m bnh hc
4.2.1. Mi lin quan gia s biu l EGFR, HER2 vi gii tnh
- S biu l EGFR khng lin quan vi gii tnh (p > 0,05).
Dong v Kim J.S. xc nhn tng t.
- S biu l HER2 khng lin quan vi gii tnh (p > 0,05).

17
Raziee, Tateishi, Allgayer, ghi nhn tng t.Garcia s dng
phng php nh lng HER2, Tanner nh gi s khuch i
HER2, cng nhn thy HER2 khng lin quan vi gii tnh.
4.2.2. Mi lin quan gia s biu l EGFR, HER2 vi tui
- S biu l EGFR khng c lin quan vi tui (p > 0,05).
Dong,Kim J.S. Lee K.E., Marx, cng ghi nhn tng t.
- S biu l HER2 khng c lin quan vi tui (p > 0,05).
Nghin cu ca Hee, Marx, Pinto-de-Sousa, Song, Yan cng cho
thy s biu l HER2 khng c lin quan vi tui.
4.2.3.Mi lin quan gia s biu l EGFR, HER2 vi tng trng
bnh nhn
4.2.4.Mi lin quan gia s biu l EGFR, HER2 vi c im hnh
nh ni soi
4.2.4.1.Mi lin quan gia EGFR, HER2v tr khi u
- S biu l EGFR khng lin quan vi v tr khi u. T l biu
l EGFR ca ung th tm v l 33,3%, cao hn so viung th khng
thuc tm v l 25%, nhng s khc bit cha c ngha thng k.
Garcia nhn thy hm lng EGFR trong khi u on gn l
khng khc so vi khi u on xa. Czyzewska cng nhn thy t l
biu l EGFR cc khi u 1/3 trn, 1/3 gia v 1/3 di khng c s
khc nhau.
- 50% ung th tm v biu l HER2, trong khi ch c 19% ung
th khng thuc tm v biu l HER2. Tuy nhin, s khc bit cha
c ngha thng k (p > 0,05).
Pinto-de-Sousa (2002) xc nhn c s lin quan c ngha gia
s biu l ca HER2 vi v tr khi u. T l ung th hang v biu l
HER2 l 7,2%, thp hn so vi ung th tm v (23,8%) v ung th
y v thn v (25,0%) (p=0,01).Lordick cng ghi nhn t l biu l

18
HER2 thay i theo v tr khi u: 32% vi khi u ch ni d dy
thc qun v 18% vi khi u d dy.
Tanner ghi nhn khuch i HER2 thng gp trong UTBMT ch
ni d dy thc qun hn UTDD (24,0% so vi 12,2%).
Ung th tm v c hai bnh nguyn ring bit. Mt nhm ging
UTDD phn xa l hu qu ca vim d dy teo do H. pylori. Nhm
khc ging vi UTBMT thc qun c kh nng l hu qu ca bnh
tro ngc d dy thc qun. C l y l yu t lm ung th tm v
v ung th khng thuc tm vbiu l HER2khc nhau.
4.2.4.2. Mi lin quan gia s biu l EGFR, HER2 vi c im i th
- S biu l EGFR trong UTDD dng polyp v dng thm
nhim cao hn so vi UTDD dng nm, dng lot vi t l ln lt
l 46,2%, 42,9%, 29,7%, 9,1% (p < 0,05).
Galizia xc nhn s biu l EGFR c lin quan vi phn loi
Borrmann, vi h s tng quan l r = 0,222 (p=0,045).
- c im hnh nh i th UTDD qua ni soic lin quan vi
biu l HER2. S biu l ca HER2 c s khc nhau gia hnh nh
tn thng i th: dng polyp v dng nm c t l biu l HER2
ln lt l 50,0% v 25,0%, cao hn so vi dng lot (13,2%) cng
nh dng thm nhim (khng thy biu l HER2). S khc bit c
ngha thng k (p < 0,05).
Nhiu tc gi nhn thy hnh nh i th c lin quan vi mc
biu l HER2. Pinto-de-Sousa ghi nhn dng nmbiu l HER2 cao
hn so vi dng lot v dng thm nhim (23,5% so vi12,6%, 0%).
Lee nhn thy biu l HER2 dng polyp v nmcao hn dng lot
v thm nhim(29,5% so vi 13,9).
Nh vy, c im i th khi u c lin quan vi s biu l
EGFR ln HER2. Ann nhn thy hnh nh i th ca khi u c lin

19
quan vi c im m bnh hc. iu ny gi c th c im m
bnh hc mi chnh l yu t quyt nh mi lin quan gia c im
khi u vi s biu l EGFR v HER2.
4.2.5.Mi lin quan gia s biu l EGFR, HER2 vi c im m
bnh hc
4.2.5.1.Mi lin quan gia s biu l EGFR vi c im m bnh hc
- Theo phn loi Lauren, th rut biu l EGFR cao hn so vi
th lan ta (41,3% so vi 9,1%, p < 0,01).
Lemoinecngghi nhn s biu l EGFR trong th rut cao hn th
lan ta ( 27% v 12%).
- Theo phn loi TCYTTG, vi t l biu l EGFR trong th
ng nh cao hn th nhy, th t bo nhn v th khng bit ha
(39,6% so vi 14,3%, 14,3% v 4,8%, p < 0,05).
Takehana nhn thy 7 trng hp EGFR 3+ ch yu thuc
UTBMT th ng nh bit ha tt v va, ngc li 2 trng hp ung
th biu m nhum EGFR 2+ thuc UTBMT th bit ha km trong
khi th t bo nhnkhng c biu l EGFR.
- S biu l EGFR c lin quan vi mc bit ha. T l biu
l EGFR trong UTDD bit ha tt v bit ha va cao hn hn so
vi UTDD bit ha km (41,4% v 50% so vi8,5%; p < 0,001).
Yasui ghi nhn th bit ha tt biu l EGFR cao hn th bit ha
km trong c UTDD sm ln UTDD tin trin. Czyzewska nhn thy
66,7% khi u bit ha va biu l EGFR, nhng ch c 20% u bit
ha km biu l EGFR(p = 0,04).
4.2.5.2.Mi lin quan gia s biu l HER2 vi c im m bnh hc
- Theo phn loi Lauren, 32,6% th rut biu l HER2, cao hn
th lan ta, ch c 9,1% c biu l HER2(p<0,01).

20
Lee nhn thy th rut biu l HER2 cao hn th lan ta (28,7%
so vi 6,6%). Lordick xc nh t l biu l HER2 l 34% trong th
rut, 6% trong th lan ta. Tanner,Barros Silvas cng ghi nhn
khuch i HER2 thng gp hn trong th rut so vi th lan ta.
- Theo phn loi m bnh hc ca TCYTTG, biu l HER2
trong th ng nh cao nht (29,2%), tip theo l th khng bit ha l
(14,3%), th nhy (14,3%), v thp nht l th t bo nhn (7,1%).
Tuy nhin, s khc bit cha c ngha thng k.
Falck nhn thy HER2 dng tnh ch yu tp trung th ng
nh, th nh bit ha tt v bit ha va, chim 75% trng
hp.Uchino nhn thy t l biu l HER2 th ng nh l 14%, trong
khi th khng bit ha hoc th t bo nhn ch c 2% . Takehana
nhn thy s biu l HER2 ch xy ra trn th ng nh v khng thy
biu l HER2 trn th t bo nhn. Kataoka cng ghi nhn t l biu
l HER2 ca th ng nh n 21,7%, trong khi th nhy v th
khng bit ha khng c biu l HER2. S khc nhau c ngha
thng k (p < 0,0001).
UTDD th ng nh, th nh, c bit l th bit ha tt v bit
ha va thng thuc v UTDD th rut theo phn loi ca Lauren .
Trn hnh nh i th, cc th ny thng c hnh nh khi u dng
polyp hoc nm. iu ny l gii cho s biu l HER2 c lin quan
vi UTDD th rut cng nh lin quan vi hnh nh i th dng
nm trn ni soi.
- Phn loi mc bit ha ca khi u
S biu l HER2 cc khi u bit ha tt (27,6%) v va
(42,9%) cao hn so vi cc khi u bit ha km (10,6%). S khc
bit c ngha thng k (p < 0,05).

21
Leeghi nhncc khi u bit ha biu l HER2 cao hn cc khi u
khng bit ha (26,4% so vi 9%).Raziee nhnthy biu l HER2
trong UTDD bit ha tt l 41%, bit ha va l 11%, bit ha km
l 7% (p = 0,001).Kim ghi nhn s biu l HER2 trong th bit ha
tt v va cao hn th bit ha km.
L do HER2biu l chn lc hn trong UTDD th rut, th ng
nh, bit ha tt v va l phc tp v cn phi tip tc nghin cu
thm v khng phi tt c cc khi u th rut u biu l HER2. Hn
na, UTDD th rut th ng nh, bit ha tt v va l nhng th
ung th c tin lng kh quan hn so vi th lan ta, trong khi biu
l HER2 thng c lin quan vi tin lng xu.
iu ny cho thy nu ch da trn c im m bnh hc, khng
th tin lng chnh xc UTDD. V vy, vic phn loi UTDD theo
hng phn t c th l hng i mi cn c nghin cu thm.

22
KTLUN
Qua nghin cu s biu l EGFR, HER2 bng k thut nhum
ha m min dch v mi lin quan vi c im lm sng, hnh nh
ni soi, m bnh hc trn 90 bnh nhn UTBMDD t thng 1/2010 12/2011, chng ti c mt s kt lun nh sau:
1.V c im lm sng, hnh nh ni soi, m bnh hc v t l biu
l ca EGFR v HER2 trong UTBMDD
1.1. Cc triu chng lm sng thng gp l au vng thng v
(98,9%), st cn (47,8%), chn n (27,8%), bun nn, nn (26,7%),
xut huyt tiu ha (11,1%), thiu mu (70,0%), khi thng v
(13,3%).
- Trn hnh nh ni soi, UTBMDD khng thuc tm v chim s
lng ch yu (93,3%). UTBMDD thng biu hin di dng lot
nhiu nht (42,2%), tip theo l dng nm (40,0%).
- Theo phn loi Lauren, th rut chim t l gn tng ng
th lan ta (51,1% v 48,9%). Theo phn loi ca TCYTTG, th ng
nh thng gp nht (53,3%), tip theo l th khng bit ha
(23,3%), th t bo nhn (15,6%), v thp nht l th nhy (7,8%);
bit ha km thng gp nht (52,2%), tip theo l bit ha tt
(32,2%) v bit ha va (15,6%).
1.2. T l biu l ca EGFR v HER2 trn mu m UTBMDD sinh
thit qua ni soi ln lt l 25,6% v 21,1%. T l ng biu l
EGFR, HER2 trong UTBMDDl 11,1%.

23
2. V mi lin quan gia s biu l EGFR v HER2 vi c im
lm sng, hnh nh ni soi, m bnh hc
- S biu l EGFR v HER2khng c lin quan c ngha
thng k vi gii tnh, tui v tng trng chung ca bnh nhn.
- S biu l EGFR, HER2khng c lin quan c ngha thng
k vi v tr khi u, nhng c lin quan vi c im i th khi u
theo phn loi Borrmann. S biu l EGFR cao nht khi u dng
polyp v dng thm nhim (50,0%), tip theo l dng nm (30,6%),
dng lot (10,5%). S biu l HER2 cao nht khi u dng polyp
(50,0%), tip theo l dng nm (25,0%), dng lot (13,2%) v thp
nht l th thm nhim khng c biu l HER2.
- S biu l EGFR, HER2 c lin quan vi th m hc theo
phn loi Lauren, vi t l biu l EGFR, HER2 trong th rut cao
hn th lan ta (41,3% so vi 9,1%, p < 0,01; 32,6% so vi 9,1%, p
< 0,01). Theo phn loi ca T chc Y t Th gii, s biu l EGFR
c lin quan vi th m hc, vi t l biu l EGFR cao nht trong
th ng nh (39,6%). S biu l EGFR, HER2 cng c lin quan vi
mc bit ha, vi t l biu l EGFR, HER2 trong th bit ha tt
v va cao hn so vi th bit ha km (41,4%, 50% so vi 8,5%, p
< 0,001; 27,6%, 42,9% so vi 10,6%, p < 0,05).
KIN NGH
Qua nghin cu ny, chng ti c mt s kin ngh nh sau:
- Tin hnh xt nghim thng quy HMMD kho st s biu l
EGFR, HER2 cc bnh nhn UTBMDD xc nh nhm bnh
nhn c th ch nh iu tr bng cc thuc iu tr ch nh
trastuzumab nhm ci thin tin lng ca bnh nhn UTBMDD.

24
- M rng nghin cu i chiu tng hp gia k thut
HMMD vi cc k thut lai ti ch trn mu m sinh thit d dy
qua ni soi cng nh mu m phu thut i vi c EGFR ln HER2
nhm xc nh gi tr ca mi k thut, t chun ha phng
php nhum, la chn khng th, cch nh gi v tnh im t
tin cy, thng nht gia cc phng xt nghim HMMD.
DANH MC CC CNG TRNH
1. L Vit Nho, Trn Vn Huy, ng Cng Thun, T Vn T,
(2011), Nghin cu s biu l HER2 bnh nhn ung th d dy,
Tp ch Y hc Thnh ph H Ch Minh Hi tho chuyn ngnh gii
phu bnh ln th 8, 15(2), tr. 47-53.
2. L Vit Nho, Trn Vn Huy, ng Cng Thun, T Vn T,
(2011), Kho st mi lin quan gia hnh nh ni soi, m bnh hc
vi s biu l HER2 bnh nhn ung th d dy, Tp ch Khoa hc
Tiu ha Vit Nam, Hi ngh khoa hc tiu ha ln th 17, 6(24), tr.
1611-1619.
3. L Vit Nho, Trn Vn Huy, ng Cng Thun, T Vn T,
(2012),

Endoscopy,

histopathological

findings

and

HER2

overexpression in gastric adenocarcinoma, Journal of Medicine and

Pharmacy, 2 (1, Special Issue in English), pp. 68-76.
4. L Vit Nho, Trn Vn Huy, (2013), Nghin cu s biu l
EGFR bng k thut ha m min dch trn mu m ung th d dy
sinh thit qua ni soi, Tp ch Y Dc hc, 15, tr. 84-91.

HUE UNIVERSITY
UNIVERSITY OF MEDICINE AND PHARMACY
**********************

LE VIET NHO

STUDYING THE EXPRESSION OF EGFR, HER2

AND THEIR RELATIONSHIP WITH CLINICAL,
ENDOSCOPIC, HISTOPATHOLOGICAL
CHARACTERISTICS IN PATIENTS WITH
GASTRIC ADENOCARCINOMA
Specialty:

Gastroenterology

Code: 62.72.01.43

SUMMARY OFTHESIS

HUE - 2014

Work was finished at:

HUE UNIVERSITY - UNIVERSITY OF MEDICINE
AND PHARMACY
Scientific tutor:
Associate Prof.PhD. TRAN VAN HUY

Thesis could be found in:

-

Vietnam National Library

Library of Hue General Science

Library of Hue University of Medicine and Pharmacy

PREFACE
1. Introduction
Gastric cancer (GC), mainly gastric adenocarcinoma (GA),is a
common malignant disease. The prognosis of GC remains poor,
with5 year survival of about 28%. Chemotherapies are necessary but
only improve prognosis in some patients (pts) with high toxicities.
No biologic marker is helpful to choose pts into chemotherapies
now.
Through

studying

cells

at

molecular

level

with

immunohistochemitry (IHC), a lot of molecular factors such as

EGFR(Epidermal

Growth

Factor

Receptor)

andHER2(Human

Epidermal Growth Factor Receptor 2) were confirmed to relate to

carcinogenesis and progress of GC. Targeted agents against EGFR
and/orHER2seem to offer the most promisein the treatment of GC.
ToGA trial showed that agents against HER2 trastuzumab lowered
mortality, lasted survival and gave good tolerancein pts with positive
HER2 advancedGC.This result suggested that it is required to select
pts into targeted therapies through molecular markers as EGFR,
HER2. InVietnam, there have not been any studies on the
expressionof EGFR andHER2in GC yet.
2. Purposes of thesis
- Observating a number of clinical, endoscopic, histopathological
characteristics and expressionrate of EGFR, HER2 in GA.
- Evaluating relationship between HER2 expressionand the
clinical, endoscopic, histopathological characteristics of GA.
3. Scientific value

2
- Applying a new technique as IHC staining to determine
expressionrate of EGFR, HER2inGAin order to create the basis to
develop a new classification of GA at molecular level.
-

Confirming

expressionand

therelationship

the

clinical,

between

endoscopic,

EGFR,

HER2

histopathological

characteristics of GAin order to know more deeply about the

molecular structure of GA.
4. Practical value
Providing physicians with a new tool, which is molecular factors
such as EGFR andHER2, to select pts into treatment with
trastuzumab, an effective targeted therapy of advanced GC.EGFR
andHER2expression status may help physicians to choose a suitable
chemotherapeutic regime as well as to predict the prognosis.
5. New contributions
Applying a new technique as IHC staining to determine that
expression rate of EGFR, HER2 in GC were 25.6%, 21.1%,
respectively in order to precisely select the patients into treatment
with trastuzumab.
Confirming thatEGFR, HER2 expressionwere not related to age,
sex but were related to the endoscopic, histopathological
characteristics of GC.
6. Lay-out of thesis
The thesis includes 118pages, including 2 pagesof introduction,
32pagesof overview, 18 pages of materials andstudy methods, 26
pages of results, 37 pages of discussion, 3 pages of conclusions and
suggestions.

There

are37tables,

9figures,

124references (25in Vietnameseand 99 inEnglish).

25picturesand

CHAPTER 1: OVERVIEW
1.1. EPIDEMIOLOGYANDRISK FACTORS OFGC
1.1.1.

Epidemiology:

GCis

common

malignant

disease.

Vietnambelongs to the region with high intermediate-risk for GC.

1.1.2. Risk factors: GC isthe consequence of complexinteractions
between host factors, environmental factors and H.pylori infection.
1.2. HISTOPATHOLOGICAL FEATURES
1.2.1. Location: GC includescardia and non-cardia cancer.
1.2.2. Gross appearance: Borrmannclassified GCinto 4 types:type I
(polypoid), type II (fungating),type III (ulcerative) andtype IV
(infiltrative).
1.2.3. Microscopic characteristics: GA is the most common GC.
1.2.3.1.Histopathological

classificationof

GCby

Lauren:

Laurenclassification divides gastric cancer into diffuse and intestinal

types.
1.2.3.2.

Histopathologicalclassification

of

GC

by

World

HealthOrganization (WHO): WHO classification system divides GC

into 10 types: tubular, papillary, mucinous, signet ring cell types are
common; other histopathological typesare rare.
1.2.3.3. Differentiation degree: GC can be divided into 3 types: well,
moderately, or poorly differentiated types.
1.2.4.Staging of GC: GC staging commonly is based on staging of
Tumor, Node and Metastasis, abbreviated to TNM staging now.
1.3. DIAGNOSIS, TREATMENT AND PROGNOSIS OF GC
1.3.1. Symptoms: Signs and symptoms are frequently non specific.
Physical signs are usually late. In ptswith these signs, tumors are
commonly at the advanced stages, which are not radically resectable.

4
1.3.2. Subclinical findings
1.3.2.1. Endoscopy and uppergastrointestinal X-ray: Endoscopy with
biopsy is the gold standard in the definitive diagnosis of GC. The
sensitivity and specificity of endoscopy are all higher than those of
uppergastrointestinal X-ray.
1.3.2.2. Serum markers: No serum markers were identified to have
good sensitivity and specificity for definitive diagnosis of GC.
1.3.2.3. Diagnostic imaging, endoscopic ultrasound and laparoscopy:
Their role is mainly staging of GCbefore treatment.
1.3.3. Treatment and prognosis of GC
1.3.3.1. Treatment of GC: Chemotherapies play quite an important
role. However, its efficacy is low and its toxicity is high. Targeted
agents

against

HERfamily

showed

favorable

results,

especiallytrastuzumab. This is a new promising wayin the treatment

of GC.
1.3.3.2.Prognosis of GC: The more early GC, the more favorable
prognosis. In many cases, however, the progress is significantly
different at the same TNM stage. There were a lot of publications on
the role of molecular factors in the prognosis of GC.
1.4.EGFR ANDHER2IN GC
1.4.1. Outline of HER family
The HER family comprises four related different receptors:
EGFR, HER2, HER3 and HER4. EGFR and HER2 are commonly
expressed in a lot of cancer cells, including GC. The aberrantEGFR
activation appearsto be an important factor in tumorigenesis, as well
as anessential driving force for the aggressive growth behaviourof
cancer

cells.

HER2

appears

to

functionprimarily

as

heterodimerisation partner for EGFR, making it an ideal candidatefor

5
use as a prognostic indicator in combinationwith the EGFR in many
kinds of cancer, including GC.
1.4.2. Techniques to assess EGFR andHER2status in GC
A lot of techniques are used to assess the EGFR, HER2 status in
cancer cells. The In situ Hybridization (ISH) and IHC are the most
commonly used now.
1.4.3. Role of EGFR andHER2in prognosis ofGC
EGFR and/orHER2are independent prognostic factors in GC.But
a few studies showed other results. EGFR and/orHER2are commonly
co-expressedwith other molecular markers, so maybe there is
existence of many different molecular factors and pathways that
influence the growth and of GC.
1.4.4. Role of EGFR andHER2 in prediction of treatment response
- EGFR: Han reported that7pts having tumor EGFR expression
with low serum EGF and TGF-a levels showed a 100% response rate
compared to 37.0% in the remaining 27 pts (p <0.001).
- HER2: Agent against HER2 trastuzumab lowered 26% of
mortality risk, prolonged survivalinptswith positiveHER2 advanced
GC. The response to trastuzumab was related toHER2 expression
degree:The

higher

HER2expression,

the

longer

survival.

Trastuzumab, therefore, become the first agent licensed in the

treatment of advanced GCwith positive HER2.
Hence, the assessment of EGFR andHER2by IHC isthe preferable
way because it is helpful in the treatment and prognosis of GC.

CHAPTER 2: MATERIALS AND METHODS

2.1.MATERIALS
Pts, who underwent endoscopy at Endoscopy Department of Hue
University of Medicine and Phamacy Hospital and Endoscopy
Department of Hue Central Hospital from 1/2010-12/2011, were
detected to have GC lesions on endoscopy.
2.1.1. Inclusion criteria
- Histopathological results of biopsy specimen were GA.
- Specimenhad enough number of cancer cells for IHC staining.
2.1.2. Exclusion criteria: metastatic GC,GC combined with other
cancers, previous chemotherapy, number of cancer cells was not
enoughfor IHC staining.
2.2.METHODS
2.2.1. Study design: Cross-sectional study.
2.2.2. Sample size: 90
2.2.3. Steps for study: All the pts had questionaire about
history,physical examination;underwent endoscopy for assessment of
location, gross appearance, biopsy;had HE stainingfor definitive
diagnosis, histopathological classification;andIHC staining for
EGFR, HER2;staging of TNM.
2.2.4. Collection of clinical data
2.2.5. Collection of result for blood hemoglobin
2.2.6. Collection of endoscopic data
- Location: Cardiaand non-cardia.
- Classification of gross appearance based on Borrmann,
includes 4 types: polypoid, fungating, ulcerative and infiltrative.
- Biopsy of lesion
+ Tool: biopsy needle FB-25K-1, diameter2mm.

7
+ Biopsy technique: strip technique.
+ Number of specimen 6,sized2mm.
2.2.7.Collectionof histopathological data
2.2.7.1. Laboratory for staining and interpretationof HE
- Pathology Department of Hue University of Medicine and
Phamacy

HospitalandPathology

Department

of

Hue

Central

Hospital:fixedandembedded biopsy specimens.

- Cytology and Pathology Department of Hanoi Cancer
Hospital: recheckedHE staining and classified by histopathology.
2.2.7.2. Technique: Routine HE staining method.
2.2.7.3. Interpretation:
- Definitive diagnosis ofGA
- Classification
+ Lauren: intestinal typeanddiffuse type.
+ WHO:papillary,

tubular,

mucinous

adenocarcinoma,

signet-ring cell carcinoma, adenosquamous carcinoma, squamous

cell carcinoma, undifferentiated carcinoma, and other types.
+ Differentiation degree: well, moderately and poorly.
2.2.8. Data of EGFR, HER2 staining
2.2.8.1. Laboratory for staining and interpretation of IHC
Cytology and Pathology Department of Hanoi Cancer Hospital.
2.2.8.2. Instrumentsandchemicals
- Instrumentsfor IHC staining: weight, pressure-cooker.
- Chemicals: EGFR PharmDx kitandHerpestest kit of Dako.
2.2.8.3. Technique of IHC:standard Avidin Biotin Complex (ABC).
2.2.8.4. Interpretation of IHC staining: Interpretation of IHC
stainingunder optical microscopywith 10 x 40 magnification.
- Positive control: Specimen was surely positive 3+.

8
- Negative control: Specimenwas not covered with first
antibody. Internal control was non-neoplastic gastric mucosa cells.
- IHC stainingof EGFR, HER2were scored as follows:
+ EGFR: positivewhenstaining of > 10% of tumor cells.
0 (Negative): no staining or unspecific staining of tumorcells;
1+: weak and incomplete stainingof >10% of tumor cells;
2+: moderate and complete stainingof >10% of tumor cells;
3+: strong and complete staining of > 10% of tumor cells.
+ HER2: HER2 staining was scored 0 to 3+in each specimen:
0: No reactivity or no membranous reactivity in any tumor cell;
1+: Tumor cell cluster with a faint or barelyperceptible
membranous reactivityirrespective of percentage of tumor cellsstained;
2+: Tumor cell cluster with a weak tomoderate complete,
basolateral or lateralmembranous reactivity irrespective ofpercentage
of tumor cells stained;
3+: Tumor cell cluster with a strong complete,basolateral or
lateralmembranousreactivity irrespective of percentage oftumor cells
stained.
Only scores of 2+ and 3+ levels were considered to be positive.
2.2.10.Statistical analysis
Using of SPSS 19.0: Comparison of mean byT-test;Comparisonof
proportion by chi-square test. The results wereconsidered statistically
significant at p < 0.05.

CHAPTER 3: RESULTS
3.1. Clinical, endoscopic, histopathological characteristics and
expressionrate of EGFR, HER2 inGA
3.1.1. Sex: Among 90 pts enrolled into the study, there are 66menand
24women. Male/female ratio: 2.75/1.
3.1.2. Age: Age of GA pts was 26-92, average age was 58.9 13.8.
Pts > 50 accounted for 75.6%.
3.1.3.Clinical characteristics
- Epigastric pain, weight loss, anemiawere common signs,
withrates of 98.9%, 70.0%, 47.8%. Hematemesis and/ormelena,
dysphagia and jaundice were rare symptoms, withrates of 11.1%,
3.3% and 1.1%, respectively.
- Common physical signs were epigastric mass (13.3%),
supraclavicular lymph node (3.3%) and ascites (2.2%).
3.1.5. Endoscopic characteristics
Non-cardia GApredominated (93.3%). Fungating typewas the
commonest (41.1%), followed byulcerative type (36.7%).
3.1.6. Histopathological characteristics
According to Lauren classification, intestinal typewas found more
frequently than diffuse typeinsignificantly. According toWHO
classification,

tubularGAwas

the

highest(53,3%);and

poorly-

differentiatedGAwas the highest.

3.1.7. Staging of GC
Among 90 pts, 44 had gastrectomy and TNM staging. Mostptshad
T2 to T4 tumors (97.7%), N1 to N3 lymph node metastasis (63.6%),
distant metastasis(27.3%). That mean that almost pts were at
advanced stages: II to IV (88.6%).
3.1.8. Expression of EGFR andHER2inGA

10
23 (25.6%) ptsshowedpositive EGFR expression, 19 (21.1%)
ptsshowed

positive

HER2expression

and

10

pts

(11.1%)

showedcoexpression of EGFR andHER2.

Negative

EGFR

tumors

showed

lower

positive

HER2

expressionthanpositive EGFR tumors (p < 0.01).

3.2. Relationship betweenexpressionof EGFR andHER2with
clinical, endosopic and histopathological characteritics
3.2.1. Relationshipbetweenexpressionof EGFR, HER2 withsex
- EGFR expressionin male was 27.3% andin female was20.8%.
The difference was statistically unsignificant (p > 0.05).
- HER2 expressionin male was 24.2% andin female was 12.5%.
The difference was statistically unsignificant (p > 0.05).
3.2.2. Relationshipbetweenexpressionof EGFR, HER2 withage
- EGFR expressionwas indifferent between agegroups ofpts (p >
0.05).
- HER2 expressionwas also indifferent between agegroups ofpts
(p > 0.05).
3.2.3.Relationshipbetweenexpression

ofEGFR,

HER2

withperformance status
Ptsperformance status was not associated with EGFR expression
(p > 0.05) as well asHER2expression (p > 0.05).

11
3.2.4.Relationshipbetweenexpression

of

EGFR,

HER2

withendoscopic characteristics
3.2.4.1.Relationshipbetween EGFR expressionwith tumor location
Table 3.24: Relationship between EGFR expression with tumor location
Location

Number

EGFR

expression

Cardia

33.3

Non-cardia

84

21

25.0

90

23

25.6

Total

> 0.05

Remark:
EGFR expressionrate of cardia tumors was higher than that of
non-cardia tumors (33.3% vs 25.0%). The difference, however,was
statistically unsignificant (p > 0.05).
3.2.4.2.RelationshipbetweenHER2 expressionwithtumor location
Table 3.25: Relationship between HER2 expression with tumor location
Location

Number

HER2

expression

Cardia

50.0

Non-cardia

84

16

19.0

90

19

21.1

Total

> 0.05

Remark:
HER2 expressionrate of cardia tumors was higher than that of
non-cardia tumors. The difference, however,was statistically
unsignificant (p > 0.05).

12
3.2.4.3.Relationship between EGFR expression with gross appearance
Table 3.26: Relationship between EGFR expression withgross
appearance
Borrmann

Number

EGFR

expression

Polypoid type

10

50.0

Fungating type

36

11

30.6

Ulcerative type

38

10.5

Infiltrative type

50.0

90

23

25.6

Classification

Total

< 0.05

Remark:EGFR expressionrate of ulcerative typewas the lowerest

compared to other types (p <0.05).
3.2.4.4.Relationship between HER2 expression with gross appearance
Table 3.27: Relationship between HER2 expression
withgross appearance
Borrmann

Number

HER2

expression

Polypoid type

10

50.0

Fungating type

36

25.0

Ulcerative type

38

13.2

Infiltrative type

90

19

21.1

Classification

Total

< 0.05

Remark:HER2 expressionrate of polypoid type(50.0%) and

fungating type(25.0%) were higher than those ofulcerative
type(13.2%) and infiltrative typewithout HER2 expression. The
difference was statistically significant.
3.2.5.Relationshipbetweenexpression
HER2withhistopathological characteristics

of

EGFR,

13
Table

3.28:

RelationshipbetweenEGFR

expressionwithhistopathological characteristics
Histopathological

Number

EGFR

characteristics

expression

Intestinal type

46

19

41.3

< 0.01

Diffuse type

44

9.1

Tubular

48

19

39.6

Mucinous

14.3

Signet ring cell

14

14.3

Undifferentiated

21

4.8

Well

29

12

41.4

Moderately

14

50.0

Poorly

47

8.5

90

23

25.6

Lauren Classification

WHO Classification
< 0.05

Differentiation degree

Total

<0.001

Remark:
According to Lauren, intestinal type showed higherHER2
expression than diffuse type (p <0.01). According to WHO
classification, EGFR expressionintubulartype was the highest,
followed by mucinous, signet ring cell, undifferentiatedtypes (p
<0.05);EGFR expressionin well-andmoderately-differentiatedtumors
was higher than poorly-differentiatedtumors (p <0.001).
Table

3.29:

RelationshipbetweenHER2

expressionwithhistopathological characteristics
Histopathological

Number

HER2

characteristics

expression

14
Lauren classification
Intestinal type

46

15

32.6

Diffuse type

44

9.1

Tubular

48

14

29.2

Mucinous

14.3

Signet ring cell

14

7.1

Undifferentiated

21

14.3

Well

29

27.6

Moderately

14

42.9

Poorly

47

10.6

90

19

21.1

< 0.01

WHO classification
> 0.05

Differentiation degree

Total

< 0.05

Remark:
According to Laurenclassification, intestinal type showed
higherHER2 expression than diffuse type (p <0.01). According
toWHO

classification,

HER2

expressionof

different

histopathological types were not different (p > 0.05). According

todifferentiation degree, well- and moderately-differentiatedtumors
showed higherHER2 expression thanpoorly-differentiatedtumors (p
<0.05).

15
CHAPTER4: DISCUSSION
4.1.

Clinical,

endoscopic,

histopathological

characteristics

andexpressionof EGFR, HER2 inGA

4.1.1. Sex: GAwas associatedwithsex.In this study, male/female ratio
was 2.75/1. Female reprodutive hormones play protective role, make
women have lower incidence of GA than man.
4.1.2. Age: GAwas associatedsignificantlywithage.Average age
ofpts:58.9 13.8, with 75.6%ptsatage>50.
4.1.3. Clinical characteristics
4.1.4. Endoscopiccharacteristics
4.1.5. Histopathological characteristics
4.1.6. GA staging characteristics
4.1.7. Expressionof EGFR andHER2inGA
4.1.7.1. EGFRexpression rate was25.6%.This rateis similar tothat of
Song (25.4%) and Yasui (27.9%).
4.1.7.2. HER2 expressionratewas 21.1%.HER2 expressionrate was
the similar to that of Lee S.(20.2%), Yano (21.5%), Hofmann (19%)
Zhang (18.6%), ToGAtrial (22.3%), meta-analysis of Chua (18%).
Some authors gave different results. Some studies, even,showed
very different results. The reasons for that may include:
- Antibodyused in the study was different
- Scoring and asessment was significantly different
+ Characterisitcs of membrane staining
+ Different percentage threshold of membrane staining cells.
+ Different way to assess positive specimen
- Factors related to IHC staining technique.
- Specimens: Some authors used specimen of resected tumors.
Becausegastric

tumors

are

usually

heterogeneous,

HER2

16
expressionin biopsy specimen is not completely concordant
withspecimen ofresected tumorbecausebiopsy specimen is tiny(about
2-3mm).
Establishing a private standard for assessment of IHC staining in
biopsy specimen is essential for both EGFR andHER2. Besides, the
characteristicsof

participants,

especiallyhistopathological

characteristics, may affect the HER2staining.

4.1.7.3.Co-expressionof EGFR andHER2
EGFR andHER2co-expression rate was 11.1%. A significant link
was observed betweenEGFR expressionandHER2expression (p
<0.01).

Matsubara

15%.Czyzewska
associatedwithHER2

realized
confirmed
expressionin

thatco-expression
thatEGFR
both

rate

was

expressionwas

primary

tumors

and

metastatic nodes.
A lot of molecular factors in HER family were related to GC.
This may be the reason for some pts non-response to monotarget
treatment against EGFR orHER2. So, multitarget approach was one
of the novel preferable ways in GC treatment nowadays.
4.2.Relationshipbetweenexpressionof EGFR, HER2 withclinical,
endoscopic, histopathological characteristics
4.2.1. Relationshipbetweenexpressionof EGFR, HER2 withsex
- EGFR expressionwas not associatedwithsex (p > 0.05).
Dong and Kim J.S. confirmed that too.
- HER2 expressionwas not associatedwithsex (p > 0.05).
Raziee, Tateishi, Allgayer, realized that too.
Garcia

using

quantity

method,

Tanner

assessing

amplification,realizedHER2expression was not associatedwithsex.

4.2.2. Relationshipbetweenexpressionof EGFR, HER2 withage

17
- EGFR expressionwas not associatedwithage (p > 0.05).
Dong, Kim J.S. Lee K.E., Marx,also gave similar results.
- HER2 expressionwas not associatedwithage (p > 0.05).
Hee, Marx, Pinto-de-Sousa, Song, Yan also admitted that.
4.2.3.Relationshipbetweenexpressionof EGFR, HER2 withstatus
4.2.4.Relationshipbetweenexpressionof

EGFR,

HER2

withendoscopic characteristics
4.2.4.1.Relationshipbetweenexpressionof EGFR, HER2 with tumor
location
- EGFR expressionwas not associatedwithtumor location. EGFR
expressionofcardia GA(33.3%)washigher thanthat of non-cardia
GA(25%), but the difference was statistically unsignificant.
Garcia confirmed that EGFR contentin proximal tumors was not
different from that in distant tumors. Czyzewska also realized EGFR
expressionin upper, middleandlowertumors were not different.
- 50% cardia cancershowed HER2 expression, while only 19%
non-cardia cancershowed HER2 expression. The difference was,
however,statistically unsignificant (p > 0.05).
Pinto-de-Sousa (2002) admitted thatthere was a significant
correlation betweenexpressionbetweenHER2expression withtumor
location. TheHER2 expressionrate of antral cancer was 7.2%,which
was lower than cardia cancer (23.8%) andfundus/body cancer
(25.0%) (p=0.01).Lordick also admitted that HER2 expressionrate
different in tumor locations: 32% withgastro-esophageal junctional
tumors and 18% withgastric tumors.
Tanner admitted thatHER2amplification was more common than
ingastro-esophageal junctional cancerthanGC (24.0% vs 12.2%).

18
There are twodistinct etiologies in cardia cancer. One was similar
to distant GCdue toatropic gastritis by H. pylori. Another one was
the

same

as

esophagus

gastroesophageal

reflux

cancerthat
disease.

may

Maybethis

be

outcome
makes

of

HER2

expressionof cardia cancerandnon-cardia cancerdifferent.

4.2.4.2.Relationship between expression of EGFR, HER2 with gross
appearance characteristics
- EGFRexpressionin polypoid type (46.2%) and infiltrative type
(42.9%) were higher than fungating type (29.7%), ulcerative type
(9.1%) at p < 0.05. Galizia admitted that EGFR expression was
associated with Borrmann classification, with r = 0.222 (p=0.045).
- No correlation was not found between endoscopic gross
appearance and HER2 expression. HER2 expression was different in
different gross types: polypoid type and fungating type showed
HER2 expression at 50.0% and 25.0%, higher than ulcerative type
(13.2%) as well as infiltrative type (did not showed HER2
expression) at p < 0.05. A great number of authors recognized gross
appearance was related to HER2 expression. Pinto-de-Sousa
admitted that HER2 expression in fungating type was higher than
ulcerative type and infiltrative type (23.5% vs 12.6%, 0%). Lee
realized that HER2 expression in polypoid and fungating type were
higher than ulcerative and infiltrative type (29.5% vs 13.9).
Shortly,

gross

andHER2expression.

appearance
Ann

was

admitted

associatedwithhistopathological

related
gross

characteristics.

toboth
appearance
This

EGFR
was

suggested

thathistopathological characteristicsmay be decisive factors in the

relationship between tumor characteritics and EGFR, HER2 expression.

19
4.2.5.Relationshipbetweenexpression

of

EGFR,

HER2withhistopathological characteristics
4.2.5.1.RelationshipbetweenEGFR

expressionwithhistopathological

characteristics
- According to Lauren classification, intestinal typeshowed
higher EGFR expression than diffuse type (41.3% vs 9.1%, p < 0.01).
Lemoinerealized thatEGFR expressioninintestinal typewas higher
thandiffuse type (27% vs 12%).
- According to WHO classification, EGFR expressionin tubular
type

was

higher

than

that

in

mucinous,

signet

ring

cellandundifferentiatedtype (39.6% vs 14.3%, 14.3% and 4.8%, p

<0.05).
Takehana realized that 7 carcinomas with 3+ EGFR were well- or
moderately differentiated tubular adenocarcinomas, whereas 2
carcinomas with 2+ EGFR were poorly-differentiated tubular
adenocarcinomas. Signet ring celltype showed no EGFR expression.
- EGFR expressionwas considered to relatedtodifferentiation
degree.

EGFR

expressionrates

inwell-andmoderately-

differentiatedGCwere higher than poorly-differentiatedGC (41.4%

and 50% vs 8.5%; p <0.001).
Yasui realized that EGFR expressionin well-differentiated
typewas higher thanpoorly-differentiatedtype in both early and
advancedGC.

Czyzewska

noted66.7%

moderately-

differentiatedtumors expressed EGFR, but only 20% poorlydifferentiatedtumors expressed EGFR (p = 0.04).

20
4.2.5.2.Relationship

between

HER2

expression

with

histopathological characteristics
- According to Lauren classification, 32.6% ofintestinal
typeshowed HER2 expression, which was higher than diffuse
type,only9.1% of that showed HER2 expression (p<0.01).
Lee identified thatHER2 expression inintestinal typewas higher
thandiffuse type (28.7% vs 6.6%). Lordick noted that HER2
expressionrate was 34% inintestinal type, 6% indiffuse type. Tanner,
Barros Silvas also realized that HER2amplification inintestinal
typewas more common thandiffuse type.
- According toWHO classification, HER2 expressionin the
tubulartype

was

the

highest

(29.2%),

followed

byundifferentiatedtype (14.3%), mucinous (14.3%), andsignet ring

celltype was the least (7.1%). However, the difference was
statistically unsignificant.
Falck admitted thatpositive HER2mainly concentrated on welldifferentiated and moderately-differentiated tubular, papilary type
(75% cases).Uchino realized thatHER2 expressionrate in tubular type
was 14%, whileHER2 expressionrate inundifferentiatedorsignet ring
celltype was only 2%. Takehana noted thatHER2 expressedonly in
tubulartype and did not appear in signet ring cell type.
Kataokarealized that HER2 expressionrate in tubularwas 21,7%,
whilemucinousandundifferentiatedtype

showed

noHER2expression.The difference was statistically significant (p <

0.0001).
According to Lauren classification,tubularGC, especially wellandmoderately-differentiatedtype, usually belong tointestinal type.
Macroscopically,

intestinal

typeusually

showed

polypoid

21
orfungatingtumors. This explains whyHER2 expressionwas related
tointestinal typeGCas well as fungating type GC at endoscopy.
- Differentiation degreeof tumor
HER2 expression in well-differentiated (27.6%) andmoderatelydifferentiated

(42.9%)

differentiatedtumors

tumors

(10.6%).The

was

higher

difference

was

thanpoorlystatistically

significant.
Leeadmitted that HER2 expressionwere higher in differentiated
tumors than undifferentiated tumors (26.4% vs 9%).Raziee
realizedHER2

expressioninwell-differentiatedGCwas

41%,

moderately- differentiatedGCwas 11%, poorly-differentiatedGCwas

7% (p = 0.001).Kim admitted HER2 expressionin well- and
moderately-differentiatedtypes was higher thanpoorly-differentiated
type.
Why HER2is expressedmore selectively in GC of intestinal type,
tubular

type,

well-

and

moderately-differentiated

types

iscomplexandrequired further studies because not all tumors of

intestinal typetumor showedHER2 expression. Moreover, intestinal
type, tubular type, well- and moderately-differentiated type were
histopathological types with more favorable prognosis than diffuse
type, while HER2 expressionusuallywas associatedwith poor
prognosis.
This showed that only based on histopathological characteristics,
it is impossible to predict precisely outcome ofGC. Classificationof
GC,therefore,at molecular level may be a new way which is required
further studies.

22
CONCLUSIONS
Through studing HER2,EGFR expressionbyIHC stainingandtheir
relationshipwithclinical, endoscopic, histopathological characteristics
in 90 ptswith GAfrom 1/2010 to 12/2011, we make some
conclusions as follows:
1.

For

clinical,

endoscopic,

histopathological

characteristicsandexpressionrate of EGFR andHER2 in GA

1.1. Common clinical signs were epigastric pain (98.9%), weight loss
(47.8%),

anorexia

(27.8%),

nausea,

vomiting

(26.7%),

gastrointestinal hemorrhage (11.1%), anemia (70.0%), epigastric

mass (13.3%).
- At endoscopy, non-cardia GApredominated (93.3%). The
commonest gross appearance of GA was ulcerative type (42.2%),
followed by fungating type (40.0%).
- According to Lauren classification, intestinal typewas nearly
equivalent to diffuse type (51.1% and 48.9%). According to WHO
classification, tubulartype was the commonest (53.3%), followed
byundifferentiatedtype (23.3%), signet ring celltype (15.6%),
andmucinoustype

(7.8%);

poorly-differentiatedtype

was

the

commonest (52.2%), followed bywell-differentiated type (32.2%)

andmoderately-differentiatedtype (15.6%).
1.2. EGFR andHER2expressionrate in the endoscopic biopsy
specimen were25.6%and21.1%, respectively. Co-expression rate of
EGFR andHER2in GA 11.1%.

23
2. For relationshipbetweenEGFR andHER2expressionwithclinical,
endoscopic, histopathological characteristics
- EGFR

andHER2expressionwere

not

associatedsignificantlywithsex, ageandperformance statusofpts.

- EGFR andHER2expressionwere not associatedsignificantly
withtumor location, but were associatedgross appearance according
to Borrmann. EGFR expressionwas the highest in polypoidand
infiltrative type (50.0%), followed by fungating type (30.6%),
ulcerative type (10.5%). HER2 expressionwas the highest in
polypoid type (50.0%), followed by fungating type (25.0%),
ulcerative

type

(13.2%)

and

the

lowerest

was

infiltrative

typewithoutHER2 expression.
- According

to

Lauren

classification,

EGFR,

HER2

expressionwere associatedwithhistopathological types.EGFR, HER2

expressionin the intestinal typewere higher than diffuse type (41.3%
vs 9.1%, p <0.01; 32.6% vs 9.1%, p <0.01). According to WHO,
EGFR expressionwas associatedwithhistopathological types. EGFR
expressionwas the highest intubulartype (39.6%). EGFR, HER2
expressionwas

also

associatedwithdifferentiation

degree.EGFR,

HER2 expressionin well-andmoderately-differentiatedtypes were

higher thanpoorly-differentiated type (41.4%, 50% vs 8.5%, p
<0.001; 27.6%, 42.9% vs 10.6%, p <0.05).
SUGGESTIONS
Through this study, we make some suggestions as follows:
- Routinely evaluating EGFR, HER2 expressionby IHC staining
in ptswith GA in order to identify group of pts who may be

24
candidates for targeted therapies such as trastuzumab to improve
prognosis of pts with GA.
- Expanding study for comparison of concordance betwween
IHC and ISH on endoscopic biopsy specimens as well as resected
tumor specimens of GAfor both EGFR and HER2 in order to
validate the value of each technique, hence to standardize the
techniques for staining, selection of antibodies, method of scoring
with good confidence and agreement in IHC laboratories.
LIST OF SCIENTIFIC WORKS
5. Le Viet Nho, Tran Vn Huy, ang Cong Thuan, Ta Van To,
(2011), HER2 expression of Gastric Adenocarcinoma, Journal of
Ho Chi Minh Medicine 8th Workshop on Pathology, 15(2), pp. 4753.
6. Le Viet Nho, Tran Vn Huy, ang Cong Thuan, Ta Van To,
(2011), Relationship between endoscopic properties, histopathology
fand HER2 overexpression in Gastric Adenocarcinoma, Vietnamese
Journal of Gastroenterology, 17th National Scientific meeting on
Gastroenterology, 6(24), pp. 1611-1619.
7. Le Viet Nho, Tran Vn Huy, ang Cong Thuan, Ta Van To,
(2012),

Endoscopic,

histopathological

findings

and

HER2

overexpression in Gastric Adenocarcinoma, Journal of Medicine

and Pharmacy, 2 (1, Special Issue in English), pp. 68-76.
8. Le Viet Nho, Tran Vn Huy, (2013), Study of EGFR
expression in endoscopic biosy sample of gastric adenocarcinoma by
immunohistochemistry, Journal of Medicine and Pharmacy, 15, pp.
84-91.