Effects of tamoxifen on steroid hormone receptors and hormone concentration and the results of DNA analysis by flow cytometry in endometrial carcinoma

OBJECTIVES: Tamoxifen is a nonsteroidal triphenylethylene derivate with a predominant antiestrogen activity, used in the endocrine treatment of breast and endometrial cancer. It is not known which endometrial carcinomas will respond favorably to tamoxifen and which ones will not. The aim of this study was to find out whether tamoxifen has an effect on hormone steroid receptors, hormone concentration, DNA content, and proliferative activity in endometrial cancer and to correlate the tamoxifen-induced changes with pathologic parameters such as clinical stage, tumor differentiation, depth of invasion, and histologic type. METHODS: Thirty postmenopausal women with endometrial carcinoma were treated with 30 mg of tamoxifen daily for 7-10 days after curettage. Steroid hormone receptors (estrogen and progesterone receptors), levels of follicle-stimulating hormone, luteinizing hormone, prolactin, estradiol, progesterone, testosterone, dehydroepiandrosterone sulfate, sex hormone binding globulin, and DNA ploidy and proliferative activity were determined before and after therapy. The patients were also divided into favorable and unfavorable prognosis groups according to classical histological parameters. The patients in the favorable group consisted of patients with stage I disease, well and moderately differentiated tumors, favorable histologic type, and a depth of myometrial invasion of less than (1/3). The patients with only one of the unfavorable parameters (clinical stage II or III, poorly differentiated tumors, unfavorable histologic types, and deeper invasion of myometrium) were included in the unfavorable prognosis group. RESULTS: After the treatment, there was a net increase in the progesterone receptors and sex hormone binding globulin and a significant decrease in the estrogen receptors. The increase in progesterone receptors and decrease in estrogen receptors occurred in the patient group with favorable prognosis regarding histologic type, degree of differentiation, and clinical stage, but also in the unfavorable prognosis group regarding the depth of myometrial invasion. Statistically significant decrease in the follicle-stimulating hormone concentration was observed in the groups with favorable prognosis regarding histologic type, depth of myometrial invasion, and grade of differentiation. Concentration of sex hormone binding globulin was significantly increased in groups with favorable prognosis if histologic type and grade of differentiation were taken into account. On the other hand, there was a significant decrease in the concentration of luteinizing hormone in the group with unfavorable histologic type and also a decrease in progesterone concentration in patients with unfavorable prognosis regarding the grade of differentiation. There was no statistical significance either in the concentrations of other hormones measured or in the DNA analysis by flow cytometry. CONCLUSIONS: Our results revealed that tamoxifen can increase progesterone receptors and decrease estrogen receptors in endometrial cancer. The effect was most pronounced in tumors with favorable clinicopathologic parameters. We conclude that tamoxifen therapy can induce progesterone receptor synthesis even in tumors with low initial progesterone receptor levels, making such tumors potentially responsive to additional hormonal therapy with progesterone.     

Heterogeneity in hormone receptor status in primary and metastatic endometrial cancer

The rationale for endocrine therapy in patients with advanced endometrial carcinoma may be based on the presence of estrogen or progesterone receptors in the primary tumor. A study was designed to evaluate tumor cell heterogeneity of steroid hormone receptors in the primary and metastatic sites in endometrial cancer. Primary endometrial cancer tissue samples from 10 patients and 16 metastatic tumor sites were simultaneously analyzed for estrogen and progesterone receptors, using a radioligand biochemical assay. The primary tumor was estrogen receptor (ER) and progesterone receptor (PR) positive in 70 and 60% of the patients, respectively. The metastatic sites were ER positive in 63% and PR positive in 25%. The primary tumor tissue and the metastatic disease showed an identical ER and PR status in only 25 and 19%, respectively. Four patients had multiple metastatic sites analyzed. In two of four patients the PR values, and in three of four patients the ER values, in these metastatic sites were discordant. These data support the concept of tumor cell heterogeneity for steroid hormone receptors in endometrial cancer. To optimize treatment planning, it may be important to biopsy primary, metastatic, and recurrent tumor sites for individual analysis of receptor activity.     

Tamoxifen and endometrial carcinoma: alterations in estrogen and progesterone receptors in untreated patients and combination hormonal therapy in advanced neoplasia

Estrogen receptors and progesterone receptors were measured in tumors from patients with previously untreated endometrial carcinoma before and after a 5-day course of tamoxifen citrate. On initial biopsy, 13 of 25 tumors (52%) were progesterone receptor-positive, whereas 21 of 25 tumors (84%) were progesterone receptor-positive after tamoxifen. Grades 1 and 2 tumors were more likely to demonstrate this increased incidence of measurable progesterone receptors. Considering these results, and the work of others who have shown that progesterone receptor-positive metastatic endometrial cancer is more responsive to progestin therapy than are progesterone receptor-negative tumors, we instituted a phase II clinical trial of tamoxifen plus progestin for patients with recurrent endometrial carcinoma. Thus far, however, the 33% total response rate achieved with the combination therapy has not been superior to standard progestin therapy.     

Endometrial carcinoma: Steroid receptors and response to medroxyprogesterone acetate

The steroid receptor content of the primary endometrial cancer of 22 patients who were treated for recurrent or advanced disease has been measured and correlated with response to medroxyprogesterone acetate. No patient with a progesterone receptor (PR)-negative tumor responded and only 2 patients with PR-positive tumors responded, perhaps related to the low levels of PR in the tumors. It waits to be assessed whether receptor status is as good a guide to response to hormone therapy as tumor differentiation, site of recurrence, or disease-free interval.     

Cytosol Oestradiol and Progesterone Receptors in Endometrial Hyperplasia and Adenocarcinoma: Determination by Single Saturating Dose Exchange Assays

Summary: Available oestradiol and progesterone binding site concentrations in endometrial cytosols were determined by a simplified single saturating dose assay in 16 normal women with proliferative endometrium, in 10 patients with endometrial hyperplasia, and in 20 patients with endometrial adenocarcinoma. The mean oestrogen receptor level tended to be higher in endometrial hyperplasia than in either proliferative or carcinomatous endometria. Mean progesterone receptor levels were comparable in proliferative and hyperplastic endometria, but were sequentially lower in highly differentiated carcinoma, moderately differentiated carcinoma, and undifferentiated carcinoma.
Correlation between results obtained by single saturating dose assays and by conventional Scatchard analysis in those endometria subjected to both procedures was high for both oestrogen (r = 0.998) and progesterone (r = 0.949) and indicates that with the simplified assays, large scale clinical studies on hormone sensitivity of endometrial adenocarcinomas are feasible.     

Reevaluating the safety of fertility-sparing hormonal therapy for early endometrial cancer

OBJECTIVE: To evaluate the safety of fertility-sparing hormonal therapy for endometrial cancer in young patients. METHODS: Six patients diagnosed with endometrial adenocarcinoma grade I and had undergone progestin treatment were reviewed. Four patients failed progestin treatment and were then found at surgery to have both endometrial and ovarian cancers. A clonality assay using the human androgen receptor gene as the X-linked polymorphic marker and immunohistochemistry for steroid hormone receptor expression were used to delineate the relation between the endometrial and ovarian lesions and to explore possible causes of treatment failure. RESULTS: The patients were followed for a mean of 48.8 months. Four of the six responded to the treatment at a mean of 3.5 months. Two of these patients had a recurrence within a mean of 4.5 months after their initial response. Two patients did not respond to progestin treatment. At surgery in those 4, both endometrial and ovarian tumors were found. All 6 are still alive, and 2 successfully delivered healthy infants. The clonality assay revealed an independent cell origin for the endometrial and ovarian lesions in 2 of the 4 women who failed progestin treatment. Progesterone receptors were absent in both endometrial and ovarian tumors in 2 of these 4 patients. CONCLUSION: The absence of progesterone receptors may relate to the failure of progestin treatment. The use of progestin treatment for well-differentiated early endometrial carcinoma should be cautious and requires very careful clinical evaluation before and after treatment.     

Hormone serum levels and hormone receptor contents of endometria in women with normal menstrual cycles and patients bearing endometrial carcinoma

Serum levels of luteinizing hormone (LH), follicle-stimulating hormone (FSH), prolactin (HPRL), 17 beta-estradiol (E2) and progesterone (P) were estimated in 46 subjects with normal menstrual cycles in whom hysterectomies were performed. Estrogen (ER) and progesterone receptor (PgR) levels in endometrial samples of these patients were estimated, and histological dating of the cycle day was carried out. Similarly, hormone serum levels and ER as well as PgR were estimated in 17 patients with endometrial carcinoma. No correlation between LH, FSH, HPRL and ER as well as PgR was noted in the normal subjects. Correlation between P and ER was observed in this group. Parallel variations between E2 and PgR were recorded in the normal females. In the carcinoma group no correlations between hormone serum levels and receptor contents were found, but ER and PgR correlated with each other. Receptor levels was highest in the well-differentiated group of endometrial carcinoma. The present experiments provide a rationale for progestagen therapy of carcinoma of the endometrium.     

DNA ploidy and steroid receptors as predictors of disease course in patients with endometrial carcinoma

Prognostic factors for outcome of malignant disease should be based on objective assessments whenever possible, so that the results may be reproduced. In a prospective study, tumor samples from 75 patients were subjected to flow cytometric DNA analysis. Samples were also taken from 61 patients for estradiol and progesterone receptor measurements. The course of the disease was analysed with regard to ploidy and receptor status. Receptor status was significantly correlated with ploidy, as diploid tumors were more often receptor-positive or receptor-rich (greater than or equal to 30 fmol/mg protein). Mortality and recurrence rates were highest among patients with aneuploid or receptor-poor tumors. Ploidy, receptor status, histological grade, surgical stage, and myometrial invasion were found to be of significant prognostic value. By multivariate analysis, ploidy was indicated to be the best predictor, followed by surgical stage. DNA and receptor measurements are recommended in research on endometrial carcinoma, and may become useful in routine clinical work.     

Steroid Receptor Concentrations in Endometrial Carcinoma: Effect on Survival in Surgically Staged Patients

Estrogen and progesterone receptor concentrations were measured in the primary tumors of 137 surgically staged women with clinical stages I and II endometrial carcinoma. For each steroid, increasing receptor concentrations were associated with a decrease in hazard (increase in survival) and the effect was linear for each receptor. When expressed dichotomously, steroid receptor status was also significantly associated with a number of known risk factors, and the significance of the association was influenced by the receptor concentration used as the criterion for receptor positivity. In a multivariate analysis, only progesterone receptor concentration affected survival independently, but the effect disappeared when the analysis was restricted to women with disease confined to the uterus. We conclude that the estrogen and progesterone receptor status of the primary tumor is of limited prognostic significance in endometrial carcinoma unless extrauterine disease is present.     

Estrogen and progesterone receptors in uterine sarcomas

Estrogen and progesterone receptors were measured in tissues from 43 patients with various uterine sarcomas using the dextran-coated charcoal assay. Estrogen receptor was present in 55.5% and progesterone receptor in 55.8% of samples, at median estrogen and progesterone receptor concentrations of 10.7 and 15.8 fmol/mg cytosol protein, respectively. These median values are much lower than those in 30 consecutive endometrial adenocarcinomas and 50 breast carcinomas assayed in our laboratory. Progesterone receptor status correlated strongly with estrogen receptor status in uterine sarcomas (P = .001). Estrogen and progesterone receptor levels were not influenced by stage, grade, or mitotic count. Patients 50 years of age or less had significantly higher progesterone receptor than those over 50. No such age effect was seen for estrogen receptor. Endometrial stromal sarcoma had higher estrogen and progesterone receptor levels than other histologic types. Low-grade endometrial stromal sarcomas had higher median estrogen receptors (238.9 fmol/mg) and better survival (all patients alive at 6-12 months) than did high grade (N = 7) endometrial stromal sarcomas (median ER = 6.6 fmol/mg, all dead of disease at 8-27 months). For all histologic types, evaluable patients with stage I or II disease (N = 16) were more likely to survive longer than one year than those with stage III or IV disease (N = 13, P = .003). Evaluable patients with estrogen receptor-positive sarcomas were more likely to survive longer than one year than those with estrogen receptor-negative tumors (P = .006). With one exception, an endometrial stromal sarcoma, hormonal therapy exerted no beneficial effect.(ABSTRACT TRUNCATED AT 250 WORDS)     

子宫内膜癌bcl-2癌基因的持续性表达及其临床意义

目的：研究子宫内膜癌ｂｃｌ－２癌基因的表达及其临床意义。方法：采用免疫组化ＡＢＣ法检测增生期、分泌期、单纯型增生、复合型增生及不典型增生子宫内膜共２６份，子宫内膜癌４９例的ｂｃｌ－２癌基因蛋白表达及雌、孕激素受体（ＥＲ、ＰＲ）的表达。结果：正常增生期子宫内膜、增生的子宫内膜存在ｂｃｌ－２的表达，与ＥＲ相关，分泌期子宫内膜ｂｃｌ－２表达下降；４９例子宫内膜癌中２６例ｂｃｌ－２表达阳性，占５３％，２９例ＥＲ表达阳性，占５９％，２５例ＰＲ表达阳性，占５１％。７２％ｂｃｌ－２表达阳性者ＥＲ阳性，７５％ｂｃｌ－２表达阴性者ＥＲ阴性（Ｐ＜０．０１）。６８％ｂｃｌ－２表达阳性者ＰＲ阳性，６２％ｂｃｌ－２阴性者ＰＲ阴性（Ｐ＜０．０５）。子宫内膜癌Ｇ１、Ｇ２级ｂｃｌ－２的表达率为６６％，显著高于Ｇ３级者（２１％）（Ｐ＜０．０５）。ｂｃｌ－２的表达与肌层浸润、手术分期无关，ｂｃｌ－２表达阳性及阴性者生存率统计差异无显著性。结论：子宫内膜ｂｃｌ－２的持续性表达与卵巢激素相互作用可能在子宫内膜癌发生、发展中起作用     

Hormone receptors in cervical intraepithelial neoplasia

The presence or absence of steroid hormone receptors has been associated with predicting response to exogenous hormone therapy in breast tumors and in the treatment of metastases. This study was conducted to determine whether hormone receptors are present in cervical epithelium showing intraepithelial neoplasia. 18 biopsies of normal cervical epithelium were collected from hysterectomy patients with normal cervical cytology. 32 abnormal epithelium specimens were similarly obtained from patients with abnormal cervical cytology. An assay method using dextran-coated charcoal was performed to determine the values of estrogen and progesterone receptors in the cervical samples. Among those with normal epithelium, 67% were found to be estrogen receptor + compared to 77% of those with cervical intraepithelial neoplasia (CIN). Progesterone receptor sites were found in 61% of normal patients and 65% of CIN patients. The % of tumors (invasive cervical carcinoma) that are estrogen receptor positive have been found to vary from 0 to 25%. This study suggests a higher % of estrogen and progesterone receptor positivity in CIN than in invasive carcinoma with increasing concentration of receptors proportionate to the degree of dedifferentiation. Further studies should be done to determine whether hormone manipulation of cervical epithelium is of therapeutic and clinical value.     

Prognostic factors in endometrial carcinoma

Endometrial carcinoma is the most common malignancy of the female genital tract in industrialized countries, and occurs predominantly after the menopause. Although most endometrial carcinomas are detected at low stage, there is still a significant mortality from the disease. In postmenopausal women, prolonged life expectancy, changes in reproductive behavior and prevalence of overweight and obesity, as well as hormone replacement therapy use, may partially account for the observed increases of incidence rates in some countries. In order to improve treatment and follow-up of endometrial carcinoma patients, the importance of various prognostic factors has been extensively studied. The identification of high-risk groups would make it possible to avoid unnecessary adjuvant treatment among patients with a good prognosis. Over the past few decades, several studies have demonstrated the prognostic importance of different parameters including lymph node status, histological type of carcinoma (serous carcinoma and clear cell carcinomas are poor prognostic types), histological grade, stage of disease, depth of myometrial invasion, lymphovascular space involvement and cervical involvement. Other factors currently being investigated are estrogen and progesterone receptor status, p53 status, flow cytometric analysis for ploidy and S-phase fraction, and oncogenes such as HER-2/neu (c-erbB-2).     

Estradiol and progesterone receptors in two cases of endometrial stromal sarcoma

The presence of estradiol and progesterone receptors in endometrial stromal sarcoma (ESS) has not been studied previously. Two cases of ESS are reported in which high concentrations of these receptors were found in the tumor tissue. One of these patients had retained the reactivity to hormone treatment for several years. It is suggested that the steroid receptors should be analyzed in all cases of ESS to find tumors with a high receptor content. Hormone treatment of these patients should be part of the primary adjuvant therapy. In cases of a good response the therapy should be prolonged and continued for the rest of the patient's life.     

Steroid receptors and clinical outcome in patients with adenocarcinoma of the endometrium

Progesterone receptor content was measured in tissue samples from 175 patients with endometrial adenocarcinoma by use of the dextran-charcoal method. The estradiol receptor content was determined in 138 of these samples. Ninety-two tumors (52.6%) tested positive for progesterone receptors (greater than 50 fmol/mg cytosol protein) and 111 (80.4%) tested positive for estradiol receptors (greater than 6 fmol/mg). Median follow-up was 27.3 months (range 1 to 152 months). Progesterone receptor status correlated significantly with grade, histology, adnexal spread, age, and recurrence rate in stage I cancer. There was no correlation between progesterone receptor status and clinical stage, myometrial invasion, peritoneal cytology, retroperitoneal lymph node involvement, or spread to the cervix. Estradiol receptor status correlated with adnexal spread and recurrence rate. Recurrence in patients with stage I disease was significantly more common if tumors were negative for progesterone receptor (16 of 43, 37.2%) than if they were positive (four of 57, 7%; p less than 0.001). Recurrence was also more common if tumors were negative for estradiol receptor (seven of 17, 41.2%) than if they were positive (eight of 63, 12.7%; p = 0.02). In recurrent or advanced disease, response to progestin was independent of estradiol receptor content, but tumors positive for progesterone receptors responded significantly more often than those lacking progesterone receptors. Overall survival was superior for patients with progesterone receptor-positive tumors (p = 0.001). Although survival in clinical stages I and II was also superior in patients with lesions positive for progesterone receptors (p = 0.13), there was no statistical difference in survival between patients with progesterone receptor-positive or -negative cancers and surgical stages I and II disease (p = 0.12). Estradiol receptor status had no apparent correlation with survival.     

Type I and Type II estrogen and progesterone binding sites in endometrial carcinomas: their value in predicting survival

A simple and inexpensive immunocytochemical technique has been used to demonstrate estrogen (EB) and progesterone binding sites (PB) in endometrial carcinoma. Tumors were considered as being 'binding-site' rich if more than 40% of the component epithelial cells were positive for hormone binding sites (HB). By this criterion, over half of the adenocarcinomas studied were HB rich. Significantly higher 5- and 10-year survival rates were found in women whose tumors were HB rich compared with those whose neoplasms were HB poor, and a similar trend was established for patients with a combined EB rich/PB rich status versus that of EB poor/EB poor. This beneficial effect of a rich Type I and Type II receptor site status on survival, however, was shown only to a limited extent for EB. These results were independent of adjuvant treatment and of all clinical and histopathological features of known prognostic importance, save tumor differentiation. It is concluded that the immunocytochemical determination of HB status in formalin-fixed paraffin-embedded tissues adds significantly to the prognostic information available for endometrial adenocarcinoma.     

Transvaginal sonography and sonohysterography as screening tools for postmenopausal bleeding

The number of postmenopausal women in the United States is rapidly increasing, and the benefits of hormone replacement therapy (HRT) for the prevention of menopausal syndromes such as osteoporosis, coronary heart disease, and urogenital atrophy are documented. Accordingly, the number of patients using HRT constitutes an increasing percentage of obstetrician/gynecologist and other primary care physician practices. The risk of estrogen-stimulated endometrial hyperplasia and carcinoma in postmenopausal women with uteri in situ using HRT is effectively counteracted by progesterone, thereby making combined estrogen-progesterone HRT regimens safer than estrogen-only regimens. Bleeding, however, continues to be a common complaint among postmenopausal HRT users and nonusers. Despite recent research on the use of transvaginal sonography (TVS), with and without sonohysterography, as a screening tool for the diagnosis of the causes of postmenopausal bleeding, practitioners continue to rely on aspiration endometrial biopsy, hysteroscopy, and dilatation and curettage as the primary methods of evaluating such postmenopausal bleeding. This article evaluates the advantages of TVS, with and without saline infusion sonohysterography (SIS), as a screening tool for postmenopausal bleeding in HRT users and nonusers. Also, the potential of TVS, with and without SIS, to decrease the number of invasive procedures performed is explored.     

Biochemical and immunohistochemical estrogen and progesterone receptors in adenomatous hyperplasia and endometrial carcinoma: correlations with stage and other clinicopathologic features.

OBJECTIVE: This study investigates clinicopathologic associations of estrogen and progesterone receptor content in endometrial carcinoma. STUDY DESIGN: One hundred fifty-two patients with endometrial cancer and 12 with adenomatous hyperplasia were included. Dextran-coated charcoal receptor assay and immunohistochemical analysis were used. The immunohistochemical analysis receptor content was estimated semiquantitatively by a total and a cancer immunohistochemical histologic score. Multiple regression analysis was used in testing independence of established correlations. RESULTS: Estrogen and progesterone receptor dextran-coated charcoal values and immunohistochemical histologic scores correlated inversely (p < 0.001) with International Federation of Gynecology and Obstetrics grade of tumor. An inverse correlation (p < 0.0001) between clinical stage and dextran-coated charcoal values was independent of International Federation of Gynecology and Obstetrics grade. Age of patient, years since menopause, and previous estrogen treatment were not related to receptor content. In adenomatous hyperplasia high progesterone receptor levels were seen. CONCLUSION: The inverse correlation between clinical stage of endometrial carcinoma and content of estrogen and progesterone receptors may reflect tumor biologic behavior.     

Estrogen and progesterone receptors in endometrial cancer and their prognostic relevance

Three hundred and nine malignant endometrial tumors were biochemically analyzed with respect to estrogen (ER) and progesterone (PR) receptors. Fifty-seven percent of endometrial carcinomas were ER and PR positive (greater than or equal to 50 fmole/mg of cytosol protein); 24% were negative for both receptors. Five sarcomas and 16 of 21 mixed müllerian tumors were receptor negative. Receptor status correlated with clinical stage and grade of histological differentiation, but not with myometrial invasion. Anamnestic data on patients showed no differences between those with receptor-negative and receptor-positive tumors. Five-year survival rate (stage I) and median survival time (stages II-IV, recurrences) for patients with ER+/PR+ and ER-/PR+ endometrial cancer were significantly better than for ER-/PR- and ER+/PR- patients. A multivariate analysis demonstrated progesterone receptor as a significant prognostic factor next to clinical stage. Estrogen receptor had no significant prognostic relevance. A retrospective analysis of gestagen treatment and progesterone receptor status confirms the importance of PR, possibly independent of hormonal treatment.     

Endokrine Therapie des Endometriumkarzinoms

Endometrial cancer originates from the endometrium which is hormone dependent. In addition, many endometrial cancers express receptors for progestagens and/or estrogens, therefore, endocrine therapy for this malignancy has been studied for many decades. High dose progestagens are the backbone of fertility sparing conservative treatment of atypical endometrial hyperplasia and of very early stages of well differentiated endometrial cancers in women wishing to preserve child bearing capability. In many studies it has been shown that adjuvant therapy with high dose progestagens after primary surgical treatment is of no benefit. In the palliative situation, when recurrent tumor and/or metastases are no longer amenable to surgery and/or radiotherapy, patients with grade 1 or 2 tumors or with expression of progesterone and/or estrogen receptors should be treated with high dose progestagens if tumor manifestations are not life-threatening. If tumors first respond to this endocrine therapy and then become resistant, a second endocrine therapy using either tamoxifen or fulvestrant (off-label use!) can be considered.