Role of HER-2/neu Overexpression and Clinical Features at Presentation as Predictive Factors in Meningiomas

Biomarkers for prognosis of meningioma patients: A systematic review and meta-analysis

Meningioma is the most common primary brain tumor and many studies have evaluated numerous biomarkers for their prognostic value, often with inconsistent results. Currently, no reliable biomarkers are available to predict the survival, recurrence, and progression of meningioma patients in clinical practice. This study aims to evaluate the prognostic value of immunohistochemistry-based (IHC) biomarkers of meningioma patients. A systematic literature search was conducted up to November 2023 on PubMed, CENTRAL, CINAHL Plus, and Scopus databases. Two authors independently reviewed the identified relevant studies, extracted data, and assessed the risk of bias of the studies included. Meta-analyses were performed with the hazard ratio (HR) and 95% confidence interval (CI) of overall survival (OS), recurrence-free survival (RFS), and progression-free survival (PFS). The risk of bias in the included studies was evaluated using the Quality in Prognosis Studies (QUIPS) tool. A total of 100 studies with 16,745 patients were included in this review. As the promising markers to predict OS of meningioma patients, Ki-67/MIB-1 (HR = 1.03, 95%CI 1.02 to 1.05) was identified to associate with poor prognosis of the patients. Overexpression of cyclin A (HR = 4.91, 95%CI 1.38 to 17.44), topoisomerase II α (TOP2A) (HR = 4.90, 95%CI 2.96 to 8.12), p53 (HR = 2.40, 95%CI 1.73 to 3.34), vascular endothelial growth factor (VEGF) (HR = 1.61, 95%CI 1.36 to 1.90), and Ki-67 (HR = 1.33, 95%CI 1.21 to 1.46), were identified also as unfavorable prognostic biomarkers for poor RFS of meningioma patients. Conversely, positive progesterone receptor (PR) and p21 staining were associated with longer RFS and are considered biomarkers of favorable prognosis of meningioma patients (HR = 0.60, 95% CI 0.41 to 0.88 and HR = 1.89, 95%CI 1.11 to 3.20). Additionally, high expression of Ki-67 was identified as a prognosis biomarker for poor PFS of meningioma patients (HR = 1.02, 95%CI 1.00 to 1.04). Although only in single studies, KPNA2, CDK6, Cox-2, MCM7 and PCNA are proposed as additional markers with high expression that are related with poor prognosis of meningioma patients. In conclusion, the results of the meta-analysis demonstrated that PR, cyclin A, TOP2A, p21, p53, VEGF and Ki-67 are either positively or negatively associated with survival of meningioma patients and might be useful biomarkers to assess the prognosis.

Biomarkers for differentiating grade II meningiomas from grade I: a systematic review

INTRODUCTION

There are a number of prognostic markers (methylation, CDKN2A/B) described to be useful for the stratification of meningiomas. However, there are currently no clinically validated biomarkers for the preoperative prediction of meningioma grade, which is determined by the histological analysis of tissue obtained from surgery. Accurate preoperative biomarkers would inform the pre-surgical assessment of these tumours, their grade and prognosis and refine the decision-making process for treatment. This review is focused on the more controversial grade II tumours, where debate still surrounds the need for adjuvant therapy, repeat surgery and frequency of follow up.

METHODS

We evaluated current literature for potential grade II meningioma clinical biomarkers, focusing on radiological, biochemical (blood assays) and immunohistochemical markers for diagnosis and prognosis, and how they can be used to differentiate them from grade I meningiomas using the post-2016 WHO classification. To do this, we conducted a PUBMED, SCOPUS, OVID SP, SciELO, and INFORMA search using the keywords; 'biomarker', 'diagnosis', 'atypical', 'meningioma', 'prognosis', 'grade I', 'grade 1', 'grade II' and 'grade 2'.

RESULTS

We identified 1779 papers, 20 of which were eligible for systematic review according to the defined inclusion and exclusion criteria. From the review, we identified radiological characteristics (irregular tumour shape, tumour growth rate faster than 3cm³/year, high peri-tumoural blood flow), blood markers (low serum TIMP1/2, high serum HER2, high plasma Fibulin-2) and histological markers (low H3K27me3, low SMARCE1, low AKAP12, high ARIDB4) that may aid in differentiating grade II from grade I meningiomas.

CONCLUSION

Being able to predict meningioma grade at presentation using the radiological and blood markers described may influence management as the likely grade II tumours will be followed up or treated more aggressively, while the histological markers may prognosticate progression or post-treatment recurrence. This to an extent offers a more personalised treatment approach for patients.

Recurrence/Regrowth in Grade I Meningioma: How to Predict?

The HLA-G and HLA-E molecules, Ki67, progesterone (PR), estrogen (ER) and androgen receptors (AR), p53, COX-2, and HER2 were studied to assess whether the biological behavior of grade I meningiomas is related to their expression. Tissue samples from 96 patients with grade I intracranial meningiomas were analyzed by immunohistochemistry on tissue microarray blocks (TMA) using antibodies specific for HLA-G, HLA-E, Ki67, PR, ER, AR, p53, COX-2, and HER2. Meningiomas were classified as small (≤2 cm, 1.0%), medium (>2 and ≤4 cm, 32.3%), and large (>4 cm, 66.7%). Tumor size was not related to recurrence/regrowth (p = 0.486), but was significantly correlated with peritumoral edema (p = 0.031) and intratumoral calcifications (p = 0.018). Recurrent meningiomas were observed in 14.6% of cases. Immunostaining for each marker was: HLA-G 100%; HLA-E 95.6%; PR 62%; ER 2.1%; AR 6.5%; p53 92.6%; COX-2 100%; HER2 0%; Ki67, mean 2.61 ± 2.29%, median 2.1%. Primary and recurrent meningiomas showed no significant relation with HLA-E and hormone receptors (p > 0.05), except for Ki67, where a higher median was observed in recurrent tumors than in primary (p = 0.014). The larger the tumor, the more severe the peritumoral edema, and the greater the presence of calcifications. Ki67 appears to be a good biomarker of recurrence/regrowth in grade I meningiomas.

Expression of Human Epidermal Growth Factor Receptor 2 in Meningiomas

Background: Meningiomas consist of 15%–30% of the primary intracranial tumors, and high-grade meningiomas have a higher recurrence after surgery. The human epidermal growth factor receptor 2 (HER2) status is important in the medical management of patients with various human cancers. This study aimed to evaluate HER2 expression in meningiomas and the correlation between this expression and age, gender, and grade. Materials and Methods: In a descriptive-analytic study, immunohistochemistry (IHC) with HER2 marker was done on confirmed cases of meningioma which were referred to the pathology laboratory from 2008 to 2015. The primary antihuman antibody against c-erbB-2 oncoprotein (DAKO Diagnostics) was used for IHC. Results: Of 117 patients, 68.4% were males. The mean age of the patients was 53.6 years. Grades I, II, and III tumors were 90.6%, 8.5%, and 0.9% of cases, respectively. Totally, 76 (65%) of patients were HER2 positive, with only 7.7% of highly expressed HER2. There was no significant correlation between the mean age (P = 0.672), age group (P = 0.256), sex (P = 0.574), and grade (P = 0.093) and HER2 expression status. Conclusions: We did not find a statistically significant correlation between age, sex, or grade and HER2 status; however, further studies with a higher number of Grades II and III meningiomas and using the fluorescent in situ hybridization in equivocal cases may be of benefit in this way.

Human epidermal growth factor receptor 2/neu protein expression in meningiomas: An immunohistochemical study

Background:

Meningiomas are common slow-growing primary central nervous system tumors that arise from the meningothelial cells of the arachnoid and spinal cord. Human epidermal growth factor receptor 2 (HER2) or HER2/neu (also known as c-erbB2) is a 185-kD transmembrane glycoprotein with tyrosine kinase activity expressed in meningiomas and various other tumors. It can be used in targeted therapy for HER2/neu positive meningiomas.

Aim:

To correlate the expression of HER2/neu protein in meningiomas with gender, location, histological subtypes, and grade.

Materials and Methods:

It was 3½ years prospective (March 2010–October 2011) and retrospective (May 2008–February 2010) study of histopathologically diagnosed intracranial and intraspinal meningiomas. Clinical details of all the cases were noted from the computerized hospital information system. Immunohistochemistry for HER2/neu protein was performed along with scoring. Statistical analysis was done using Chi-square test to look for any association of HER2/neu with gender, location, grade, and various histological subtypes of meningiomas at 5% level of significance.

Results:

A total of 100 cases of meningiomas were found during the study period. Of which, 80 were Grade I, 18 were Grade II, and 2 were Grade III meningiomas as per the World Health Organization 2007 criteria. The female-male ratio was 1.9:1 and the mean age was 47.8 years. HER2/neu protein was expressed in 75% of Grade I and 72.2% of Grade II and none of Grade III meningiomas. About 72.7% brain invasive meningiomas showed HER2/neu immunopositivity.

Conclusion:

HER2/neu protein was expressed in 73% of meningiomas. Statistically significant difference of HER2/neu expression was not seen between females and males of Grade I and Grade II/III meningiomas, intracranial and spinal tumors, Grade I and Grade II/III cases, and various histological subtypes of meningiomas.

Prognostic value of ErbB2/HER2 in human meningiomas

INTRODUCTION

Among clinical challenges regarding human meningiomas is their propensity to recur even in cases with benign histology. Reliable biomarkers that can identify these cases are therefore highly desired. ErbB2/HER2 status is important in the medical management of patients with various human malignancies, whereas its clinical relevance in human meningiomas is ambiguous. For this reason, we wanted to investigate the expression of intra- and extracellular domains of ErbB2/HER2 as well as the level of activated receptor in these tumors. Further, we wanted to elucidate any clinicopathological associations to antibody expression and if gene amplification was present.

METHODS

In total, 186 human meningiomas of all malignancy grades were included in the study, 163 of these were in tissue microarrays (TMA). Antibody expression was assessed by means of immunohistochemistry (IHC) and gene amplification by fluorescence in situ hybridization (FISH).

RESULTS

All cases were immunoreactive with antibodies targeting the intracellular domain, whereas about 48% and 11% were positive with antibodies against the extracellular domain and against the activated receptor, respectively. Normal meninges were not immunoreactive. There were no relations to malignancy grade, and only the activated receptor was significantly correlated with increased risk for recurrence or death (time to recurrence: HR 1.568, CI (1.153 to 2.132), p = 0.004). No gene amplification was found.

CONCLUSION

ErbB2/HER2 is generally upregulated in human meningiomas, but in an activated state only in a few cases. Only the activated receptor is associated with poorer prognosis, a link that needs further investigations.

Effect of lapatinib on meningioma growth in adults with neurofibromatosis type 2

INTRODUCTION

Epidermal growth factor receptors EGFR and ErbB2 are overexpressed in schwannomas and meningiomas. Preclinical and clinical data indicate that lapatinib, an EGFR/ErbB2 inhibitor, has antitumor activity against vestibular schwannomas in neurofibromatosis type 2 (NF2) patients. Its antitumor activity against meningiomas, however, is unknown.

METHODS

We conducted a retrospective review of patients with NF2 and progressive vestibular schwannomas treated on a phase 2 clinical trial with lapatinib (NCT00973739). We included patients with at least one volumetrically measurable meningioma (> 0.5 cm³) who received at least five 28-day courses of treatment. Patients received lapatinib 1500 mg daily. Meningioma response was assessed using 3-dimensional MRI volumetrics. Progressive meningioma growth and response were defined as + 20 and - 20% change in tumor volume from baseline, respectively. Off-treatment was defined as any period > 5 months without lapatinib.

RESULTS

Eight patients (ages: 20-58 years) who met criteria had 17 evaluable meningiomas with a combined volume of 61.35 cc at baseline, 61.17 cc during treatment, and 108.86 cc (+ 77.44% change) off-treatment, p = 0.0033. Median time on-treatment and off-treatment was 15.5 and 16.7 months, respectively. On-treatment mean and median annualized growth rates were 10.67 and 1.32%, respectively. Off-treatment mean and median annualized growth rates were 20.05 and 10.42%, respectively. The best volumetric response was - 26.1% after 23 months on lapatinib. Two tumors increased > 20% volumetrically on-treatment, compared to eight tumors off-treatment.

CONCLUSIONS

These data suggest that lapatinib may have growth-inhibitory effects on meningiomas in NF2 patients, and support prospective studies of lapatinib for NF2 patients with progressive meningiomas.

C-erbB2/HER2 in human gliomas, medulloblastomas, and meningiomas: a minireview

C-erbB2/HER2 serves as an important prognostic and predictive biomarker in various human tumors, especially in breast cancer, whereas its role in human intracranial tumors is more uncertain. We therefore performed a search in PubMed to get an update. This literature review comprises immunohistochemical studies on the clinical significance of c-erbB2/HER2 overexpression in gliomas, medulloblastomas, and meningiomas. In general, the findings were discrepant with regard to correlations between overexpression, tumor grade, and prognosis. Use of various antibodies may be a contributing factor to these discrepancies. Standardization of the immunohistochemical procedures is a relevant topic for discussion.

An immunohistochemical study of HER2 expression in meningioma and its correlation with tumor grade

Meningiomas account for about 15-30% of all primary intracranial tumors. According to the 2007 WHO classification, meningiomas are divided into three grades (I, II and III). Recurrence is an issue following surgical treatment of meningioma, especially in grades II and III. HER2 (also known as erbB-2) is a 185-kD transmembrane glycoprotein with tyrosine kinase activity. HER2 is expressed in some human malignancies and can be a potential target for therapeutic intervention with selective inhibitors. There are only a few studies on the relationship between meningioma and HER2 expression, and the results are different as well. The aim of this study was to determine this relationship. Seventy-two paraffin blocks of meningioma were selected randomly, and immunohistochemical staining was then performed for each specimen. Thirty-one of the 72 meningiomas were HER2-positive. HER2 expression was observed in 11 (55%) of the 20 grade II/III, and 20 (38.5%) of the 52 grade I meningiomas. Consequently, HER2 expression was detected in 43% of meningiomas. No significant difference was seen between grade I and grade II/III meningiomas, primary and recurrent tumors, and males and females from the point of view of HER2 expression.

Review of meningioma histopathology

✓The histological appearance of a meningioma is an important predictor of tumor behavior and is frequently a factor in decisions concerning therapy. The relationship between histological features and prognosis is formalized in grading schemes such as those published by the World Health Organization (WHO), most recently in 2007. Although the latest edition is an improvement over previous grading schemes, the WHO scheme still fails to fully address a variety of important issues regarding the relationship between meningioma histological characteristics and behavior. In particular, routine histological examination fails to identify the subset of Grade I tumors that behave aggressively. Because of this, many additional prognostic markers that require immunohistochemical, cytogenetic, or molecular techniques to evaluate are under investigation. Only one, immunohistochemistry for the proliferation marker, Ki 67 (MIB-1), is used routinely and it has only limited utility. It is hoped that an understanding of the genetic changes that underlie tumor progression will improve healthcare professionals' ability to predict the behavior of meningiomas.

Frontotemporal clear cell meningioma. Report of 3 cases

Clear cell meningioma (CCM) is an uncommon meningioma. Some cases have been reported, and the localization of most of them is the spinal region. We present 3 cases of CCMs in the frontotemporal lobes. All cases were postmenopausal women with a history of arterial hypertension and uterine leiomyomatosis. The radiologic appearance in 2 cases was similar to that of dural hematomas, and in 1 case, the imaging study was consistent with the diagnosis of meningioma. On histologic examination, there were sheets of glycogenated polygonal cells with abundant clear cytoplasm and round, uniform, bland appearing nuclei. Numerous hyalinized blood vessels and collagenous stroma with fibrillary appearance were present in 2 cases. They were immunoreactive to epithelial membrane antigen, epithelial cell adhesion molecule, and progesterone receptors. However, 2 cases showed weak and focal reaction to Her-2/neu. In our knowledge, some cases of CCMs have been reported and no immunoexpression has been noted with those markers used. These cases illustrate a rare variant of meningioma in the frontotemporal lobes and their immunohistochemical profiles. Differential diagnosis is discussed.