Significantly decreased P27 expression in endometrial carcinoma compared to complex hyperplasia with atypia (correlation with p53 expression)

Expression of p53 and PTEN in human primary endometrial carcinomas: Clinicopathological and immunohistochemical analysis and study of their concomitant expression

Endometrial carcinoma is a common malignancy of the female genital tract. Alterations in the expression levels of various oncogenes and tumor suppressor genes serve important roles in the carcinogenesis and biological behavior of endometrial carcinoma. The aim of the present study was to evaluate the combination and individual expression of p53 and phosphatase and tensin homolog (PTEN) protein in human endometrial carcinoma. In addition, the correlation of these proteins with clinicopathological parameters was also assessed. Retrospective immunohistochemical analysis of the expression of p53 and PTEN tumor suppressor proteins was conducted in 99 women with endometrial carcinoma. The overall rate of p53 and PTEN positivity was 89 and 77%, respectively, according to the sum of stain intensity and scores of immunopositive cells. The sum of p53 positivity correlated strongly with PTEN expression (ρ=0.256; P=0.044). The concomitant sum of p53 and PTEN expression was identified in 45% of patients with endometrial adenocarcinoma. Notably, the sum of the immunohistochemical expression of p53 was significantly correlated with patient age (P=0.037), histologic type (P=0.008), histologic grade (P=0.002) and fallopian and/or ovarian invasion (P=0.014). Furthermore, PTEN expression was associated with myometrial invasion (ρ=−0.377; P=0.002) and clinical stage (P=0.019). In addition, concomitant p53 and PTEN expression was correlated with patient age (P=0.008) and histologic differentiation (P=0.028). The findings indicated a correlation between the expression of p53 and PTEN in endometrial adenocarcinoma, which suggested an intrinsic association between expression levels of these tumor suppressor genes. The study also suggested that concomitant p53 and PTEN expression contributed in characterizing the tumor behavior of endometrial carcinoma. Taken together, the present study suggested the combined expression of p53 and PTEN in the development of high-grade endometrial carcinoma in older patients. In addition, the findings indicated activation of different molecular pathways in the tumor progression between low-grade and high-grade endometrial carcinomas.

New concepts for an old problem: the diagnosis of endometrial hyperplasia

BACKGROUND

Endometrial hyperplasia (EH) is a uterine pathology representing a spectrum of morphological endometrial alterations. It is predominantly characterized by an increase in the endometrial gland-to-stroma ratio when compared to normal proliferative endometrium. The clinical significance of EH lies in the associated risk of progression to endometrioid endometrial cancer (EC) and 'atypical' forms of EH are regarded as premalignant lesions. Traditional histopathological classification systems for EH exhibit wide and varying degrees of diagnostic reproducibility and, as a consequence, standardized patient management can be challenging.

OBJECTIVE AND RATIONALE

EC is the most common gynaecological malignancy in developed countries. The incidence of EC is rising, with alarming increases described in the 40-44-year-old age group. This review appraises the current EH classification systems used to stratify women at risk of malignant progression to EC. In addition, we summarize the evidence base regarding the use of immunohistochemical biomarkers for EH and discuss an emerging role for genomic analysis.

SEARCH METHODS

PubMed, Medline and the Cochrane Database were searched for original peer-reviewed primary and review articles, from January 2000 to January 2016. The following search terms were used: 'endometrial hyperplasia', 'endometrial intraepithelial neoplasia', 'atypical hyperplasia', 'complex atypical hyperplasia', 'biomarker', 'immunohistochemistry', 'progression', 'genomic', 'classification' and 'stratification'.

OUTCOMES

Recent changes to EH classification reflect our current understanding of the genesis of endometrioid ECs. The concept of endometrial intraepithelial neoplasia (EIN) as a mutationally activated, monoclonal pre-malignancy represents a fundamental shift from the previously held notion that unopposed oestrogenic stimulation causes ever-increasing hyperplastic proliferation, with accumulating cytological atypia that imperceptibly leads to the development of endometrioid EC. Our review highlights several key biomarker candidates that have been described as both diagnostic tools for EH and markers of progression to EC. We propose that, moving forwards, a 'panel' approach of combinations of the immunohistochemical biomarkers described in this review may be more informative since no single candidate can currently fill the entire role.

WIDER IMPLICATIONS

EC has historically been considered a predominantly postmenopausal disease. Owing in part to the current unprecedented rates of obesity, we are starting to see signs of a shift towards a rising incidence of EC amongst pre- and peri-menopausal woman. This creates unique challenges both diagnostically and therapeutically. Furthering our understanding of the premalignant stages of EC development will allow us to pursue earlier diagnosis and facilitate appropriate stratification of women at risk of developing EC, permitting timely and appropriate therapeutic interventions.

Status of p53 and p27(KIP1) in Iranian Patients With Oral Squamous Cell Carcinoma

Background:

Alterations in p53 and p27^KIP1 have been documented as important events in the carcinogenesis of various cancers, but their prognostic role in oral squamous cell carcinoma (OSCC) remains controversial.

Objectives:

The present investigation aimed to evaluate the clinicopathologic and prognostic significance of p53 and p27^KIP1 expression in a group of Iranian patients with OSCC.

Patients and Methods:

In this analytical cross-sectional study, medical records of patients with primary OSCC, diagnosed from 1994 to 2004 were reviewed and 28 subjects were selected based on the inclusion/exclusion criteria. Immunohistochemical staining using monoclonal antibodies against p53 and p27^KIP1 was performed on representative archival paraffin blocks. Demographic data along with information on p53 and p27^KIP1 expression, recurrence, and tumor grade was statistically analyzed using the Fischer exact test. Prognostic factors for overall survival were determined by Cox regression analysis (P < 0.05).

Results:

p53 and p27^KIP1 expression were found in 28.57% (8 positive versus 20 negative) and 67.85% (19 positive versus 9 negative) of OSCC cases, respectively. There was no significant association between these two proteins (P = 0.371), and neither of them showed a significant relationship with the studied clinicopathologic variables (P > 0.05). In survival analysis, only histopathologic differentiation (17 low and moderate, 11 poor) demonstrated a significant correlation with overall survival (P = 0.048).

Conclusions:

Despite the fact that abnormalities in p53 and p27^KIP1 may be involved in the development of OSCC, their clinical significance in the studied population seems limited. Further investigation on the combined p53/p27^KIP1 expression may be helpful in predicting the biologic behavior of this tumor.

Morphometric and DNA Image Analysis of Endometrial Hyperplasia and Carcinoma

Endometrial hyperplasia is believed to increase the risk of endometrial carcinoma and represents a spectrum of morphologic and biological alterations of endometrial glands and stroma ranging from an exaggerated physiological state to carcinoma in situ. Considering the overlap between the various entities, it is not surprising that the morphologic assessment of endometrial lesions is particularly challenging. This work aimed to evaluate endometrial lesions according to their nuclear and glandular morphometric parameters, their D score, and their DNA ploidy, which help in making an accurate diagnosis. In this study, 50 endometrial biopsy specimens were stained with hematoxylin and eosin for their histopathologic and morphometric study and Feulgen stain for DNA analysis. The cases were classified into 20 cases of simple hyperplasia, 10 cases of atypical hyperplasia, and 20 cases of endometrial carcinoma. Morphometric analysis of nuclear, glandular, and stromal parameters was performed using the Leica Qwin 500 image analysis system. In the studied cases, a significant difference was found in the mean values of the morphometrical parameters of endometrial lesions, including the nuclear area and the nuclear roundness, and all glandular measurements including their complexity, area, volume percentage of stroma, and D score were significantly different. The DNA index and diploid and aneuploid values could differentiate significantly between endometrial lesions. We conclude that nuclear morphometric evaluation of the hyperplastic and carcinomatous endometrium may be used as an ancillary technique in the diagnosis of atypical changes occurring in precancerous endometrial lesions. In addition, DNA and D score assessment may be a reproducible and accurate predictor of the outcome of endometrial hyperplasia and may add some objective criteria for the correct diagnosis of difficult cases.

Mullerian inhibiting substance suppresses proliferation and induces apoptosis and autophagy in endometriosis cells in vitro

Objective. To determine the effects of Mullerian inhibiting substance (MIS) treatment on endometriosis cells through study of apoptosis and autophagy. Design. Experimental in vitro study. Setting. University research laboratory. Cell Line. CRL-7566 endometriosis cell line. This line was established from a benign ovarian cyst taken from a patient with endometriosis. Interventions. In vitro treatment with MIS. Main Outcome Measures. The main outcome measures were cellular viability, proliferation, cell-cycle arrest, and induction of apoptosis and autophagy in endometriotic cells. Results. MIS treatment inhibited proliferation of endometriosis cells and induced apoptosis, as indicated by Annexin V staining, and induced caspase-9 cleavage and cell-cycle arrest, as evidenced by increased expression of p27 CDK-inhibitor. MIS treatment also induced autophagy in endometriosis cells as demonstrated by a significant increase in LC3-II induction, a hallmark of autophagy. Conclusions. MIS inhibits cell growth and induces autophagy, as well as apoptosis, in ectopic endometrial cell lines. Our results suggest that MIS may have a potential as a novel approach for medical treatment of endometriosis. Further studies may be needed to test the efficacy of MIS treatment in animal models and to develop MIS treatment specifically targeted to the endometriosis.

New insights in endometrial carcinogenesis

Endometrial carcinoma is the most common cancer of the female genital tract in Europe and in the United States. Despite advances in defining the biology of endometrial carcinomas, there has been poor progress in determining markers that distinguish preinvasive endometrial proliferations. The aim of this review is to highlight the most recent studies regarding the molecular markers involved in endometrial adenocarcinoma pathogenesis and carcinogenesis. We focus on studies that describe markers with potential to progress from endometrial hyperplasia to invasive disease.

Cadherins, catenins and cell cycle regulators: impact on survival in a Gynecologic Oncology Group phase II endometrial cancer trial

OBJECTIVE

We evaluated the clinical relevance of catenins, cadherins and cell cycle regulators in stage IV or recurrent endometrial carcinoma in a multi-center phase II trial (GOG protocol #119).

METHODS

Tissue microarrays of metastatic or recurrent (n=42) tumor were developed and immunohistochemistry was performed. Average expression (percent staining x intensity) was assessed in tumor epithelium ((E)) and stroma ((S)) and categorized into tertiles (T1, T2, T3) for E-cadherin(E), N-cadherin(E), alpha-catenin(E), beta-catenin(E), gamma-catenin(E), p120-catenin(E) and Ki-67(E); as negative, below median or above median for p16(E), p27(E) and CD44(S); or as negative or positive for p53(E), Ki-67(S) and APC(S) (adenomatous polyposis coli). End points included response and survival.

RESULTS

E-cadherin(E), p16(E), and p53(E) varied by race (p=0.003, p=0.024, p=0.002,) and N-cadherin(E), Ki-67(E), p16(E) and p27(E) by tumor type (p=0.015, p=0.011, p=0.005, p=0.021). Correlations were observed among E-cadherin(E) with p120(E) (r=0.66), p53(E) (r=-0.32), alpha-catenin(E) (r=0.52), beta-catenin(E) (r=0.58), and gamma-catenin(E) (r=0.58). High E-cadherin(E) (T2 or T3) versus low (T1) expression was associated with better survival in unadjusted (hazard ratio [HR]=0.14, 95% confidence interval [CI]=0.06-0.37 or HR=0.17, 95% CI=0.07-0.42) and adjusted models (HR=0.18, 95% CI=0.05-0.59 or HR=0.22, 95% CI=0.07-0.70). High p16(E) versus negative expression was associated with worse survival in unadjusted (HR=3.87, 95% CI=1.74-8.61) and adjusted (HR=4.18, 95% CI=1.28-13.6) models. Positive versus negative expression of p53(E) was associated with worse survival in unadjusted (HR=2.31, 95% CI=1.16-4.60) but not adjusted models.

CONCLUSIONS

E-cadherin(E) and p16(E) appear to be clinically relevant, independent prognostic factors in stage IV or recurrent endometrial cancers treated with Tamoxifen and Medroxyprogesterone acetate, and merit further study.

The prognostic value of molecular biomarkers in tissue removed by curettage from FIGO stage 1 and 2 endometrioid type endometrial cancer

OBJECTIVE

To analyze the prognostic value of molecular biomarkers in curettages of endometrioid endometrial cancer pathologic FIGO stages 1 and 2.

STUDY DESIGN

Population-based survival analysis in 258 patients of classical prognostic features and molecular biomarkers of cell cycle regulation, (anti)apoptosis, proliferation, squamous differentiation, and PTEN/Akt pathway.

RESULTS

With 74 months median follow-up (range, 1-209), 24 (9.3%) patients had metastases develop. Pathologic FIGO stage 2B (6% of all cases) and age > 68 years had independent multivariate prognostic value. Many molecular biomarkers were prognostic, particularly cell-cycle regulators p16, p21, p27, p53, p63, and the antiapoptosis marker survivin (which mostly stains mitoses). The strong prognostic value of a multivariate model with survivin, p21, and p53 overshadowed all other prognosticators in pathologic FIGO 1 and 2A.

CONCLUSION

In pathologic FIGO stage 1 and 2A endometrioid endometrial cancer curettages, combined biomarkers survivin, p21, and p53 expression patterns are prognostically stronger than classical feature combinations.

Immunohistochemical markers in endometrial hyperplasia: is there a panel with promise? A review

OBJECTIVE

Despite advances in defining the biology of endometrial carcinomas, there has been little progress in determining markers that distinguish preinvasive endometrial proliferations. The goal of this literature review was to identify studies on endometrial hyperplasia (EH) that describe markers with potential to predict response to progestin therapy or potential for progression to invasive disease.

METHODS

Articles published between January 2000 and October 2006 were identified using the key words endometrial hyperplasia and progesterone receptor or estrogen receptor or biologic marker or immunohistochemistry/immunohistochemical. Articles that reported immunohistochemical studies on specimens of human EH +/-endometrioid endometrial carcinoma with a normal comparison group were included. Only those who reported hyperplasia with atypia separately from nonatypical hyperplasia and with a sample size greater than 10 specimens for the sum of complex and atypical samples were included.

RESULTS

A total of 289 abstracts were reviewed and 150 articles potentially met inclusion criteria. Of these, 123 described immunohistochemical studies on human EH specimens. Only 46 met all criteria for analysis of 61 different markers.

CONCLUSIONS

PTEN seems to have the greatest potential for diagnostic utility in EH, perhaps in combination with Bcl-2 and Bax. However, more uniform and rigorous studies are required to confirm these and additional markers' utility diagnostically in a diagnostic panel. As a major clinical priority is to determine which lesions can be treated medically and which require surgical intervention, focusing future studies on markers that distinguish response to hormone therapy or are involved in hormone regulation, will be important future considerations.

Subcellular localization and protein levels of cyclin-dependent kinase inhibitor p27 independently predict for survival in epithelial ovarian cancer

PURPOSE

p27 protein is regarded as a valuable prognostic biomarker in cancer with a potential use as a molecular target. However, different methods of immunohistochemical assessment have yielded conflicting results. Here, we sought to determine the prognostic value of p27 in ovarian cancer using a novel method of compartmentalized in situ protein analysis.

EXPERIMENTAL DESIGN

A tissue array composed of 150 advanced stage ovarian cancers uniformly treated, with surgical debulking followed by platinum-paclitaxel combination chemotherapy, was constructed. For evaluation of p27 protein expression, we used an immunofluorescence-based method of automated in situ quantitative measurement of protein analysis [automated quantitative analysis (AQUA)].

RESULTS

The mean follow-up time of the patients was 34.3 months. Patients with low Fédération Internationale des Gynaecologistes et Obstetristes stage were more likely to have low nuclear p27 expression (P = 0.008). Low nuclear p27 expression was associated with improved 3-year overall survival (66% versus 20%, P = 0.0047) and disease-free survival (27% versus 12%, P = 0.022). In multivariable analysis, adjusting for well-characterized prognostic variables, low nuclear p27 expression level was the most significant prognostic factor for both disease-free and overall survival.

CONCLUSIONS

Our results indicate that quantitative assessment of nuclear p27 expression level by automated in situ quantitative analysis is a strong predictor for outcome in ovarian cancer.