Nuclear DNA content, proliferative activity, and p53 expression related to clinical and histopathologic features in endometrial carcinoma

Abstract. Lundgren C, Auer G, Frankendal B, Moberger B, Nilsson B, Nordström B. Nuclear DNA content, proliferative activity, and p53 expression related to clinical and histopathologic features in endometrial carcinoma.
The purpose of this study was to evaluate the prognostic impact of image cytometry DNA ploidy, MIB-1, and p53 in relation to clinicopathologic variables in 376 consecutive patients with endometrial carcinoma stages I–IV. Following primary treatment 358 patients were considered tumor-free. Relapses and tumor-specific deaths of these patients were noted. Image cytometry DNA ploidy ( n = 340) and expression of MIB-1 ( n = 318) and p53 ( n = 323) were studied. In univariate analysis, stage ( P < 0.001), histopathologic subtype ( P < 0.001), degree of differentiation ( P < 0.001), HRT ( P = 0.034), DNA ploidy ( P < 0.001), and p53 ( P < 0.001) were significant predictors of relapse. Patient age showed that the estimated mean risk of relapse increases with nearly 64% per decade in life ( P 0.003), and the MIB-1 expression with 21% per 10-unit increment ( P 0.004). In multivariate analysis, degree of differentiation, MIB-1, and p53 lost their prognostic capability. However, after stage and histopathologic subtype, image cytometry DNA ploidy was the strongest predictor of outcome and was of value in predicting the risk for relapse. The combination of DNA ploidy, MIB-1, and p53 expression was an even stronger predictor of relapse-free survival than the individual prognostic factors.     

Use of trastuzumab in the treatment of metastatic endometrial cancer

Systemic therapy of metastatic endometrial cancer is relatively ineffective. Response rates to chemotherapy and hormonal therapy in published studies range from 11% to 57%, but most responses are partial and of limited duration. In this case, we present a 76-year-old woman with stage IIIA endometrial adenocarcinoma who was initially treated with surgery and pelvic radiation. She developed multiple pulmonary metastases. She was treated with weekly paclitaxel chemotherapy. Immunostaining revealed that the primary endometrial cancer overexpressed HER-2/neu. Trastuzumab was added to the regimen, and a dramatic partial response was achieved. After a second pulmonary relapse following discontinuation of prior therapy, she was again successfully treated with trastuzumab in combination with paclitaxel and then docetaxel. Therefore, trastuzumab may be a useful adjuvant to taxane-based chemotherapy in some patients with metastatic endometrial cancers that overexpress HER-2/neu.     

Proliferating cell nuclear antigen (PCNA) immunoreactivity in stage I endometrial carcinoma: a new prognostic factor

The objective of this study was to evaluate the prognostic significance of proliferating cell nuclear antigen (PCNA) immunoreactivity in tumor cells in patients with endometrial carcinoma. A population of 74 patients with FIGO stage I endometrioid adenocarcinoma of the endometrium, who underwent primary surgical management, were selected from January, 1986 to June, 1993 at the Department of Gynecologic and Obstetrics, Ancona University. The archival paraffin blocks from the uterine tumor specimens were recut and assessed for histologic reexamination and PCNA immunostaining (PC 10 monoclonal antibody; Dako, Denmark). A significant increase in PCNA index was observed with respect to nuclear grade ( P < 0.001) and depth of myometrial invasion ( P < 0.001), with the highest percentage values in nuclear grade 3 tumors and in 50% myometrial invasion. A PCNA index 50% was related significantly to disease-recurrence risk ( P < 0.001) and PCNA index seems to be a significant prognostic parameter in stage I endometrial carcinoma, for disease-free survival.     

The activity of letrozole in patients with advanced or recurrent endometrial cancer and correlation with biological markers – a study of the National Cancer Institute of Canada Clinical Trials Group

A multicenter phase II trial was conducted to define the activity of letrozole in postmenopausal women with recurrent or advanced endometrial carcinoma, who had no more than one prior line of progestins and never had chemotherapy (except adjuvant). Archival paraffin-embedded tumor samples were retrieved to determine the expression level of estrogen (ER) and progesterone receptor (PgR), p53, HER-2, bcl-2 and PTEN protein, and phosphorylation status of protein kinase B (PKB/Akt). Thirty-two eligible patients were treated with letrozole at 2.5 mg daily continuously, of whom 10 (31%) had prior progestins. Of the 28 patients evaluated for response, one complete and two partial responses were noted; overall response was 9.4% (95% confidence interval 2-25%). Eleven patients had stable disease for a median duration of 6.7 months (range 3.7-19.3 months). Amongst 22 patients who had tumor blocks available, the proportion showing positive expression of the following markers includes: PgR (86%), ER (86%), PTEN (82%), phosphorylated PKB/Akt (59%), bcl-2 (45%), p53 (32%), and HER-2 (0%). None of these markers correlated with response to letrozole or disease progression. In conclusion, letrozole is well tolerated but has little overall activity in this cohort of women with endometrial cancer.     

Positive peritoneal cytology in endometrial cancer: enhancement of other prognostic indicators

OBJECTIVE: The goal of this study was to investigate the prognostic significance of positive peritoneal cytology in endometrial cancer. METHODS: A clinicocytopathological study was performed in 534 patients with endometrial cancer to assess the prognostic value of positive peritoneal cytology. The study population was divided into three groups: a low-risk group (disease limited to the uterus, grade 1, and depth of invasion < or =1/2), a moderate-risk group (disease limited to the uterus, grade 2 or 3, and/or depth of invasion >1/2), and a high-risk group (extrauterine disease). In each group, disease-free survival was compared in the patients who were positive or negative for malignant cells. RESULTS: The overall incidence of positive peritoneal cytology was 22.3% (119/534). The 5-year disease-free survival of patients positive or negative for malignant cells was 98.1% versus 100% in the low-risk group (n = 250), 77.5% versus 91.3% in the moderate-risk group (n = 211), and 42.9% versus 72.1% in the high-risk group (n = 73). A significant difference was noted in the moderate-risk (P = 0.044) and high-risk (P = 0.015) groups, but not in the low-risk group (P = 0.56). CONCLUSIONS: Positive peritoneal cytology is not a negative prognostic indicator itself, but it potentiates other prognostic indicators for endometrial cancer. Our findings also suggest that patients with positive peritoneal cytology in the absence of other adverse prognostic factors do not need upstaging.     

The prognostic value of PTEN, p53, and beta-catenin in endometrial carcinoma: a prospective immunocytochemical study

Mutations of the PTEN, p53, and beta-catenin genes are the most frequent molecular defects in endometrial carcinomas. The aim of this study was to investigate their prognostic significance in this form of cancer. Imprint smears were obtained from 80 fresh endometrial tumor specimens and studied immunocytochemically for the expression of PTEN, p53, and beta-catenin proteins. The staining pattern was correlated with several well-established prognostic parameters, including 5-year survival. Positive staining of p53 was significantly correlated with increased stage (P < 0.0001), lymph node metastases (P = 0.001), and a nonendometrioid histology (P = 0.001). On the contrary, positive beta-catenin expression was significantly associated with decreased stage (P = 0.002), decreased grade (P = 0.007), and a negative lymph node status (P = 0.023). PTEN positivity was correlated with decreased stage (P = 0.002) and negative lymph nodes (P = 0.008). All the three markers affected survival significantly in univariate analysis but only beta-catenin had an independent prognostic impact. An independent prognostic significance was also shown for PTEN in the stage I subgroup of patients. The results of our study indicate that loss of beta-catenin expression is a strong and independent predictor of an unfavorable outcome in patients with endometrial carcinoma. Loss of PTEN may also be associated with a worse prognosis in patients with early-stage disease.     

卵巢的子宫内膜样癌临床情况及DNA倍体分析与p~(53)基因蛋白增殖细胞核抗原表达测定的研究

目的：研究卵巢的子宫内膜样癌ｐ５３基因蛋白、增殖细胞核抗原（ＰＣＮＡ）的表达与ＤＮＡ倍体分析之间的相互关系，并对其与临床分期、病理学分级与残存瘤的关系等进行分析、比较。方法：应用流式细胞技术及ｐ５３、ＰＣＮＡ单克隆抗体免疫组化技术对卵巢的子宫内膜样癌１３例进行倍体分析及基因、抗原测定。结果：ＤＮＡ异倍体率为７８％，ｐ５３基因蛋白表达率为４６％，ＰＣＮＡ表达率为９２％。ＤＮＡ倍体分析与临床Ⅱ～Ⅳ期、病理２～３级及残存瘤＞２ｃｍ者有关，异倍体阳性率分别为９０．９％、８８．８％、８７．５％，明显高于临床Ⅰ期、病理１级及无残存瘤者。ｐ５３在临床Ⅱ～Ⅳ期、病理２～３级表达率分别为６８．６％和５５．５％，均高于临床Ⅰ期及病理１级者，并对ＤＮＡ倍体水平与ｐ５３表达之间的关系进行了探讨。结论：ＤＮＡ异倍体与ｐ５３基因蛋白表达阳性可作为卵巢的子宫内膜样癌恶性程度的重要指标。     

The significance of p53 mutation and over-expression in ovarian cancer prognosis

Mutation of the p53 tumor suppressor gene is the most commonly observed genetic abnormality in human tumors and associations between p53 aberration and patient survival have been shown for several tumor types. Previous studies have found that approximately 50% of epithelial ovarian carcinomas exhibit abnormalities in the p53 gene. The aim of this study, therefore, was to examine the potential prognostic significance of aberrant p53 in patients with primary epithelial ovarian carcinoma. Using immunohistochemistry (IHC) and the anti-p53 antibodies CM1, PAb240 and PAb1801, p53 over-expression was observed in 20/39 (51%) tumors. When these results were combined with previously reported IHC and sequencing analyses, 37/61 (61%) tumors exhibited a p53 aberration. Although there was no significant difference between sequencing and IHC results, several cases gave discordant results, indicating that a combination of both methods may be required to estimate accurately the proportion of tumors with p53 aberrations. Univariate statistical analysis showed that p53 aberrations were significantly associated with tumor grade 3/4, FIGO stage III/IV, serous tumors and the presence of bulk (>2 cm) residual disease following surgery. In univariate survival analysis, tumor grade and stage, ascites and post-surgical residual tumor> 2 cm were associated with both overall survival (OS) and disease-free survival (DFS). p53 status, however, was not a predictor of either OS or DFS. Using the Cox proportional hazards model, only FIGO stage and post-surgical residual disease> 2 cm had an independent effect on OS and only stage was found to be an independent predictor of DFS. In conclusion, p53 mutation and overexpression does not appear to be a significant indicator of patient survival in this series of ovarian carcinomas.     

Racial disparity in overexpression of the p53 tumor suppressor gene in stage I endometrial cancer

OBJECTIVE: This study was conducted to determine whether overexpression of the p53 tumor suppressor gene is associated with poor outcome in early-stage endometrial cancers and whether a racial difference in the frequency of p53 overexpression contributes to the observed racial disparity in survival rates.STUDY DESIGN: Immunostaining for the p53 gene was performed in 164 women with stage I endometrial adenocarcinomas.RESULTS: Overexpression of mutant p53 protein was seen in 28 out of 164 (17%) cases and was associated with a poor histologic grade (p = 0.003) and a nonendometrioid histologic appearance (p = 0.06). Overexpression also was three times more frequent in blacks (15 out of 44, 34%) than in whites (13 out of 117, 11%) (p = 0.003). Recurrent disease developed in 15 out of 164 (9%) cases and was more than twice as frequent in cases when the p53 gene was overexpressed (5 out of 28, 18%) than in cases with normal expression (10 out of 136, 7%). Recurrent disease was seen in 6 out of 44 (14%) blacks compared to 9 out of 117 (8%) whites.CONCLUSIONS: These data support the hypothesis that differences in the frequency of alteration of the p53 tumor suppressor gene contribute to the racial disparity in endometrial cancer survival. (Am J Obstet Gynecol 1997;176:S229-32.)     

雌激素受体、孕激素受体、C-erbB-2和Ki-67在子宫内膜癌中的表达及其与临床病理相关性

目的 探讨雌激素受体（ER）、孕激素受体（PR）、C-erbB-2和Ki-67在不同子宫内膜组织中的表达及其与临床病理的相关性。方法 采用免疫组化S-P法检测2004年1月至2013年1月郑州人民医院病理科存档30例正常子宫内膜、30例不典型增生、80例子宫内膜癌组织中ER、PR、C-erbB-2、Ki-67的表达。结果　ER、PR在正常子宫内膜、不典型增生和子宫内膜癌中表达逐渐降低(P<0.05),在不同分化子宫内膜癌组织类型中表达有差异(P<0.05);C-erbB-2在正常子宫内膜中不表达,在不典型增生中表达为53.33%和子宫内膜癌中表达为80.00%,两两比较差异有统计学意义(P<0.05);Ki-67在正常子宫内膜仅有少量表达,在不典型增生子宫内膜中表达为33.33%和子宫内膜癌中表达为63.75%,差异均有统计学意义(P<0.05)。C-erbB-2及Ki-67的表达与子宫内膜癌的分化程度、临床分期、肌层浸润深度及淋巴结转移4种病理特征均有关(P<0.05)。结论　ER、PR、C-erbB-2和Ki-67表达与子宫内膜癌的临床病理相关,可作为判断子宫内膜癌预后及指导临床治疗的指标。     

Prognostic importance of the nuclear proteins p53 and Rb in conjunction with DNA, nuclear morphometry and grading in endometrial carcinoma

In a series of 227 cases of endometrial carcinomas in FIGO stages I–IV, treated during the years 1984–89, immunohistochemical staining for the protein products of the two tumor suppressor genes p53 and retinoblastoma (Rb) were evaluated as prognostic factors with regard to tumor stage, FIGO grade, nuclear grade, morphometric nuclear parameters, DNA ploidy and S-phase fraction. Long-term survival analyses were endpoints and the Cox multivariate technique was used to evaluate the prognostic factors. In 20% of the cases p53 was positive. This was a genuine high-risk group associated with primary advanced carcinoma, nonendometrioid histology, poorly differentiated tumors, severe nuclear atypia, DNA aneuploidy, primary persistent tumors, recurrent tumors and a poor long-term survival rate (37% 5-year survival). In patients dying of their disease, 54% of the tumors stained positive for p53, compared with only 10% of the tumors not killing their hosts. Positive p53 staining was more common in older women. A pathologic Rb status (negative staining) was recorded in 6% of the cases. The Rb factor had only a minor influence on long-term survival and was not significant in multivariate analyses. The p53 staining status was the second most important prognostic factor after the nuclear grade in Cox multivariate analyses, after correcting for stage and age. Immunohistochemical staining for p53 protein should be included among previous available and important prognostic factors in endometrial carcinoma.     

The significance of cell type and tumor growth markers in the prognosis of unscreened cervical cancer patients

ter Harmsel B, van Muyden R, Smedts F, Hermans J, Kuijpers J, Raikhlin N, Petrov S, Lebedev A, Ramaekers F, Trimbos B. The significance of cell type and tumor growth markers in the prognosis of unscreened cervical cancer patients. Int J Gynecol Cancer 1998; 8 : 336–344.
The clinical significance of p53, Ki-67-Ag, and BCL-2 as markers for patient prognosis in cervical carcinoma was compared to established prognostic tumor parameters. The examined population consisted of 159 unscreened Russian women, presenting with Stage I ( n = 74) and Stage II ( n = 85) cervical carcinoma. Relevant clinical information was available in all cases. Thirty-five percent of cases were either adenocarcinoma or contained an adenocarcinomatous component. Lymph node status and stage of disease appeared to be statistically significant parameters for patient survival. Depth of tumor infiltration was a significant indicator of 5-year relapse risk, while tumor size and histologic classification were not predictive. When analyzed separately, p53, Ki-67-Ag, and BCL-2 were not significantly correlated with clinical parameters. However, high Ki-67-Ag combined with high BCL-2 indices predicted a shorter relapse-free interval than did low Ki-67-Ag combined with low BCL-2 index. We conclude that the relatively high incidence of cervical adenocarcinomas is merely due to an increased awareness in the histologic classification criteria of this tumor subtype. Furthermore, histologic parameters are not of value in predicting patient outcome. Although tumor stage and lymph node status are superior to individual markers of tumor growth and genomic instability in determining patient prognosis, a combination of markers for proliferation index and protection from apoptotic cell death shows a tendency to predict clinical outcome.     

Multivariate survival analysis of clinicopathologic features in surgical stage I endometrioid carcinoma including analysis of HER-2/neu expression

OBJECTIVE: We previously described vascular invasion-associated changes, defined as the presence of vascular invasion or perivascular lymphocytic infiltrates, as key prognostic indicators in stage I endometrioid carcinoma. The current study was undertaken to examine the prognostic value of HER-2/neu expression in relation to other factors, including vascular invasion-associated changes, in surgical stage I endometrioid carcinoma.STUDY DESIGN: Seventy-one patients with surgical stage I endometrioid carcinoma treated by hysterectomy and followed up were randomly chosen for retrospective analysis of prognostic indicators including standard clinicopathologic features, deoxyribonucleic acid ploidy, and HER-2/neu expression. The latter was examined by an objective computerized quantitative immunohistochemical system.RESULTS: By univariate analysis many factors were found to correlate with outcome, including age, tumor grade, depth of invasion, ploidy, HER-2/neu expression, and vascular invasion-associated changes. By multivariate analysis only vascular invasion-associated changes, aneuploidy, and HER-2/neu overexpression were found to independently correlate with survival. Stratification of patients on the basis of these three features revealed survival rates of 100%, 92%, and 60% when none, one, and two or three features were present, respectively.CONCLUSION: This study suggests that HER-2/neu expression correlated with outcome independent of other factors in endometrial carcinoma and may aid in estimating prognosis. The prognostic value of HER-2/neu overexpression independent of vascular invasion suggests that this factor may operate by increasing the ability of tumor cells to grow at a distal site once vascular invasion occurs.     

PTENMutations in Endometrial Cancers with 10q LOH: Additional Evidence for the Involvement of Multiple Tumor Suppressors

Objective.The aim of this study was to assess the involvement ofPTENand other putative 10q tumor suppressors in endometrioid-type adenocarcinomas characterized by loss of 10q sequences.Methods.PCR-based single-stranded conformational variant analysis and sequencing of individualPTENexons in 34 tumor specimens and their corresponding normal DNA were used.Results.Thirteen of the 34 tumors (38%) revealed aPTENmutation: 2 frameshift, 3 nonsense, 3 missense, 3 splice site alterations, and 2 homozygous deletions.Conclusion.The observation that greater than 60% of endometrial cancers with 10q LOH lackPTENmutations, in addition to previously reported LOH data, provides evidence for the existence of other tumor suppressors on 10q. Consideration ofPTENmutation status may prove important in deletion mapping studies to locate additional tumor suppressors on the long arm of chromosome 10.     

The pattern of Protease Activated Receptor 1 (PAR1) expression in endometrial carcinoma

OBJECTIVE: Protease Activated Receptors (PARs) form a family of G-protein-coupled proteins uniquely activated by proteolytic cleavage. While the role of either soluble or matrix-immobilized protease in tumor invasion is well established, the part of cell surface PARs is beginning to emerge. We sought to investigate the expression pattern of Protease Activated Receptor 1 (hPar1) in endometrial carcinoma, the most common type of gynecological malignancy. METHODS: Tissue biopsy specimens taken from seventy-four formalin-fixed, paraffin-embedded endometrial tissue blocks were obtained from archival material. Analysis of PAR1 expression was evaluated by riboprobe in situ hybridization for detection of RNA and immunohistochemistry techniques for localization of protein. Histological scoring was performed. RESULTS: The levels of hPar1 mRNA and protein were high and abundant in high-grade endometrial carcinoma, regardless of the histological subtype. In contrast, no hPar1 was detected in endometrial epithelia with conserved glandular structure represented by normal, hyperplastic or low-grade carcinomas. CONCLUSIONS: PAR1 over-expression is selectively confined to the highly aggressive, high-grade endometrial carcinoma and absent in tissue obtained from benign endometrium or low-grade endometrial cancer. This finding highlights the significance of hPar1 gene involvement in invasive endometrial carcinoma and appoints it an attractive candidate for anti-cancer therapy.     

Programmed cell death (apoptosis) as a possible pathway to metalloproteinase activation and fetal membrane degradation in premature rupture of membranes

OBJECTIVE: Increased matrix metalloproteinase 2 expression and activity are associated with premature rupture of fetal membranes. A proapoptotic protein produced in response to deoxyribonucleic acid fragmentation, p53, can bind to the matrix metalloproteinase 2 gene promoter and cause increased gene expression. It promotes apoptosis by inducing the expression of the proapoptotic bax gene and inhibiting the antiapoptotic bcl-2 gene. This study was undertaken to investigate the expression pattern of apoptotic elements in pregnancy complications that may cause increased expression of the gene for matrix metalloproteinase 2. STUDY DESIGN: Amniochorial membranes were collected from the following groups of women: (1) women with premature rupture of fetal membranes, (2) women with preterm labor and intact membranes, and (3) women with term labor after vaginal delivery. Deoxyribonucleic acid fragmentation was tested with ligation-mediated polymerase chain reaction and the terminal deoxynucleotidyl transferase-mediated biotinylated deoxyribonucleoside triphosphate end-labeling assay. Matrix metalloproteinase 2, p53, bcl-2, and bax gene expression patterns were studied with quantitative competitive polymerase chain reaction. Statistical analysis was performed with the Tukey-Kramer multiple comparison test. RESULTS: Quantitative competitive polymerase chain reaction documented a 10-fold increase in the expression of the gene for matrix metalloproteinase 2 in premature rupture of fetal membranes with respect to term and preterm labor. This induction coincided with an increase in the expressions of the proapoptotic genes p53 and bax and a drop in the expression of the antiapoptotic gene bcl-2. Ligation-mediated polymerase chain reaction revealed deoxyribonucleic acid fragmentation in specimens from premature rupture of fetal membranes and not in those from preterm labor or labor at term. Histochemical analysis documented fragmented deoxyribonucleic acid in chorionic and amniotic cells. CONCLUSION: This study suggests that apoptosis is associated with premature rupture of fetal membranes. Deoxyribonucleic acid fragmentation, associated with elevations in the levels of the two proapoptotic gene products evaluated (p53 and bax ) and a drop in the level of the antiapoptotic bcl-2, was seen in premature rupture of the fetal membranes. Induction of matrix metalloproteinase 2 may be a function of p53 gene expression increase in premature rupture of fetal membranes.     

Effects of Ureaplasma parvum lipoprotein multiple-banded antigen on pregnancy outcome in mice

Ureaplasma spp. are members of the family Mycoplasmataceae and have been considered to be associated with chorioamnionitis and preterm delivery. However, it is unclear whether Ureaplasma spp. have virulence factors related to these manifestations. The purpose of the present study was to determine whether the immunogenic protein multiple-banded antigen (MBA) from Ureaplasma parvum is a virulence factor for preterm delivery. We partially purified MBA from a type strain and clinical isolates of U. parvum, and also synthesized a diacylated lipopeptide derived from U. parvum, UPM-1. Using luciferase assays, both MBA-rich fraction MRF and UPM-1 activated the NF-κB pathway via TLR2. UPM-1 upregulated IL-1β, IL-6, IL-12p35, TNF-α, MIP2, LIX, and iNOS in mouse peritoneal macrophage. MRF or UPM-1 was injected into uteri on day 15 of gestation on pregnant C3H/HeN mice. The intrauterine MRF injection group had a significantly higher incidence of intrauterine fetal death (IUFD; 38.5%) than the control group (14.0%). Interestingly, intrauterine injection of UPM-1 caused preterm deliveries at high concentration (80.0%). In contrast, a low concentration of UPM-1 induced a significantly higher rate of fetal deaths (55.2%) than the control group (14.0%). The placentas of the UPM-1 injection group showed neutrophil infiltration and increased iNOS protein expression. Our data indicate that MBA from the clinical isolate of U. parvum is a potential virulence factor for IUFD and preterm delivery in mice and that the N-terminal diacylated lipopeptide is essential for the initiation of inflammation.