RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, KARNATAKA

BANGALORE

ANNEXURE – II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

1 / NAME OF THE CANDIDATE AND ADDRESS ( IN BLOCK LETTERS) / : / Dr. ANSHUMAN SINHA,
POST GRADUATE,
DEPARTMENT OF PATHOLOGY
M.R. MEDICAL COLLEGE,
GULBARGA – 585 105.
PERMANENT ADDRESS / : / Dr. ANSHUMAN SINHA
S/O. Dr. K. C. SINHA
ROAD NO 2, SIKANDARPUR,
MUZAFFARPUR – 842001.
BIHAR.
PHONE – 0621- 2215970
9431239144
2 / NAME OF THE INSTITUTION / : / H.K.E. SOCIETY’S MAHADEVAPPA
RAMPURE MEDICAL COLLEGE,
GULBARGA – 585105
3 / COURSE OF STUDY AND SUBJECT / : / M.D. (PATHOLOGY)
4 / DATE OF ADMISSION TO THE COURSE / : / 01 JUNE 2012
5 / TITLE OF TOPIC / : / CORRELATION OF HISTOMORPHOLOGICAL FEATURES WITH HER-2 EXPRESSION IN GASTROINTESTINAL CARCINOMAS.
6 / BRIEF RESUME OF THE INTENDED WORK
6.1 / NEED FOR THE STUDY
Pattern of Gastrointestinal malignancies differ in different geographical areas and depends upon genetic, cultural, dietary and socioeconomic factors [1]. Gastrointestinal cancers are commonest malignant tumors among Indians accounting for around 34.9 % of all malignancies (Paymaster 1967) [2]. Esophageal cancer constitutes 11%, Gastric Cancer 18%, Colon Cancers around 2% of the total number of Gastrointestinal cancers (S. L. Malhotra 1967) [3]. Majority were Adenocarcinomas in cases of Stomach, small intestine, Colon and Rectum and Squamous cell carcinoma being the most common histological type in Esophagus as reported by R kalyani (2010)[1].
HER-2 is a proto-oncogene located on chromosome 17q21 and is a member of Human Epidermal Growth Factor receptor (EGFR) family. HER-2, encodes for membrane bound tyrosine kinase, is over expressed in various human cancers like breast, colon, bladder, ovary, fallopian tubes, endometrium, Lungs, head and neck, prostate, pancreas, salivary glands, esophagus, and Gastric Carcinoma[4].
Its over expression and amplification is considered an indicator of bad prognosis [6].
Data of HER-2 over expression in gastro-esophageal cancer varies widely from 9 to 60%. It correlates with tumor invasion, nodal metastasis and is indicative of poor prognosis [6]. In Gastric tumors, intestinal type are more likely to be HER-2 positive than diffuse or mixed [9]. In colorectal cancers, only a small subset of cases show HER-2 positivity, but further study is needed in this area [8].
Various studies on HER-2 expression in Gastrointestinal cancers indicate that it can be used as routine predictive marker. Also, monoclonal antibody against HER-2 is available and is being used as targeted therapy [9].
Hence with increase in Gastrointestinal cancer at approximately 1% every year[3], majority of these being diagnosed at an advanced stage, HER-2 testing is opening new fields to understand the biology of the gastrointestinal tract cancers and its role in molecular therapy.
6.2 / REVIEW OF LITERATURE
The HER2 protein is a transmembrane tyrosine kinase (TK) receptor and a member of the epidermal growth factor receptors (EGFRs) family. This family is composed of four members: HER1 (also known as the EGFR), HER2, HER3 (also termed ErbB-3), and HER4 (also termed ErbB-4). These receptors share the same molecular structure with an extracellular ligand-binding domain, a short transmembrane domain, and an intracellular domain with TK activity (excepting the HER3). The binding of different ligands to the extracellular domain initiates a signal transduction cascade that can influence many aspects of tumor cell biology, including cell proliferation, apoptosis, adhesion, migration, and differentiation.
Oesophageal cancer is the third leading cause of cancer death in male and fourth in females
and the incidence is low in rural India[1],[3]. Several studies have shown that Her-2 is over-expressed in esophageal cancer in both Squamous Cell Carcinomas and Adenocarcinomas. There is a wide range of expression from 0% to 43% (Squamous Cell Carcinoma 0% to 42%, Adenocarcinoma 6% to 43%)[4]. In general, HER2 over-expression is related to worse prognosis in esophageal adenocarcinomas [6]. Different studies have found HER2 over-expression in esophageal adenocarcinoma to be associated with increasing depth of invasion, lymph node and distant metastases and poor survival [6].
There is mounting evidence of the role of HER2 overexpression in patients with gastric cancer, and it has been solidly correlated to poor outcomes and a more aggressive disease [9]. Additionally, preclinical data are showing significant antitumor efficacy of anti-HER2
therapies (particularly monoclonal antibodies directed towards the protein) in in-vitro and in-vivo models of gastric cancer[9]. At least three studies reported that HER2 expression is more
common in Gastroesophageal Junction cancers than in gastric tumors. Regarding pathologic variables, a higher rate of HER2 expression in intestinal type than in diffuse type has consistently been reported[9].
Studies on colorectal carcinomas have demonstrated the existence of a small subset of cases harbouring Her-2 membranous expression. Strong and moderate membranous Her-2 protein expression, was detected by immunohistochemistry only in 5.6% primary colorectal carcinomas whereas cytoplasmic staining was detected in 12.26% of the cases [8]. Studies indicate that Her-2 protein expression and gene amplification are rarely encountered in colorectal carcinoma [8]. Whether anti-Her-2 targeted therapies should be restricted only to cases presenting Her-2 gene amplification or whether non-amplified cases could be favoured from a combined targeted therapy as a result of the co-receptor function of Her-2 is an issue that needs further investigation [8].
6.3 / OBJECTIVES OF THE STUDY
1.  To study histopathological patterns of Adenocarcinomas and Squamous Cell Carcinomas of GIT.
2.  To study Her-2 expression in GI Adenocarcinomas and Squamous Cell Carcinomas.
3.  To correlate tumor histology with Her-2 expression.
7 / MATERIALS AND METHODS
7.1 / SOURCE OF DATA
All cases of Adenocarcinomas and Squamous Cell Carcinomas of the Gastrointestinal tract received in the Department of Pathology, M. R. Medical College, Gulbarga from Basaweshwar Teaching and General Hospital, Government General Hospital, and various private laboratories and hospitals in and around Gulbarga will be studied.
7.2 / METHODS OF COLLECTION OF DATA
A thorough gross examination of various biopsy and resected specimens will be done carefully to detect any abnormalities. Representative sections from any identifiable lesions will also be submitted.
From obtained biopsy specimens, the dimensions and/or volume of the specimen will be documented. The entire specimen will be submitted for microscopic examination.
All specimens will be fixed in 10% formalin solution and paraffin blocks will be prepared which will be cut at 4-5 microns thickness. They will be subsequently stained with haematoxylin and eosin.
The technique for Immunohistochemistry will include antigen retrieval in tris buffer in a retriever, blocking endogenous peroxidase with 3% hydrogen peroxide, incubating with primary mouse monoclonal antibody, developing chromogen with diaminobenzidine (DAB) and counterstaining with haematoxylin. The immunostained slides will be examined for membrane staining for HER2/neu. In each case, the proportion of positive staining tumor cells (expressed in percentage) and the average intensity of staining will be evaluated.
The relationship between various parameters such as age, sex, histological grade, the expression of HER2 will be studied.
Duration of Study:
The study includes two years of prospective study – July 2012 to June 2014.
Inclusion criteria :
1.  All Adenocarcinomas and Squamous Cell Carcinomas of the Esophagus, Stomach, Intestine including Rectum will be studied.
Exclusion criteria:
(a)  Carcinomas of the Oral Cavity, Oropharynx and Salivary Glands will be excluded.
(b)  Malignancies other than Adenocarcinomas and Squamous Cell Carcinomas of the gastrointestinal tract will be excluded.
(c)  Lymph node metastasis from the Carcinomas will be excluded.
Sample size : A Minimum of 50 cases.
7.3 / DOES THE STUDY REQUIRE ANY INVESTIGATION OR INTERVENTION TO BE CONDUCTED ON PATIENTS OR OTHER HUMANS OR ANIMALS? IF SO PLEASE DESCRIBE BRIEFLY
NO.
7.4 / HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION IN CASE OF 7.3?
YES.
8 / LIST OF REFERENCES
1.  Kalyani R, Das S, Kumar ML. Spectrum of gastro-intestinal cancers- A ten year study. J Indian Med Assoc, 2010 Oct;108(10):659-62.
2.  J. C. Paymaster. Cancer and its distribution in India. Ibid., 17, 1026-1034.
3.  S.L. Malhotra. Geographical Distribution of Gastrointestinal cancers with special reference to causation, From the Medical Department, Western Railways, Bombay, India; Gut, 1967, 8: 361-372.
4.  Sebastian F. Schoppmann, Bettina Jesch et al. Expression of Her-2 in Carcinomas of the Esophagus; Am J Surg Pathol 2010;34: 1868–1873.
5.  Christa L. Whitney-Miller, David G. Hicks. HER2 Testing in Gastric and Esophageal Adenocarcinoma: Emerging Therapeutic Options and Diagnostic Challenges; Connection 2010: 47 – 51.
6.  Yingchuan Hu, Santhoshi Bandla et al. HER2 amplification, overexpression and score criteria in esophageal adenocarcinoma; Mod Pathol. 2011 July ; 24(7): 899–907.
7.  Kitty Pavlakis, Panteleimon Kountourakis et al. Her-2 Protein Expression, Cellular Localization, and Gene Amplification in Colorectal Carcinoma; Appl Immunohistochem Mol Morphol, 2007 Dec; 15(4): 441-445.
8.  Anna Dorothea Wagner , Ulrich Wedding. Advances in the Pharmacological Treatment of Gastro-Oesophageal Cancer. Drugs Aging 2009; 26 (8): 627-646.
9.  C. Gravalos, A. Jimeno. HER2 in gastric cancer: a new prognostic factor and a novel therapeutic target. Annals of Oncology, 2008, http://annonc.oxfordjournals.org/.
9 / SIGNATURE OF CANDIDATE
10 / REMARKS OF GUIDE
11 / 11.1 / NAME AND DESIGNATION OF THE GUIDE / Dr. PRATIMA S.,
M.D
PROFESSOR,
DEPARTMENT OF PATHOLOGY,
M.R. MEDICAL COLLEGE, GULBARGA
11.2 / SIGNATURE
11.3 / CO- GUIDE (IF ANY)
11.4 / SIGNATURE
11.5 / HEAD OF THE DEPARTMENT / Dr. S.K. ANDOLA
M.d. dcp. ficp. fiams. miac
PROFESSOR AND HEAD,
DEPARTMENT OF PATHOLOGY,
M.R.MEDICAL COLLEGE, GULBARGA
11.6 / SIGNATURE
12 / 12.1 / REMARKS OF THE CHAIRMAN AND PRINCIPAL
12.2 / SIGNATURE