VEGF-A and i-NOS expression are prognostic factors in serous epithelial ovarian carcinomas after complete surgical resection

AIMS

Clinical stage at the time of diagnosis and achievement of complete macroscopic resection during initial surgery are key factors determining the outcome of ovarian cancer. However, prediction of outcome lacks accuracy and more reliable prognostic factors are required. Therefore, an analysis and evaluation of key angiogenic factors was carried out to determine their diagnostic and prognostic value in serous ovarian cancer.

METHODS

Expression levels of vascular endothelial growth factor (VEGF)-A, hypoxia-inducible factor (HIF)1-alpha and inducible nitric oxide synthase (i-NOS) were analysed by immunohistochemistry in a homogenous group of 112 patients with serous adenocarcinoma of the ovary. Vascular density as an indicator of angiogenesis was assessed using the Chalkley eyepiece method after staining for CD34. The correlation of these data with survival and established prognostic factors such as histological grade, Federation of Gynecology and Obstetrics (FIGO) stage, and residual tumour after surgery, was evaluated. Survival analyses, multivariate analyses and correlation tests were performed.

RESULTS

In the patient group with macroscopic complete tumour resection (R0) there was a significant correlation between VEGF-A and i-NOS expression. Kaplan-Meier analysis further revealed improved progression-free survival for R0 patients with VEGF-A-positive and i-NOS-negative tumours. The predictive relevance of VEGF-A regarding progression-free survival was sustained in multivariate analysis using FIGO stage, grading and resection status as fixed variables.

CONCLUSION

VEGF-A and i-NOS are prognostic markers for clinical outcome in serous ovarian cancer patients with macroscopic complete tumour resection (R0). Hence, pre-therapeutic assessment of VEGF-A as predictive factor for an antiangiogenic therapy might be of clinical value.

Pathologisch-anatomische Aufarbeitung und Befundung von Dysplasien und Karzinomen der Cervix uteri*

A careful macroscopic description with selection of representative tissue for histological examination is required for quality assurance, for assessing prognostic factors and for answering legal questions in (pre)cancerous lesions of the cervix uteri. Exact and standardized gross inspection and preparation are decisive for the quality of the histopathological statement. The extent of cervical carcinomas should be given in three dimensions, including the relative depth of invasion into the cervical wall. The report should include size, type (according to the WHO classification) and grading of the tumor, the presence of lymphatic as well as blood vessel invasion and perineural involvement. The statement for resection margins should include the vaginal, parametrial, rectal and vesical directions. It is also mandatory to document the number of lymph nodes with metastatic disease in relation to the total number of nodes investigated. The staging should follow the TNM system. In the handling of conisation specimens, it is important to appropriately document localization, horizontal expansion, depth of invasion including microinvasion of any dysplastic or malignant lesions. Clockwise dissection of the conisation specimen, total submission, and step sections are recommended. The preparation of exenteration specimens is a highly skilled job: the exact tumor dimension should be given in its relation to all resected organs and structures with special focus on resection margins.

Das transitionalzellige Ovarialkarzinom

Transitional cell carcinoma of the ovary (TCC-O) is a less common type of malignant surface epithelial-stromal tumor of the ovary, still with uncertain incidence. Histologically, TCC-O resembles urothelial carcinoma of the urinary system, and by definition does not contain a Brenner tumor component. TCC-O may not be a bona fide urothelial neoplasm, however, but rather a lesion of the Müllerian type derived from the ovarian surface epithelium. This notion is supported by the existence of mixed tumors consisting of TCC-O and other histological types of ovarian carcinoma, as well as the observation that TCC-O has a Müllerian type but not a urothelial-like immunohistochemical profile. Besides metastatic urothelial carcinoma of the urinary tract, the other types of ovarian carcinoma, as well as sex cord-stromal tumors such as adult granulosa cell tumors, have to be considered in the differential diagnosis of TCC-O. A recent analysis of a large series of advanced ovarian carcinomas treated by radical surgery and postoperative chemotherapy confirms studies that had suggested that TCC-O has a better prognosis (with current treatment) than that of the other histological types of ovarian carcinoma. Further studies applying standardized histopathological criteria are needed to clarify the true incidence and behavior of TCC-O. In addition, it is important to study the biological and molecular background of this apparently less aggressive phenotype.

Immunhistochemische Keimstrangmarker

Sex cord markers comprise proteins and hormones that are produced in sex cord-derivatives in normal ovaries and testes as well as in gonadal sex cord-stromal tumors. Sex cord markers (e.g. inhibin-alpha) are used clinically as serum tumor markers. Immunohistochemical staining of sex cord markers may be helpful in the differential diagnosis of ovarian sex cord-stromal tumors versus surface epithelial-stromal tumors, germ cell tumors, other ovarian tumors, and ovarian metastases. Inhibin-alpha has been shown to be the most specific marker of sex cord differentiation. In comparison, calretinin is a somewhat more sensitive albeit less specific marker. Currently, an immunohistochemical panel including inhibin-alpha and calretinin is considered most helpful in the differential diagnosis of ovarian sex cord-stromal tumors. CD99, Müllerian inhibiting substance (MIS), melan A and CD10, being sex cord markers of limited sensitivity and specificity, should only be used as part of an antibody panel in specific diagnostic settings. EMA, CK7 and chromogranin are considered additional markers that may be useful in the differential diagnosis of ovarian sex cord-stromal tumors.

Teratome des Ovars

Teratomas are the most frequent germ cell tumors of the ovary. Two main groups can be distinguished: mature and immature teratomas. Mature teratomas are benign tumors, which are most often composed of derivatives of two or three germ cell layers. Only in rare cases is the transition into a malignant tumor observed (most often squamous cell carcinoma). In contrast, immature teratomas are malignant ovarian tumors. They contain immature tissue elements in addition to the mature components, most often consisting of immature neural tissue. Histologically, this tumor component can be identified as neurotubules or rosettes. The proportion of immature tissue elements defines the grade of immaturity. Four grades have been defined in to the WHO classification. Grade 0 represents a mature teratoma. With the exception of childhood cases, grade 2 and 3 immature teratomas are treated with chemotherapy. In childhood cases, foci of yolk sac tumor (YST) must be looked for, since this determines the prognosis. If a focus of YST is present, the patient is treated with chemotherapy. Both in cases of mature and immature teratoma, peritoneal implants can be found (gliomatosis peritonei), which are also graded. In cases of immature peritoneal implants, patients are also treated with chemotherapy. Gliomatosis peritonei is most likely derived from metaplasia of subperitoneal stem cells; it does not represent a metastatic disease of the ovarian teratoma.

[Diagnosis and differential diagnosis of granulosa cell tumor]

Clinically and morphologically, two types of granulosa cell tumor can be distinguished, the more frequent adult type and the juvenile type. In the adult type, different growth patterns can be observed: microfollicular (most frequent, characterized by Call-Exner bodies), macrofollicular, trabecular, insular, solid-tubular, gyriform and diffuse (sarcomatoid). The juvenile type is characterized by solid and follicular structures. The neoplastic granulosa cells in the adult type have limited cytoplasm and haphazardly arranged angular, pale, mostly grooved nuclei. In the juvenile type, the cells have ample eosinophilic cytoplasm and polymorphic, sometimes bizarre nuclei, which are usually non-grooved. The number of mitoses in the adult type usually does not exceed 2/10 HPF, whereas it is considerably higher in the juvenile type, including atypical mitoses. A common feature in both types of tumor is the expression of inhibin-alpha, calretinin and CD 99. Epithelial membrane antigen is negative. Molecular genetics has demonstrated loss of heterozygosity at 19p13.3 in 52% of the cases. Besides chromosomal aberrations, there are a large number of cytogenetic anomalies. The most important prognostic factor in both types of tumor is tumor stage. Whereas recurrences in the adult type can develop even after decades, in the juvenile type they usually occur during the first 3 years after diagnosis.

Independent prognostic significance of cell cycle regulator proteins p16(INK4a) and pRb in advanced-stage ovarian carcinoma including optimally debulked patients: a translational research subprotocol of a randomised study of the Arbeitsgemeinschaft Gynaekologische Onkologie Ovarian Cancer Study Group

The purpose of the study is to test the hypothesis that expression of cell cycle regulatory proteins p16^INK4a and pRb is significantly associated with prognosis in ovarian carcinomas. We performed immunohistochemical analysis of p16^INK4a and pRb expression and correlated with survival in a series of 300 patients with FIGO stage IIb-IV ovarian carcinoma which were enrolled in a randomized prospective trial evaluating two different platinum and paxlitaxel chemotherapy combinations after radical surgery. p16^INK4a negative tumours (17/300; 6%) had a significantly worse prognosis (univariate analysis, P<0.001; multivariate analysis: odds ratio 2.41, P=0.009). Among p16^INK4a-positive tumours (283 out of 300; 94%), survival was better for patients with intermediate expression as compared to low or high expression levels (P=0.001). High expression levels of pRb were associated with an incremental deterioration of prognosis (univariate analysis, P=0.004; multivariate analysis: odds ratio 2.98, P=0.002). This observation held also true in the subgroup of optimally debulked patients (n=82), in whom the most important established prognostic factor, postoperative residual tumour cannot be applied. In conclusion p16^INK4a and pRb are independent prognostic factors in advanced-stage ovarian carcinomas after radical surgery and postoperative chemotherapy. High pRb expression is a significant prognosticator in optimally debulked patients and may hold potential for subgroup stratification in postoperative treatment.

Primary ovarian angiosarcoma--review of the literature and report of a case with coexisting chylothorax

BACKGROUND

Primary ovarian angiosarcoma is a very rare gynaecologic malignancy with poor prognosis and uncertain, up-to-date, treatment options. Its exact diagnosis is challenging for surgeons and difficult for pathologists. There are only a few cases reported in the international literature.

CASE

We report a case of primary pure ovarian angiosarcoma with coexisting chylothorax which is, to the best of our knowledge, the first reported case. An extensive review of the literature analyzing all clinical and pathological parameters related to this condition is presented.

RESULT

In spite of all therapeutic efforts, surgical and medical, prognosis of ovarian angiosarcoma remains very poor in most cases.

CONCLUSION

Primary ovarian angiosarcoma is a rare and aggressive malignancy. The report of such cases is interesting in order to exchange knowledge and experience, and possibly to further improve our diagnostic and therapeutic capabilities.

VEGF-A and COX-2 expression correlate with platinum resistance in ovarian cancers

5062

Background: Regulators of angiogenesis such as VEGF-A and cell cycle such as p53 and COX-2 influence tumor behavior and response to chemotherapy. Methods: 114 patients with primary ovarian cancer treated in Frankfurt or Wiesbaden between 1999 and 2004 were examined. Primary surgery was followed by a platinum and taxane based chemotherapy in all patients. Expression of i-NOS, COX-2, VEGF-A, HIF-1 alpha was analyzed immunohistochemically using tissue micro arrays of primary tumor samples. Results were scored according to staining intensity and percentage of positive tumor cells resulting in an immune-reactive score (IRS) from 0 to 12. Vascularity was assessed using the Chalkley-Grid method after highlighting vessels with CD34 antibodies in whole tissue sections. These results were correlated with classical prognostic factors and survival. Non-parametric correlations were done using Spearman’s rho, correlations were significant at the 0,05 level (2-tailed). Results: The median age at the time of surgery was 63y (33–89y). The majority of the patients (85%) had advanced disease (FIGO III-IV). Tumor grading was G1 in 2%, G2 in 37%, and G3 in 61%. Expressions were as follows: i-NOS 60% positive (IRS ≥4); COX-2 50% positive (IRS ≥5); VEGF-A 50% strong (IRS ≥8), 32% moderate (IRS 4–7), 18% weak (IRS ≤4); HIF-1 alpha 37% positive (IRS ≥3), p53 33% weak (IRS ≤4), 67% strong (IRS >4); vascularity 41% low (≤5), 52% moderate (6–9), 7% high (>9). I-NOS correlated positively with COX-2 (p = 0,03), VEGF-A (p = 0,05), and p53 (p = 0,01). Grading correlated positively with HIF-1 alpha (p = 0,02) and vascularity (p = 0,01). Up to now none of the new parameters did show correlations with recurrence free survival (median follow-up 36 months). Platinum resistant tumors (time from primary diagnosis to relapse <12 months) were significantly more often negative for VEGF-A (p = 0,005) and COX-2 (p = 0,02). Conclusions: I-NOS correlates with markers of angiogenesis and cell cycle regulation. VEGF-A and COX-2 expression might predict platinum resistance in ovarian cancers.

No significant financial relationships to disclose.

Diagnostik und Therapie maligner Ovarialtumoren 2005: Die Empfehlungen der Kommission Ovar der AGO

Recommendations for diagnosis and treatment of malignant ovarian tumors with regard to the most recent data were worked out in a consensus process and valued by level of evidence (LoE) and grade of recommendation (GoR) of the Canadian Task Force for Preventive Health Care by the members of the Kommission Ovar der Arbeitsgemeinschaft für Gynäkologische Onkologie (AGO) in June 2005. A short version of these guidelines is presented.

Pathologisch-anatomische Aufarbeitung und Befundung von Lymphknoten bei gynäkologischen Malignomen

The nodal status is one of the strongest prognostic factors in gynecologic malignancies. Metastatic involvement of regional and distant lymph nodes represents the selection basis for adjuvant therapy in a large number of solid neoplasms. The number of resected lymph nodes is one of the most important parameters in the quality control of the surgical procedure, in particular with respect to radicality. The present paper provides recommendations for gross dissection, laboratory procedures and reporting for lymph node biopsies, lymph node dissections and sentinel lymph node biopsies (SLN) for cancers of the vulva, vagina, uterine cervix, endometrium, Fallopian tubes and the ovaries, submitted for the evaluation of metastatic disease. The pathologic oncology report should include information about the number and size of resected lymph nodes, the number of involved lymph nodes with the maximum size of metastases and the presence of paranodal infiltration. In addition, the detection of isolated tumor cells should be reported, particularly with respect to the detection method (immunostains or molecular methods). In cases of metastatic disease and carcinoma of unknown primary (CUP-syndrome), information should be given regarding the primary tumor.

Neuroendokrine Karzinome der Cervix uteri

Neuroendocrine carcinomas of the cervix are rare. They cover a wide age range occurring in young adult women and very old women. Two types are distinguished: small cell carcinoma (oat cell) and large cell neuroendocrine carcinoma. They either occur in pure form or in combination with adenocarcinoma or squamous cell carcinoma. By immunohistochemistry, the expression of at least one neuroendocrine marker (chromogranin, synaptophysin, NSE) is a constant finding. PRb protein can not be detected, whereas the expression of p53 varies. Typically, there is an association with a high risk HPV infection. HPV 18 is found more often than HPV 16. The prognosis is still poor with early metastases to regional lymph nodes and distant sites such as lung, liver, bone, and brain.

[Histopathology of squamous cell carcinoma and adenocarcinoma of the uterine cervix]

The introduction of a screening programme for carcinoma of the cervix uteri has lead to a reduction in the number of invasive carcinomas and to a relative increase in the frequency of preinvasive cervical lesions. The most frequent type of invasive cancer of the cervix is squamous cell carcinoma. Adenocarcinomas are much more infrequent. Special subtypes of squamous cell carcinomas are the papillary (squamotransitional) subtype, the verrrucous subtype and the lymphoepithelioma-like subtype. Among the various forms of adenocarcinoma, the mucinous subtype is the most frequent, either as endocervical or interstinal subtype. Much more rare are the serous and clear cell carcinomas. Great concern in daily diagnosis causes the adenoma malignum (minimal deviation adenocarcinoma), since this type of adenocarcinoma demonstrates only minor cytological atypia and greatly resembles the different types of endocervical glandular hyperplasia.A report on a cervical carcinoma should always include the typing and grading of the tumor. Immunohistochemical stains are often useful to distinguish the various types of primary cervical cancer and to distinguish these from metastatic lesions.

Immunohistochemical expression analysis of inhibin-alpha and -beta subunits in partial and complete moles, trophoblastic tumors, and endometrial decidua

The expression of inhibin-alpha subunit has been described in normal placentas, hydatidiform moles, and trophoblastic tumors. We performed a double immunohistochemical expression analysis of inhibin-alpha and inhibin-beta subunits in a cytogenetically well characterized series of 21 complete and 22 partial hydatidiform moles, 2 placental site trophoblastic tumors, and one choriocarcinoma. Syncytiotrophoblastic cells were consistently inhibin-alpha and inhibin-beta positive in all hydatidiform moles and in the one choriocarcinoma. Cytotrophoblast was negative for both subunits in all trophoblastic lesions studied. While villous intermediate trophoblastic cells were consistently inhibin-alpha negative in all hydatidiform moles, focal inhibin-beta immunoreactivity was detected in villous intermediate trophoblast in approximately one third of complete and partial hydatidiform moles. Decidual stromal cells in 40 hydatidiform moles were inhibin-alpha and inhibin-beta positive in approximately one third of cases. Both placental site trophoblastic tumors were inhibin-alpha positive but inhibin-beta negative. Our findings indicate that inhibin-alpha and -beta subunits are consistently coexpressed in syncytiotrophoblast in complete and partial moles. Immunohistochemical detection of inhibin subunits may be useful in the differential diagnosis of trophoblastic lesions.

Adenovirus-mediated wild-type p53 gene transfer in patients receiving chemotherapy for advanced non-small-cell lung cancer: results of a multicenter phase II study

PURPOSE

To study the additional benefit from adenoviral p53 gene therapy in patients undergoing first-line chemotherapy for advanced non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Twenty-five patients with nonresectable NSCLC were enrolled in an open-label, multicenter phase II study of three cycles of regimen A, carboplatin (area under the curve, 6; day 1) plus paclitaxel (175 mg/m(2), day 1), or regimen B, cisplatin (100 mg/m(2), day 1) plus vinorelbine (25 mg/m(2), days 1, 8, 15, and 22) in combination with intratumoral injection of 7.5 x 10(12) particles of SCH 58500 (rAd/p53, day 1). Responses of individual tumor lesions were assessed after each cycle, and gene transfer was examined in posttreatment tumor biopsies using reverse transcriptase polymerase chain reaction.

RESULTS

There was no difference between the response rate of lesions treated with p53 gene therapy in addition to chemotherapy (52% objective responses) and lesions treated with chemotherapy alone (48% objective responses). Subgroup analysis according to the chemotherapy regimens revealed evidence for increased mean local tumor regressions in response to additional p53 gene therapy in patients receiving regimen B, but not in patients receiving regimen A. There was no survival difference between the two chemotherapy regimens, and the median survival of the cohort was 10.5 months (1-year survival, 44%). Transgene expression was confirmed in tumor samples from 68% of patients, and toxicities attributable to gene therapy were mild to moderate.

CONCLUSION

Intratumoral adenoviral p53 gene therapy appears to provide no additional benefit in patients receiving an effective first-line chemotherapy for advanced NSCLC.

Renal tubular dysgenesis (RTD) - an important cause of the oligohydramnion-sequence. Report of 3 cases and review of the literature

Renal tubular dysgenesis (RTD) is a disorder characterized by neonatal renal failure and regular gross renal architecture, although the histological features of immature and shortened proximal tubules lead to neonatal death. The pathogenesis of this condition includes a congenital familial condition, a twin-twin transfusion syndrome, and an angiotensin-converting enzyme inhibitor intake by the mother. The clinical picture shows an association with oligohydramnia, pulmonary hypoplasia, and skull ossification defects. In the present paper, we report the occurrence of RTD in three infants of a consanguinous couple and compared our data with those of the literature. Our data confirm that late second trimester demonstration of oligohydramnion, with structurally normal kidneys and with or without skull ossification defects, allows the diagnosis of renal tubular dysgenesis, which, however, has to be confirmed by histological and immunohistological examinations of the kidney.

The Expression of Cathepsins in Osteoclast-like Giant Cells of an Anaplastic Thyroid Carcinoma with Tracheal Perforation

Anaplastic carcinoma of the thyroid gland (ACT) is a rapidly growing neoplasm with a very poor prognosis. In this study, we examined an ACT with osteoclast-like giant cells expressing matrix--degrading cysteine proteinases and their endogeneous inhibitor cystatin C. Bronchoscopic evaluation of a 50-year-old man suffering from hoarseness, dysphagia, and dyspnea revealed an irregular tumor mass infiltrating into the trachea and the cricothyroid ligament region. On histological examination, a necrotizing undifferentiated anaplastic carcinoma with osteoclast-like giant cells was detected. An immunohistochemical study of the tumor tissue was performed using a panel of 15 antibodies, including double labeling techniques. Most of the osteoclast-like multinucleated giant cells (MGC) expressed CD68 and cathepsin K. Colocalization of cathepsin B and its endogenous inhibitor cystatin C occurred in the majority of MGC. Mononuclear cells (MC) were positive for cathepsin B, cystatin C, and CD 68, but only faintly for cathepsin K. Expression of cathepsins B and K in the MGC of the ACT might contribute to the invasive behavior of this tumor, thus promoting metastatic ability and destruction of the cartilagenous trachea.