Loss of heterozygosity among tumor suppressor genes in invasive and in situ carcinoma of the uterine cervix

Abstract. Lu X, Nikaido T, Toki T, Zhai Y-L, Kita N, Konishi I, Fujii S. Loss of heterozygosity among tumor suppressor genes in invasive and in situ carcinoma of the uterine cervix.
The aim of the present study was to further clarify the histogenesis of cervical carcinoma by investigating loss of heterozygosity (LOH) among a number of tumor suppressor genes in invasive and in situ carcinoma of the cervix. Materials consisted of 16 in situ and 29 invasive carcinomas (16 squamous cell carcinomas, nine adenocarcinomas, and four adenosquamous carcinomas). DNA samples were collected by microdissection from ordinary formalin-fixed, paraffin-embedded tissues, both from the lesions and from normal tissues. LOH was analyzed using eight DNA polymorphic tumor suppressor markers. Of the 16 cases of carcinoma in situ , three cases exhibited LOH at one locus. Of the 29 cases of invasive carcinomas, six cases exhibited LOH at two loci and nine cases exhibited LOH at one locus. Overall, LOH was found more frequently in invasive carcinomas than in in situ carcinomas. LOH was most frequently detected at the PTCH (Drosophila patched gene) locus. There was no significant correlation between LOH at a specific site and either histologic subtype or clinical stage. These results suggest that LOH might already occur in a fraction of preinvasive squamous lesions and that accumulation of LOH may in part play a role in carcinogenesis of the cervix.     

Expression of blood group antigens A, B, H, Lewis a, Lewis b, in malignant lesions of the uterine cervix

The fetal, normal adult, and malignant squamous epitheliums of the cervix were immunohistochemically examined by the avidin-biotin-peroxidase complex method with monoclonal antibodies for blood group antigens (BGAs) A, B, H, Lewis a, and Lewis b. The results were as follows. 1) ABH antigen compatible with ABO status was found in most normal squamous epithelium of fetal and adult cervix. 2) Compatible ABH and A antigen were abolished in small cell nonkeratinizing squamous cell carcinomas (SNKCs) and large cell nonkeratinizing squamous cell carcinomas (LNKCs), respectively. But no remarkable change in ABH antigen expression was observed in other types of cervical lesions. 3) Precursor H antigen was accumulated in all types of malignant lesions. 4) Incompatible expression of A or B antigen was observed in some cases of LNKCs and keratinizing squamous cell carcinomas. 5) Lewis antigens were abolished to various degrees in malignant lesions of the cervix. The present study showed the change in BGAs expression during carcinogenesis of the cervix, but further investigation is needed to elucidate the interaction between these changes in BGAs and the biological behavior of cancer cells.     

Verrucous squamous cell carcinoma of the female genital tract. Report of three cases and survey of the literature

Three new cases of gynecological verrucous squamous cell carcinomas are reported; one in the uterine cervix, and two in the vulva. The English literature covering the 49 cases reported previously is surveyed with special reference to the diagnostic and therapeutic aspects of these tumors, as well as with their clinical behavior and possible relationship to viral (HPV) lesions (Condylomas) of the genital tract.It was concluded that so far the exact relationship between the different verrucous squamous cell lesions in the genital tract remains obscure, all such lesions should be regarded as potentially malignant, and treated accordingly by radical surgery.     

Estrogen and progesterone receptor sites in malignancies of the uterine cervix, vagina, and vulva

Cytoplasmic receptors for 17 beta-estradiol (ER) and progesterone (PR) were measured in uterine cervical, vaginal, and vulvar carcinomas by the dextran-coated charcoal (DCC) technique. Tissues from 30 patients with cervical carcinoma were examined. Thirteen percent (2 of 16) of well-differentiated squamous carcinomas had positive ER, and 19% (3 of 19) had positive PR. None of the three patients with moderately well-differentiated disease have positive ER or PR, while two of five patients with poorly differentiated lesions contained measurable ER and PR. In contrast, all four of the well-differentiated adenocarcinomas of the cervix had detectable ER, and three of four for PR. Neither of the two patients with poorly differentiated adenocarcinoma had either ER or PR. None of the five vulvar and seven vaginal epidermoid carcinomas studied had ER or PR activity. Hormonal therapies may be useful in the treatment of adenocarcinoma of the cervix.     

Immunohistochemical investigations of steroid receptors in normal and neoplastic squamous epithelium of the uterine cervix

The proliferation of squamous cells of the vagina and cervix uteri is induced by steroid hormones during the menstrual cycle. However, carcinoma of the cervix cannot be influenced by any hormone therapy. Forty-four different cervical specimens (different days in the menstrual cycle of healthy women and those with dysplastic lesions and carcinomas of the cervix) have been tested for estrogen (ER) and progesterone (PR) receptor protein content by means of immunohistochemistry. The ER content of the squamous epithelium depends upon the menstrual cycle: in the early proliferative phase cells of all layers are negative. In the midphase of proliferation the basal and parabasal layers become positive, and in the secretory phase positive cell nuclei can be found up to the superficial layers. A weak reaction to ER staining is found only in mild dysplastic lesions of the uterine cervix; severe dysplastic forms and invasive carcinomas were all negative. No positive PR was found in any squamous cell tissue. Stroma cells of the uterine cervix showed different straining intensity for ER and PR, regardless of the menstrual cycle. The loss of ER in the neoplastic cell could be an explanation for three clinical experiences: premenopausal patients have no tumor progression of the cervix uteri despite normal ovarian function; the duration of survival shows no relation to the receptor status of cervical carcinomas; and antihormonal treatment of cervical carcinomas produces no appreciable therapeutic success.     

Micro-invasive carcinoma of the cervix uteri

Micro-invasive carcinomas of the cervix (Stage Ia of the IFGO) are characterized by an absence of clinical signs. Among the prognostic criteria are the depth of the invasion (5 mm for the IFGO, 3 mm for us), the superficial extension (7 mm in the largest diameter) and the possible presence of lymphatic or vascular emboli in the connective tissue of the cervix. Only semi-successive secretions (every 300 microns) enable to accurately define these lesions. It is then possible to individualize two types of micro-invasive carcinoma. Group A (less than 3 mm deep, less than 7 mm on the surface and without emboli) may be treated by conization if the resection line is in healthy tissue and the operative specimen studied in semi-successive sections. In the other cases (group B) a Wertheim procedure with lymphadenectomy is indicated.     

Prognosis and treatment of primary adenocarcinoma and adenosquamous cell carcinoma of the uterine cervix.

PURPOSE: To evaluate a cohort of women with primary invasive carcinomas of the uterine cervix, and to compare the biological characteristics and behavior of a cohort of adenosquamous carcinomas with a cohort of adenocarcinomas and squamous cell carcinomas. METHODS: One hundred and fourteen cases of primary invasive cervical carcinoma presenting between 1 January 1987 and 31 December 1997 were studied. Sixteen (14%) women with adenosquamous cell carcinomas and eight (7%) adenocarcinomas were compared with 90 (79%) women with squamous cell carcinomas. Patients with Stage Ib and IIa were treated by radical hysterectomy and pelvic lymph node dissection. All patients with stage IIb and over were treated by radiation. Patients with bulky, large, barrel-shaped lesions were selected for treatment by a combination of radiation and extrapelvic hysterectomy. RESULTS: The corrected survival rate for stage Ib patients with adenosquamous cell carcinoma was only 27.2%, compared with a 92.2% corrected survival rate for squamous cell, and a 100% corrected survival rate for adenocarcinoma. CONCLUSION: There is a higher proportion of adenosquamous cell and adenocarcinoma of the cervix than generally appreciated. The epidemiological risk factors associated with adenosquamous carcinomas of the cervix are more similar to those of squamous cell carcinomas than of adenocarcinomas. The survival difference between two groups is explained by effects of clinical stage, nodal spread, and vascular space involvement.     

Immunohistochemical localization of keratin and secretory component in carcinoma of the uterine cervix

Carcinoma of the uterine cervix is said to frequently show a combination of squamous epithelial and glandular epithelial characteristics. In the present study, immunohistochemical localization of keratin and secretory component (SC) was studied to clarify these characteristics of cancers of the cervix, and the following results were obtained. Demonstration of the localization of keratin and SC was useful in providing functional markers of the squamous and glandular epithelium of the cervix. In epidermoid carcinomas, the squamous epithelial character of the keratinizing carcinomas was strongest and decreased in the large cell non-keratinizing, followed by the small cell non-keratinizing carcinomas. The glandular character of these lesions decreased in the same order. Subclassification of CIS did not reveal any major changes with either kind of staining. So-called bipotential differentiation was found in 21% of the epidermoid, 53% of the adenocarcinomas and 13% of the CIS. In the clinical stages of epidermoid carcinomas, the stage I and II cases more frequently showed squamous characteristics than did the stage 0 cases.     

Cytogenetic studies of preinvasive lesions and invasive carcinomas of the cervix uteri. II. Structural chromosome abnormalities. Karyotype deviations (author's transl)]

An analysis of karyotypes was possible in 17 preinvasive lesions (3 dysplasias, 14 carcinomas in situ) and 15 invasive lesions of the cervix uteri (3 carcinomas in situ with microinvasion, 12 invasive squamos carcinomas - at least clinical stage I b). With regard to the structural chromosome abnormalities or karyotype deviations in this study the preinvasive lesions analysed could not be differentiated in principle as a group from the invasive lesions. The question of whether the dysplasia group would be different on further investigation with more cases and could be differentiated like the numerical deviations cannot yet be answered, because of the small numbers, only preinvasive lesions and invasive lesions could be studied comparatively as groups.     

Adenoid cystic and adenoid basal carcinomas of the cervix

Adenoid basal and adenoid cystic carcinomas of the cervix are uncommon and differ from each other in their histology, treatment, and prognosis. Whereas adenoid basal carcinoma is a slow-growing, locally invasive lesion amenable to simply hysterectomy, adenoid cystic carcinoma is an aggressive tumor associated with regional lymph node involvement and late pulmonary metastases. This study, based on the evaluation of nine cases of adenoid cystic and five cases of adenoid basal carcinoma of the cervix, reviews the literature and formulates a program for the management of these rare lesions.     

Laminin immunostaining in hyperplastic, dysplastic, and neoplastic lesions of the endometrium and uterine cervix

The distribution of basement membrane laminin was investigated in normal endometrium and cervix, as well as in a variety of non-neoplastic and neoplastic lesions of these tissues. Normal epithelial structures were surrounded by a generally intact basement membrane. Minor breaks in continuity and alterations of linearity were seen in association with inflammation and stromal fibrosis. Metaplasias, atypical hyperplasias, dysplasias, and in situ carcinomas characteristically rested on an essentially intact basement membrane, although minor disruptions were seen, occasionally in association with inflammation. Superficially and deeply invasive adenocarcinomas and squamous carcinomas exhibited impaired laminin production. In well differentiated carcinomas of the endometrium and cervix, an intact basement membrane was often seen around infiltrating glandular and squamous elements, although focal reduplications and small disruptions were seen in all cases. In high-grade carcinomas, considerable impairment of basement membrane integrity was seen, but immunostainable laminin was still evident, at least focally, in all cases. The findings confirm that endometrial and cervical carcinomas, even those of high histologic grade, are capable of basement membrane production.     

Investigation of human papillomavirus by hybrid capture II in cervical carcinomas including 113 adenocarcinomas and related lesions

Hybrid capture is an easy and highly sensitive technique for screening population due to its capacity to detect malignant and premalignant lesions of the cervix. To evaluate its sensitivity, we investigated the frequency of high-risk human papillomavirus (HPV) infection and its correlation with glandular malignant lesions, analyzing a total of 113 cases of adenocarcinomas and related lesions. High-risk HPV was investigated using a hybrid capture II (HC2) assay. Samples were collected in two different ways: either brushed directly from surgical specimens before fixation or collected from the patients. We also investigated the frequency of HPV in squamous malignant lesions, 65 squamous cell carcinomas (SCC) and 66 in situ squamous cell carcinomas (ISSCC), to compare the occurrence of HPV for these lesions. The 113 glandular lesions comprised 62 invasive adenocarcinomas (IAC), 8 in situ adenocarcinomas (ISAC), 26 IAC plus SCC, and 17 adenosquamous cells carcinomas (ASCC). The HPV-positive reactions were as follows: 51 (82.2%) in IAC, 8 (100%) in ISAC, 25 (96.1%) in IAC plus SCC, and 14 (82.3%) in ASCC. HC2-positive results in the squamous malignant lesions were as follows: 58 of 63 (89.0%) for SCC and 94 of 103 (91.2%) for ISSCC. High-risk HPV infection was quite similar for glandular and pure squamous invasive malignant lesions, 82.2% and 89.0%, respectively, indicating that high-risk HPV is also highly prevalent in glandular lesions. Although hybrid capture proved to be an excellent adjunctive technique, we do not believe its results merit replacing the Pap smear as a screening tool.     

E-cadherin expression during progression of squamous intraepithelial lesions in the uterine cervix

Alterations of E-cadherin expression in cervical intraepithelial neoplasias and invasive carcinomas of the uterine cervix have been described by some authors but their clinical significance has not yet been clarified. Archival specimens of 27 normal cervical epithelia, 15 atypical cells of undetermined origin (ASCUS), 53 low-grade squamous intraepithelial lesions (LSIL), 19 high-grade squamous intraepithelial lesions (HSIL) and six invasive squamous carcinomas were evaluated for E-cadherin expression. The cytological material was processed using liquid based cytology (ThinPrep technique) and immunostained for E-cadherin. All HPV infections (koilocytes) showed strong cell membranous E-cadherin expression. In HSIL a strong decrease in E-cadherin expression and heterogeneous distribution was noticed. In the relatively small number of squamous cell carcinomas of the cervix studied, a significant decrease or loss in E-cadherin expression, predominantly cytoplasmic, was noted. We concluded that decreased E-cadherin expression appears to be a useful parameter of malignant potential of cervical lesions. E-cadherin immunoexpression could provide an additional criterion in correlation with cyto- and histomorphology and colposcopy to define high grade CIN lesions.     

An immunohistochemical study of small-cell and poorly differentiated carcinomas of the cervix using neuroendocrine markers

Small-cell and poorly differentiated carcinomas of the cervix were studied immunohistochemically for several neuroendocrine and epithelial markers. Neuroendocrine markers were frequently expressed in small-cell carcinomas with argyrophilia; of the seven such tumors, four were immunoreactive with anti-chromogranin, seven with antineuroendocrine, five with anti-Leu 7, and seven with anti-neuron-specific enolase. Only neuron-specific enolase, however, was expressed in two of the three small-cell carcinomas without argyrophilia. On the other hand, one of the epithelial markers, epithelial membrane antigen, was strongly positive in all three small-cell carcinomas without argyrophilia and all seven poorly differentiated carcinomas, while it was expressed only weakly and focally in all small-cell carcinomas with argyrophilia except in one case. In conclusion, it is suggested that the immunohistochemical demonstration of several neuroendocrine markers may be helpful in diagnosing neuroendocrine carcinoma of the cervix as a supplement to conventional light microscopy, silver staining, and electron microscopy.     

Squamous carcinoma of the uterine cervix with CIN 3-like growth pattern: An under-diagnosed lesion

Abstract. Al-Nafussi AI, Monaghan H. Squamous carcinoma of the uterine cervix with CIN 3-like growth pattern: An under-diagnosed lesion.
Invasive squamous carcinomas of the cervix have traditionally been classified into keratinizing, non-keratinizing, verrucous, warty (condylomatous), papillary transitional (squamo-transitional), and lymphoepithelioma-like carcinomas. The majority of these tumors are easily recognized. We present for the first time the pathological appearances of six cases of invasive squamous carcinoma with growth pattern simulating tangentially cut CIN 3 involving endocervical glandular crypts/clefts. In all cases initial diagnosis on biopsy and/or loop excision was thought to be CIN 3, perhaps with suspicion of early invasion. On further excision and/or on clinical grounds the tumors were frankly invasive. We propose the use of the term squamous carcinoma with "CIN 3-like growth pattern" for such lesions. This is in order to avoid misinterpretation as CIN 3 with subsequent inappropriate management of patients with this type of tumor.     

c-mos immunoreactivity aids in the diagnosis of gestational trophoblastic lesions.

C-mos is an important proto-oncogene involved in the mitogen-activating protein kinase pathway. This study was designed to explore c-mos immunoreactivity in gestational trophoblastic lesions and compare it with immunoreactivity in normal placentas as well as other gynecological lesions and germ cell tumors using antibody P-19. The immunohistochemical distribution of c-mos in 159 cases of gynecological lesions and 26 germ cell tumors using formalin-fixed, paraffin-embedded tissues was evaluated. The lesions included 45 (32 complete and 13 partial) hydatidiform moles, 17 choriocarcinomas, 5 placental site trophoblastic tumors, 18 squamous cell carcinomas and 5 adenocarcinomas of the cervix, 11 endometrial carcinomas, 9 ovarian carcinomas, 4 primary peritoneal papillary serous carcinomas, 9 low-grade endometrial stromal sarcomas, 4 epithelioid leiomyomas, 6 leiomyosarcomas, and 26 gem cell tumors (3 embryonal carcinomas, 5 yolk sac tumors, 6 immature teratomas, and 3 mature teratomas from the ovary; 9 testicular seminomas). Twenty-six normal placentas also were included for comparison. Among cases of gestational trophoblastic diseases, c-mos immunoreactivity was found in all hydatidiform moles and choriocarcinomas, but in none of the placental site trophoblastic tumors. The c-mos staining pattern was similar in trophoblastic diseases and normal placentas with strong expression in syncytiotrophoblast, moderate expression in villous intermediate trophoblast, and predominantly negative expression in implantation site intermediate trophoblast, chorionic-type intermediate trophoblast, and villous cytotrophoblast. All the nontrophoblastic tumors, including carcinomas, sarcomas, and germ cell tumors, were negative for c-mos expression. Immunohistochemical detection of c-mos is useful in differentiating choriocarcinoma from placental site trophoblastic tumor and nontrophoblastic tumors of the female genital tract that may sometimes cause problems in differential diagnosis.     

Investigations about the incorporation of nucleotide precursors in single cell suspensions of ovarian- and cervix-carcinomas under the influence of cytostatic therapy (author's transl)]

The behaviour of 34 carcinomas of the cervix and 30 ovarian carcinomas under the influence of cytostatic agents was investigated in vitro by the method of Volm et al. The ovarian carcinomas showed a significantly higher incorporation rate of nucleotide precursors in the single cell suspensions. The incorporation rate in "chemosensitive" carcinomas was higher than in "chemoresistent" carcinomas independent of the type of the carcinomas. Carcinomas with a high decrease in incorporation rates of nucleotide precursors under the influence of cytostatic drugs were called chemosensitive. A cyclophosphamide-sensitivity in vitro was found in 9% of the carcinomas of the cervix and in 34% of the ovarian carcinomas. An adriamycin-sensitivity in vitro could be shown in 17% of the carcinomas of the cervix and in 46% of the ovarian carcinomas. These findings agree well with the experiences of cytostatic therapy of these carcinomas.     

Human papillomavirus DNA in glandular dysplasia and microglandular hyperplasia: presumed precursors of adenocarcinoma of the uterine cervix

Presumed precursors of adenocarcinoma of the uterine cervix were investigated with specific techniques to identify human papillomavirus (HPV) DNA. The presence of HPV DNA in 36 lesions of glandular dysplasia and 16 lesions of microglandular hyperplasia of the uterine cervix was studied by in situ hybridization using 3H-labeled HPV 16 and HPV 18 DNA probes. Only two of 36 lesions (6%) of glandular dysplasia contained HPV 18 DNA, although 64% of coexisting adenocarcinoma in situ, microinvasive adenocarcinoma, and cervical squamous intraepithelial neoplasia III lesions contained HPV 18 and/or HPV 16 DNA. Two lesions of HPV 18 DNA-positive glandular dysplasia coexisted with adenocarcinoma in situ that contained the same type of HPV DNA. None of the microglandular hyperplasia lesions contained HPV 16 DNA or HPV 18 DNA. These results suggest that, if HPV infection is an initial step toward carcinogenesis, it is unlikely that glandular dysplasia and microglandular hyperplasia are precursor lesions of adenocarcinoma of the uterine cervix. A large proportion of glandular dysplasia may represent reactive lesions of endocervical columnar epithelium. Two lesions of HPV 18 DNA-positive glandular dysplasia may represent well-differentiated components of adenocarcinoma in situ of the uterine cervix.     

Cervical carcinoma in the aged

The previous impression that both carcinoma in situ and invasive carcinoma of the uterine cervix are rare in patients 65 years of age and older was not found to be correct. In fact, these lesions together were twice as common in women 65 and over than in women under 65. The invasive group, both early and late, was mainly responsible. Thus, Papanicolaou smear examinations must be continued in this older age group. Thirty-three cases of carcinoma in situ in the aged are reviewed in detail. It was found that (1) estrogens are apparently not needed in the morphogenesis; (2) that from the cytologic smear it is usually very difficult to separate the in situ carcinomas from the invasive carcinomas, this being principally due to the fact that most of the lesions in our present study group were at least questionably invasive by tissue studies.     

Microscopic ovarian metastasis of the uterine cervical cancer

Six hundred forty-seven cases of carcinoma of the uterine cervix with FIGO stages Ib or more were initially treated with hysterectomy at Kyushu University Hospital from 1973 to 1987. In these, 597 cases could be pathologically reviewed for ovarian metastasis. In these 597 cases, 335 were stage Ib, 71 IIa, 185 IIb, and 6 IIIb. Only 3 (0.5%) of 597 showed ovarian metastasis. All 3 cases were stage IIb. None of stage Ib cancer cases had ovarian metastasis. One (0.19%) of 524 squamous cell carcinomas metastasized to the ovary, whereas 2 (5.5%) of 36 pure adenocarcinomas revealed ovarian metastasis. Interestingly, all ovarian metastatic lesions were microscopic in size and found in the ovarian hilus. As for the primary lesion, all cases with ovarian metastasis showed deep myometrial invasion, corpus invasion, and lymphatic permeation. Two cases showed pelvic lymph node metastases and positive peritoneal washing cytology. From the results of our study, it can be said that it is fairly safe to preserve the ovary at the time of radical operation in squamous cell carcinoma of the uterine cervix, but it may not be safe to preserve the ovary in pure adenocarcinoma of the uterine cervix.