Deoxyribonucleic acid analysis facilitates the pretreatment identification of high-risk endometrial cancer patients

Aneuploidy related transcriptional changes in endometrial cancer link low expression of chromosome 15q genes to poor survival

Aneuploidy is a widely studied prognostic marker in endometrial cancer (EC), however, not implemented in clinical decision-making. It lacks validation in large prospective patient cohorts adjusted for currently standard applied prognostic markers, including estrogen/progesterone receptor status (ER/PR). Also, little is known about aneuploidy-related transcriptional alterations, relevant for understanding its role in EC biology, and as therapeutic target.

We included 825 EC patients with available ploidy status and comprehensive clinicopathologic characterization to analyze ploidy as a prognostic marker. For 144 patients, gene expression data were available to explore aneuploidy-related transcriptional alterations.

Aneuploidy was associated with high age, FIGO stage and grade, non-endometrioid histology, ER/PR negativity, and poor survival (p-values<0.001). In patients with ER/PR negative tumors, aneuploidy independently predicted poor survival (p=0.03), lymph node metastasis (p=0.007) and recurrence (p=0.002). A prognostic ‘aneuploidy signature’, linked to low expression of chromosome 15q genes, was identified and validated in TCGA data.

In conclusion, aneuploidy adds prognostic information in ER/PR negative EC, identifying high-risk patients that could benefit from more aggressive therapies. The ‘aneuploidy signature’ equally identifies these aggressive tumors and suggests a link between aneuploidy and low expression of 15q genes. Integrated analyses point at various dysregulated pathways in aneuploid EC, underlining a complex biology.

Flow Cytometric Analysis of DNA Ploidy in Liquid Based Cytology for Cervical Pre-Cancer and Cancer

Background:

DNA ploidy analysis of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer samples by flow cytometry (FCM) has been established as an aid to prognostic assessment. Liquid based cytology (LBC) increases diagnostic specificity by using ancillary techniques that provide information beyond morphology. The present study was undertaken to assess DNA ploidy in LBC samples as an adjunct for early detection of cervical pre-cancer and cancer.

Methods:

DNA ploidy assessment was performed on LBC samples of 50 cases and 31 controls. Cell pellets were obtained by centrifugation and stained with Telford reagent. At least 20,000 R1 gate (G0-G1) events were acquired on a BD FACSCalibur by using a 575±10 nm filter.

Results:

Mean diploid G1 values were lowered significantly (p<0.01) while diploid S values were significantly elevated (p<0.01) in both high grade squamous intraepithelial lesions (HSILs) and squamous cell carcinomas (SCCs) as compared to controls. Receiver operating curve (ROC) analysis of the diploid G1 value was found to have significant diagnostic potential (AUC=0.682, Z=2.00, p=0.046) for distinction between control and low grade squamous intraepithelial lesion (LSIL) at a cut off value of ≤91.6 with a sensitivity and specificity of 50.0 and 87.1%, respectively.

Conclusions:

ROC analysis of diploid G1 and diploid S values allows discrimination between LSIL and HSIL with sensitivities and specificities of 65 and 100% and 70 and100%, respectively, and between LSIL and SCC cases with values of 71.4 and 100% and 64.3 and 100%, respectively.

Prognostic importance of DNA ploidy and DNA index in stage I and II endometrioid adenocarcinoma of the endometrium

BACKGROUND

We evaluated the prognostic importance of DNA ploidy in stage I and II endometrioid adenocarcinoma (EAC) of the endometrium with a focus on DNA index.

PATIENTS AND METHODS

High-resolution DNA ploidy analysis was carried out in tumor material from 937 consecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage I and II EAC of the endometrium.

RESULTS

Patients with diploid (N = 728), aneuploid tumor with DNA index ≤ 1.20 (N = 118), aneuploid tumors with DNA index >1.20 (N = 39) and tetraploid tumor (N = 52) had 5-year recurrence rates 8%, 14%, 20% and 12%, respectively. Patients with aneuploid tumor with DNA index >1.20 had a poorer 5-year progression-free survival (67%) and overall survival (72%) compared with the patients with aneuploid tumor with DNA index ≤ 1.20 (81% and 89%, respectively). Aneuploid tumors with DNA index ≤ 1.20 relapsed mainly in the vagina and pelvis, whereas aneuploid tumors with DNA index >1.20 relapsed predominantly outside pelvis.

CONCLUSIONS

The recurrence risk for the patients with aneuploid tumor is higher than the patients with diploid tumor in EAC of the endometrium. Based on DNA index with cut-off 1.20, aneuploid tumors can be separated into two subgroups with different recurrence pattern and survival.

Ploidy and S-phase fraction are correlated with lymphovascular space invasion that is predictive of outcomes in endometrial cancer

BACKGROUND

Pathological detection of lymphovascular space invasion (LVSI) is a useful prognostic marker for patients with endometrial cancer. However, LVSI is criticized for its subjectivity and poor reproducibility. To improve the outcomes of patients with endometrial cancer, we evaluated objective parameters associated with LVSI to generate more accurate LVSI assessments and to identify patients with high-risk disease.

METHODS

We reviewed the medical records of 137 patients with endometrial cancer. Flow cytometry was used to determine DNA ploidy and S-phase fraction. Estrogen and progesterone receptor (ER and PR) levels and p53 and k-ras mutational status were tested.

RESULTS

LVSI was found in 36 patients (26.3%). Patients with LVSI had significantly decreased recurrence-free survival and overall survival compared to those without LVSI. Aneuploid tumors were significantly more frequent in LVSI-positive patients compared with LVSI-negative patients (odds ratio = 5.208, P < 0.001). With the exception of p53 mutational status, there was a statistically significant relationship between LVSI and other parameters tested. However, by multivariate analysis, DNA ploidy and S-phase fraction were significantly correlated with LVSI (P = 0.034 and 0.001, respectively).

CONCLUSION

Ploidy and S-phase fraction correlate with LVSI, which is a significant independent predictor of clinical outcome in patients with endometrial cancer.

Prognostic significance of DNA ploidy in stage I endometrial cancer

OBJECTIVE

To improve the outcome for patients with endometrial cancer, a more accurate prognostic assessment is needed. The current study was undertaken to determine the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with stage I endometrial cancer and to verify if ploidy is able to identify high-risk cases among the apparent 'low-risk' patients, defined as stage (IA), grade (1 or 2), and histologic type (endometrioid).

METHODS

This was a retrospective study. DNA ploidy was evaluated from tumor samples in 217 patients with stage I endometrial cancer who underwent definitive surgery as the first treatment between 2003 and 2009. Ploidy and other classic parameters were analyzed in relation to the length of recurrence-free survival.

RESULTS

Among the 217 evaluated patients, 184 (84.8%) had diploid tumors and 33 (15.2%) had aneuploid tumors. There were 12 recurrences during the median follow-up intervals of 42.7 months. Stage, grade, histologic type, lymphovascular space invasion (LVSI), and ploidy were significantly correlated with recurrence-free interval by univariate Cox analysis. Based on multivariate Cox analysis, ploidy was an independent prognostic factor, with a hazard ratio of 4.5 (95% confidence interval [CI], 1.3-15.3; P=0.017) adjusted for stage, grade, histologic type, and LVSI. In low-risk patients (n=156), the recurrence rate was 2.1% for diploid tumors and 12.5% for aneuploid tumors (P=0.038).

CONCLUSIONS

DNA aneuploidy is an independent prognostic factor in patients with endometrial cancer and can identify high-risk patients among those considered 'low-risk' with stage I endometrial cancer.

DNA ploidy heterogeneity in endometrial carcinoma: comparison between curettage and hysterectomy specimens

DNA ploidy has been reported to be a prognostic marker for patients with endometrial carcinoma. In this study, DNA ploidy and histologic heterogeneity were evaluated by comparing curettage and hysterectomy specimens in 99 consecutive patients diagnosed with endometrial carcinoma. High-resolution DNA ploidy image analysis and review of histologic specimens were performed. The histologic subtypes were identical in 77 (78%) and differed in 22 (22%) cases. The DNA ploidy results were concordant in the curettage and hysterectomy specimens in 72 (72.7%) and discordant in 27 (27.3%) cases. Histologic heterogeneity was significantly associated with DNA ploidy heterogeneity (P=0.03). On the basis of histologic heterogeneity, DNA ploidy-discordant cases were divided into 2 groups. One group (16.2% of cases) consisted of specimens with similar histology in curettage and hysterectomy, all belonging to the endometrioid subtype. This group showed DNA ploidy discordance because of a DNA diploid peak in 1 specimen and an aneuploid peak (DI=1.05-1.2) in the other. The other group (11.1% of cases) consisted of cases with different histologic subtype or grade and showed a more pronounced DNA ploidy difference (diploid vs. aneuploid with DI>1.2). Our results suggest that the DNA ploidy results of the hysterectomy and curettage specimens are not identical. The difference observed, which we believe reflects the intratumoral heterogeneity, should be taken into account when applying DNA ploidy to endometrial carcinoma specimens.

Deoxyribonucleic acid ploidy in endometrial carcinoma: a reproducible and valid prognostic marker in a routine diagnostic setting

OBJECTIVE

The objective of the study was to investigate the prognostic impact of deoxyribonucleic acid (DNA) ploidy in endometrial carcinoma in a routine diagnostic series as compared with a research series.

STUDY DESIGN

We studied a population-based series of 363 endometrial carcinomas prospectively collected, with long and complete follow-up. The prognostic value of DNA ploidy was investigated in a routine diagnostic series (n=262) and compared with the results from a previous research series (n=101).

RESULTS

The proportion of DNA aneuploid tumors was 21% in the research series and 25% in the routine diagnostic series (P=NS). In both series, DNA aneuploidy was significantly correlated to higher age at diagnosis, nonendometrioid subtype, and high histologic grade. Patients with DNA aneuploid tumors had significantly poorer survival, adjusted for established clinicopathologic prognostic factors.

CONCLUSION

DNA ploidy estimation in endometrial carcinoma adds independent prognostic information in a routine diagnostic setting.

Aneuploidy predicts outcome in patients with endometrial carcinoma and is related to lack of CDH13 hypermethylation

PURPOSE

Many investigators have reported that aneuploidy detected by flow cytometry is a useful prognostic marker in patients with endometrial cancer. Laser scanning cytometry (LSC) is a technology similar to flow cytometry but is more feasible for clinical laboratory use. We evaluated the usefulness of DNA ploidy detected by LSC as a prognostic marker in patients with endometrial cancer and investigated genetic and epigenetic factors related to aneuploidy.

EXPERIMENTAL DESIGN

Endometrial cancer specimens from 106 patients were evaluated. The methylation status of CDH13, Rassf1, SFRP1, SFRP2, SFRP4, SFRP5, p16, hMLH1, MGMT, APC, ATM, and WIF1 and mutations in the p53 and CDC4 genes were investigated. LSC was carried out to determine DNA ploidy. Fluorescence in situ hybridization was done with chromosome-specific centromeric probes to assess chromosomal instability.

RESULTS

Univariate and multivariate analyses revealed that p53 mutation and lack of CDH13 hypermethylation associated positively with aneuploidy. Univariate analysis showed that aneuploidy, chromosomal instability, and lack of CDH13 hypermethylation as well as surgical stage were significantly predictive of death from endometrial cancer. Furthermore, multivariate analysis revealed that stage in combination with either DNA aneuploidy or lack of CDH13 hypermethylation was an independent prognostic factor.

CONCLUSION

These results suggest that analysis of DNA ploidy and methylation status of CDH13 may help predict clinical outcome in patients with endometrial cancer. Prospective randomized trials are needed to confirm the validity of an individualized approach, including determination of tumor ploidy and methylation status of CDH13, to management of endometrial cancer patients.

Ten-year results of a prospective study on the prognostic role of ploidy in endometrial carcinoma

BACKGROUND

To improve the outcome of endometrial cancer patients, a more accurate prognostic assessment is mandatory. The aims of the study were to evaluate the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with endometrial cancer and to verify if ploidy was able to distinguish patients with different prognosis into homogeneous subgroups for grade of differentiation and stage.

METHODS

In a prospective study, DNA ploidy was evaluated from fresh tumor samples in 174 endometrial cancer patients who underwent surgery as the first treatment. Ploidy, as well as classical parameters, were analyzed in relation to the length of disease-free survival and disease-specific survival.

RESULTS

DNA aneuploidy was found in 49 patients (28.2%). Patients with DNA-aneuploid tumors had a significantly reduced disease-free interval and disease-specific survival (P < .0001). The 10-year survival probability was 53.2% for DNA-aneuploid patients and 91.0% for patients with DNA-diploid tumors. By multivariate analysis DNA-aneuploid type was the strongest independent predictor of poor outcome, followed by age and stage. Patients with DNA-aneuploid tumor had a significantly higher risk ratio for recurrence (5.03) and death due to disease (6.50) than patients with DNA-diploid tumors. Stratification by DNA-ploidy within each group by grade of differentiation allowed identification of patients with significantly different outcome. In grade 2 tumors, 10-year survival was 45.0% in aneuploid cases and 91.9% in diploid cases (P < .0001). Patients with advanced-stage (>I) diploid tumor did significantly better than patients with stage I aneuploid tumor (P = .04).

CONCLUSIONS

The presence of DNA-aneuploid type in endometrial cancer identifies high-risk cases among the patients considered 'low risk' according to stage and grade of differentiation.

Endometrial cancer: can nodal status be predicted with curettage?

OBJECTIVE

To determine whether histologic or molecular markers assessed in pretreatment curettage specimens predict nodal metastasis in endometrial cancer.

METHODS

Phenotypic and molecular variables (ploidy, proliferating cell nuclear antigen, MIB-1, p53, HER-2/neu, and bcl-2) were analyzed in preoperative specimens from 82 patients with endometrial cancer who had lymph nodes dissected. These 82 patients had been selected from a total population of 283 patients with endometrial cancer, using a case-cohort design. Weighted logistic regressions were then used to determine significant predictors of positive lymph nodes, and results were estimated for the total population of 283 patients.

RESULTS

Of the overall population, 12% of patients were estimated to have positive lymph nodes. Histologic subtype, p53, and bcl-2 each were significantly correlated (P <0.05) with lymph node status. With application of stepwise logistic regression, p53 was the only independent predictor of lymph node status. In addition, a statistical model predictive of positive lymph nodes was generated which incorporated the risk factors p53, bcl-2, and histologic subtype.

CONCLUSION

In pretreatment curettage specimens, the presence of unfavorable levels of p53 or bcl-2 or of nonendometrioid histologic features, or combinations of those, significantly predicted lymph node status, thus facilitating the preoperative identification of patients at risk of lymph node metastases.

Asian-Pacific Islander race independently predicts poor outcome in patients with endometrial cancer

OBJECTIVE

The Department of Defense health care system provides access to care without respect to age, race, or socioeconomic status. We sought to determine the effect of race as a predictor of survival in patients with endometrial cancer treated in the Department of Defense medical system.

METHODS

Information on patients with endometrial carcinoma was extracted from the Department of Defense centralized tumor registry for the period 1988 to 1995. Data included age at diagnosis, military status, race, tumor histology, grade, FIGO surgical stage, adjuvant therapies, and disease-free survival. The chi(2) test was used for analysis of prognostic factors and adjuvant treatments between racial groups. Actuarial survival curves were calculated by using the method of Kaplan and Meier and compared by the log-rank test. Variables found to be significant on univariate analysis (P < 0.05) were entered into a multivariate Cox regression analysis.

RESULTS

Of 1811 patients meeting criteria for the study, racial distribution was 90% Caucasian, 4.4% African-American, and 5.5% Asian-Pacific Islander. African-Americans had more advanced stages of disease compared to Caucasians (P < 0.001). Both African-Americans and Asian-Pacific Islanders had higher grade tumors and less favorable histologic types than Caucasians (P < 0.05). The extent of adjuvant therapies was similar for racial groups. African-Americans and Asian-Pacific Islanders had significantly worse 5-year disease-free survivals than Caucasians (P = 0.007). Additional poor prognostic factors included age >60 years, grade, unfavorable histology, and stage. On multivariate analysis age >60 years, stage, and Asian-Pacific Islander race remained significant prognostic factors.

CONCLUSION

African-Americans and Asian-Pacific Islanders had worse survivals than Caucasians. After controlling for imbalances in clinicopathologic factors, Asian-Pacific Islander race was found to be a newly identified poor prognostic factor.

Molecular and histopathologic predictors of distant failure in endometrial cancer

A case-cohort study was designed to correlate various histopathologic and molecular variables with distant failure in endometrial cancer by analyzing phenotypic and molecular indices in hysterectomy specimens. From an overall population of 283 patients with endometrial cancer, we selected a cohort including all 49 patients who experienced any recurrence and 76 randomly chosen patients without recurrence. Expression of nuclear proliferating cell nuclear antigen (PCNA), MIB-1 (a marker of cell proliferation), and p53 was determined with digital image analysis, and cell membrane HER-2/neu and bcl-2 were quantitated visually. Ploidy and DNA indices were determined with flow cytometry. Overall, 6 immunohistochemical and 11 flow cytometric cases were eliminated because of technical inadequacies. Distant failures were defined as primary recurrences that developed outside the pelvis or vagina. Median follow-up was 91 months. Distant failures occurred in 13% of the patients. Cervical stromal invasion, positive adnexae, myometrial invasion >50%, positive lymph nodes, positive peritoneal cytology, lymphovascular invasion, grade 3 histology, nonendometrioid subtype, p53 >33%, strong HER-2/neu membranous staining, aneuploidy, S-phase fraction > or =9%, proliferative index > or =14%, and DNA index > or =1.5 significantly (P<0.05) predicted distant failures. However, a logistic regression model identified only p53 (OR=43.73; P<0.005), lymphovascular invasion (OR=11.59; P<0.001), and cervical stromal invasion (OR=11.29; P=0.001) as cogent predictors of distant failures. Only 3% of patients without any of these three predictors developed distant failures compared with 36% of those with at least one of the three (P<0.01). Thus, locoregional therapy may be insufficient when at least one of these predictors is present.

Molecular pathogenesis and prognostic factors in endometrial carcinoma

Endometrial carcinoma is today among the most common gynecologic malignancies in industrialized countries. In order to improve the treatment and follow-up of these patients, various prognostic factors have been extensively studied. Patient age, stage of disease, histologic type and histologic grade have been shown to influence survival significantly, and the prognostic impact of these traditional clinicopathologic variables is well established. In addition, parity, hormone receptor concentration in the tumor, DNA ploidy and morphometric nuclear grade have all been found to influence prognosis. Information about DNA ploidy has especially been used in the clinical situation to determine individualized treatment. The prognostic significance of markers for tumor cell proliferation, cell cycle regulation (p53, p21 and p16) and angiogenesis is discussed as well as the molecular basis of endometrial carcinoma. In conclusion, several prognostic markers have been identified. It is likely that the information derived from these tumor biomarkers will reduce the need for extensive surgical staging and adjuvant treatment in endometrial carcinoma.

Concomitant radiotherapy and paclitaxel for high-risk endometrial cancer: first feasibility study

OBJECTIVE

Postoperative radiotherapy (RT) is the most used adjuvant treatment in high risk endometrial cancer (HREC), and it appears to reduce the incidence of pelvic relapses but doesn't seem to improve survival. Paclitaxel (P) has shown in vitro and clinical activity against endometrial cancer, and it is also a potent radiosensitizer by blocking dividing cells in G2/M phase. This is the first study that verifies the feasibility of a treatment with concomitant weekly chemotherapy and RT to potentially reduce the incidence of local and distant relapses in order to improve survival in HREC.

PATIENTS AND METHODS

Thirteen patients with HREC have entered the feasibility study at San Raphael Hospital University of Milan. All patients underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and surgical staging. Four patients presented stage IC disease, 2 women had IIB stage tumors, 5 patients revealed IIIA stage disease, and 2 had stage IIIC. The patients received P (60 mg./m(2)) via a continuous 1-h infusion once weekly during the 5 weeks of RT (mean radiation dose of 50.4 Gy). At the end of RT three additional consolidation courses of P (80 mg/m(2)) were subministered. Eleven patients received only pelvic irradiation; in 2 cases radiotherapy was performed on an extended field.

RESULTS

Eleven of the 13 enrolled patients have completed the radiochemotherapy regimen. A total of 100 courses of P were performed. All patients completed the RT. Adverse effects were evaluated. Hematological toxicity was mild: four cycles (4%) were delayed 1 week because of grade 1 neutropenia. No severe thrombocytopenia was identified. No hemotrasfusions were performed. One cycle was delayed for fever. Gastrointestinal adverse effects were observed in 2 patients, in which the cycles were delayed 1 week because of diarrhea. One cycle was delayed 1 week because of dermatitis. One patient developed a subocclusion 8 weeks after the end of the treatment, with medical resolution. No patients developed hypersensitivity reactions.

CONCLUSIONS

Concomitant P and RT is safe and acceptable treatment in patients with HREC. Prospective clinical studies are necessary to evaluate the benefits of this regimen for the long-term survival rate.

Pretreatment assessment of prognostic indicators in endometrial cancer

OBJECTIVE

The object of this study was to assess the association of histologic, cytokinetic, and molecular variables in preoperative endometrial samples with extrauterine disease, recurrence, and survival among patients with endometrial cancer.

STUDY DESIGN

In a case-cohort study of 125 women, ploidy, S-phase fraction, proliferative index, deoxyribonucleic acid index, proliferating cell nuclear antigen, MIB-1 proliferation marker, p53 tumor suppressor gene, and cytoplasmic HER-2/neu oncogene and bcl-2 expressions were quantitated.

RESULTS

A model with only one independent term predicted progression-free survival; that variable was p53 (P <. 0001; relative risk, 5.60). A model with two independent terms predicted disease-related survival; these variables were p53 (P =. 0002; relative risk, 7.39) and MIB-1 (P =.03; relative risk, 3.27). Among patients with tumors with both p53 and MIB-1 expression exceeding 33%, a total of 32% had died of disease by 2 years. A model for predicting extrauterine disease selected two independent variables: p53 (odds ratio, 3.20; P =.01) and ploidy (odds ratio, 2. 16; P =.04). An advanced surgical stage was encountered in 26% to 35% of cases in which either the p53 expression exceeded 33% or the deoxyribonucleic acid content was nondiploid and in 53% of cases in which both variables were unfavorable.

CONCLUSIONS

Preoperative evaluation of quantifiable cytokinetic and molecular variables can assist in identifying tumor types that are predisposed toward a more aggressive clinical course.

Low-risk corpus cancer: is lymphadenectomy or radiotherapy necessary?

OBJECTIVE

The objective of this study was to find readily ascertainable intraoperative pathologic indicators that would discriminate a subgroup of early corpus cancers that would not require lymphadenectomy or adjuvant radiotherapy.

STUDY DESIGN

Between 1984 and 1993, a total of 328 patients with endometrioid corpus cancer, grade 1 or 2 tumor, myometrial invasion < or =50%, and no intraoperative evidence of macroscopic extrauterine spread were treated surgically. Pelvic lymphadenectomy was performed in 187 cases (57%), and nodes were positive in nine cases (5%). Adjuvant radiotherapy was administered to 65 patients (20%). Median follow-up was 88 months.

RESULTS

The 5-year overall cancer-related and recurrence-free survivals were 97% and 96%, respectively. Primary tumor diameter and lymphatic or vascular invasion significantly affected longevity. No patient with tumor diameter < or =2 cm had positive lymph nodes or died of disease.

CONCLUSION

Patients who have International Federation of Gynecology and Obstetrics grade 1 or 2 endometrioid corpus cancer with greatest surface dimension < or =2 cm, myometrial invasion < or =50%, and no intraoperative evidence of macroscopic disease can be treated optimally with hysterectomy only.

Molecular and cytokinetic pretreatment risk assessment in endometrial carcinoma

OBJECTIVE

Our objective was to determine whether cytokinetic and molecular analyses of curettage specimens can provide a mechanism for triage of patients with endometrial cancer before initiating definitive surgical treatment.

METHODS

Pretreatment analysis consisted of flow cytometric determination of ploidy, S-phase fraction (SPF), and proliferative index (PI) and immunohistochemical determination of expression of proliferating cell nuclear antigen, HER-2/neu, and p53 in curettage specimens from 134 patients with endometrial carcinoma who subsequently had surgical staging and definitive surgical treatment. Fisher's exact test or chi(2) was used to examine the association between pretreatment variables and traditional surgical-pathologic indices. The log-rank test was used for univariate survival analysis. Cox proportional hazards identified the most important molecular factors.

RESULTS

Nondiploid status, SPF >/=9%, and PI >/=14% were associated with the traditional posttreatment prognostic indices, stage, grade, and histologic subtype. Univariate survival analysis demonstrated a correlation between nondiploid status, SPF >/=9%, PI >/=14%, and p53 overexpression and decreased progression-free survival (PFS) and disease-related survival (DRS). Stepwise Cox regression analysis identified p53 overexpression and SPF >/=9% as the most significant pretreatment molecular risk factors. A model stratifying patients according to whether none, one, or both of these two pretreatment factors were present showed that when both factors are present the risk for recurrence was higher (RR = 7.07; 95% confidence interval [CI], 3.06-16.38; P < 0.01) and death due to disease was higher (RR = 9.93; 95% CI, 3.92-25.19; P < 0.01) than when no factors are present. In the group with both factors, 5-year PFS and DRS estimates were 41 and 44%, respectively, compared with 86 and 86% and 90 and 92% for the "none" and "one" groups, respectively.

CONCLUSION

When observed simultaneously, increased SPF and p53 overexpression defined a group of patients at high risk for rapid recurrence and death due to disease. Pretreatment molecular analysis of curettage specimens could provide a mechanism of triage that could be applied before definitive surgical treatment.

Preoperative evaluation of tumor ploidy in endometrial carcinoma: An accurate tool to identify patients at risk for extrauterine disease and recurrence

BACKGROUND

Tumor ploidy is a strong prognostic factor in patients with endometrial carcinoma, but generally is evaluated only after surgery. The availability of a simple and reliable method to determine tumor ploidy before any treatment is initiated could be helpful in the selection of patients at high risk for advanced primary disease and subsequent recurrence, with several possible benefits. The objectives of the current study were: 1) to test the accuracy of flow cytometric determination of tumor ploidy from preoperative outpatient endometrial biopsies compared with standard postoperative evaluation from the surgical specimen and 2) to correlate this preoperative parameter with the local recurrence and extrauterine tumor spread.

METHODS

Tumor ploidy from both preoperative biopsy material and the macroscopic surgical specimens was evaluated prospectively in 50 consecutive patients with endometrial carcinoma. DNA analyses were performed in a blind fashion. Patients were followed for a median of 26 months (range, 16-46 months).

RESULTS

In 9 of 50 cases (18%) an aneuploid tumor was found by the standard postoperative analysis. All 9 aneuploid tumors (100%) also were identified correctly by the preoperative test on biopsy material. Occult extrauterine tumor spread was found in 10 patients (20%). The incidence rate of aneuploidy among these tumors was 50% compared with 10% in surgical International Federation of Gynecology and Obstetrics Stage I tumors (P = 0.01). The recurrence rate was 55.5% (5 of 9 tumors) in the aneuploid group and 2.4% (1 of 41 tumors) in the diploid group (P < 0.001). The disease free survival rates of patients with diploid and aneuploid tumors were 97.5% and 44.4%, respectively (P < 0.0001).

CONCLUSIONS

Preoperative tumor ploidy determination based on outpatient endometrial biopsy is as accurate as the standard postoperative evaluation in patients with endometrial carcinoma. Tumor aneuploidy confirms the usefulness of this method in selecting patients at risk for occult extrauterine tumor diffusion and recurrence.

Prognostic significance of DNA ploidy in endometrial cancer

OBJECTIVE

The aim of this study was to analyze the prognostic significance of DNA ploidy in patients with endometrial cancer.

METHODS

Between October 1988 and January 1997, DNA ploidy was determined prospectively in 208 women who were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy. Median follow-up was 48 months.

RESULTS

Diploid tumors were identified in 154 (74%) patients and aneuploid tumors in 54 (26%). Patients with aneuploid tumors had a significantly higher prevalence of metastases to the cervix, adnexa, and omentum, malignant pelvic cytology, and advanced surgical stage. Patients with aneuploid tumors had a 4.5 times higher prevalence of pelvic lymph node metastases and a 5.8 times higher prevalence of para-aortic lymph node metastases. A significantly higher proportion of patients with aneuploid tumors was diagnosed with recurrent or progressive endometrial cancer (22.2 versus 6.5%, P = 0.002). Patients with aneuploid tumors had a significantly lower rate of survival from cancer death (P = 0.038) with 83% versus 94% surviving 5 years.

CONCLUSION

Patients with aneuploid tumors are at high risk for lymph node metastases and should be surgically staged, including pelvic and para-aortic lymphadenectomy. Aneuploidy confers a risk for endometrial cancer death and these patients should be candidates for clinical trials evaluating treatment following surgery.

Prognostic significance of angiogenesis and Ki-67, p53, and p21 expression: a population-based endometrial carcinoma study

PURPOSE

For endometrial carcinoma patients, there is a need for improved identification of high-risk groups that may benefit from postoperative adjuvant therapy. We therefore studied the prognostic impact of markers for cell proliferation, cell-cycle regulation, and angiogenesis among endometrial carcinoma patients in a population-based setting.

PATIENTS AND METHODS

All patients diagnosed with endometrial carcinoma between 1981 and 1985 in Hordaland County, Norway, were studied. The median follow-up for the survivors was 11.5 years (range, 8 to 15 years), with no patient lost because of insufficient follow-up information. Paraffin-embedded tumor tissue, available in 96% of the cases (n = 142), was studied immunohistochemically for microvessel density (MVD) and expression of Ki-67, p53, and p21 proteins. We used the hot spot method for calculation of MVD, and expression of Ki-67 and p21 protein, because this approach may increase the probability of detecting small aggressive clones of possible prognostic relevance. The importance of these tumor markers was investigated in univariate survival analyses and Cox regression analysis.

RESULTS

The majority of traditional clinicopathologic variables was significantly associated with the tumor biomarkers. Age, International Federation of Gynecology and Obstetrics (FIGO) stage, histologic type, histologic grade, MVD, as well as Ki-67, p53, and p21 protein expression, all significantly influenced survival in univariate analyses (P < or = .05). In the Cox regression analysis, age, FIGO stage, MVD, Ki-67 expression, and p53 expression were the only variables with independent prognostic impact (P < or = .05), whereas histologic type, histologic grade, and p21 expression had no independent influence. A group of high-risk patients with more than one unfavorable marker was identified.

CONCLUSION

In addition to age and FIGO stage, MVD, Ki-67, and p53 protein expression showed an independent prognostic impact. Thus, information derived from routine histologic specimens identified a subgroup of high-risk endometrial carcinoma patients in this population-based study.

Relations between various DNA-parameters and degree of malignancy in endometrial carcinoma

120 imprint-cytology specimens obtained from standardized areas of 20 endometrial carcinomas were investigated by use of a computed-controlled image analysis system to determine special quantitative DNA-parameters. The stem line ploidy, the 2c deviation index (2cDI), the DNA-associated graduation of malignancy (DNA-MG) as well as the 5c exceeding rate (5cER) were calculated for each preparation. 85% of the imprint-cytology preparations had diploid stem lines, and aneuploidy was found in 15%. There were statistically significant correlations between the DNA-MG, the 5cER and the stem line ploidy as well as between the DNA-MG and the 5cER. The sensitivity of the 5cER was 76.6% in our study and so we cannot regard this parameter as prouding accurate information about tumor malignancy in endometrial carcinoma. Special DNA-parameters defined mathematically should be utilized for objective grading of tumor malignancy.

Molecular basis of endometrial cancer

BACKGROUND

Most human cancers are thought to arise from alterations in oncogenes and tumor suppressor genes.

METHODS

Molecular techniques have been used to identify specific genetic alterations in endometrial cancers.

RESULTS

Overexpression of the HER-2/neu oncogene occurs in 10% of endometrial cancers and correlates with poor survival. Alterations in other receptor tyrosine kinases (c-fms and epidermal growth factor receptor) also occur in some cases. The c-myc oncogene, which encodes a nuclear transcription factor, also may be overexpressed in some invasive cancers. Mutations in the K-ras oncogene occur in 10% and in 20-30% of American and Japanese endometrial cancers, respectively. K-ras mutations also have been observed in endometrial hyperplasias, and this may represent an early event in the development of some cancers. Mutation of the p53 tumor suppressor gene, with resultant overexpression of mutant p53 protein, occurs in 20% of endometrial adenocarcinomas. Overexpression of p53 is associated with advanced stage and poor survival. Because p53 mutations do not occur frequently in endometrial hyperplasias, this may be a relatively late event in endometrial carcinogenesis. Recent studies have shown that mutations occur in microsatellite sequences in some endometrial cancers. Because microsatellite instability in hereditary nonpolyposis colon cancer has been found to be caused by mutations in DNA repair genes, similar mutations are being sought in endometrial cancers.

CONCLUSIONS

Although several molecular alterations have been identified, the molecular pathogenesis of endometrial cancer remains poorly understood.

Multivariable analysis of DNA ploidy, p53, and HER-2/neu as prognostic factors in endometrial cancer

BACKGROUND

Several molecular-genetic alterations in endometrial cancers, including aneuploidy and aberrant expression of p53 and HER-2/neu, have been associated with poor prognosis. To determine the importance of molecular-genetic factors relative to more traditional surgical-pathologic prognostic factors, a multivariable analysis was performed.

METHODS

Immunohistochemical staining for p53, HER-2/neu, estrogen receptor, progesterone receptor, and epidermal growth factor receptor was performed on frozen sections from 100 primary endometrial cancers. DNA ploidy was determined using computerized image analysis of Feulgen-stained touch preparations. In addition, information regarding surgical-pathologic features of the cancers was obtained. Univariable analysis was performed followed by multivariable analysis using Cox's proportional hazards model to identify variables predictive of poor prognosis.

RESULTS

With univariable analysis, race, histologic type, stage, grade, myometrial invasion, estrogen receptor, progesterone receptor, ploidy, p53 and HER-2/neu were predictive of the presence of persistent or recurrent disease. In the multivariable analysis, only International Federation of Gynecology and Obstetrics stage (P = 0.005), grade (P = 0.005), myometrial invasion (P = 0.024), and ploidy (P = 0.028) were significant.

CONCLUSIONS

Among molecular-genetic prognostic factors, DNA ploidy was the most strongly predictive of persistent or recurrent disease.