NEU protein overexpression in benign, borderline, and malignant ovarian neoplasms

Predicting Response to Anthracyclines in Ovarian Cancer

(1) Background: Anthracyclines are intriguing drugs, representing one of the cornerstones of both first and subsequent-lines of chemotherapy in ovarian cancer (OC). Their efficacy and mechanisms of action are related to the hot topics of OC clinical research, such as BRCA status and immunotherapy. Prediction of response to anthracyclines is challenging and no markers can predict certain therapeutic success. The current narrative review provides a summary of the clinical and biological mechanisms involved in the response to anthracyclines. (2) Methods: A MEDLINE search of the literature was performed, focusing on papers published in the last two decades. (3) Results and Conclusions: BRCA mutated tumors seem to show a higher response to anthracyclines compared to sporadic tumors and the severity of hand-foot syndrome and mucositis may be a predictive marker of PLD efficacy. CA125 can be a misleading marker of clinical response during treatment with anthracyclines, the response of which also appears to depend on OC histology. Immunochemistry, in particular HER-2 expression, could be of some help in predicting the response to such drugs, and high levels of mutated p53 appear after exposure to anthracyclines and impair their antitumor effect. Finally, organoids from OC are promising for drug testing and prediction of response to chemotherapy.

EGFR/HER-targeted therapeutics in ovarian cancer

Despite decades of research and evolving treatment modalities, survival among patients with epithelial ovarian cancer has improved only incrementally. During this same period, the development of biologically targeted therapeutics has improved survival for patients with diverse malignancies. Many of these new drugs target the human epidermal growth factor receptor (EGFR/HER/ErbB) family of tyrosine kinases, which play a major role in the etiology and progression of many carcinomas, including epithelial ovarian cancer. While several HER-targeted therapeutics are US FDA approved for the treatment of various malignancies, none have gained approval for the treatment of ovarian cancer. Here, we review the published literature on HER-targeted therapeutics for the treatment of ovarian cancer, including novel HER-targeted therapeutics in various stages of clinical development, as well as the challenges that have limited the use of these inhibitors in clinical settings.

Associations between ERBB2 amplification and progression-free survival and overall survival in advanced stage, suboptimally-resected epithelial ovarian cancers: a Gynecologic Oncology Group Study

OBJECTIVE(S)

The Gynecologic Oncology Group (GOG) examined the association between ERBB2 amplification and clinical covariates, tumor response, disease status post-chemotherapy, progression-free survival (PFS), and overall survival (OS) in epithelial ovarian cancer (EOC).

METHODS

Women with suboptimally-resected, advanced stage EOC who participated in GOG-111, a multi-center randomized phase III trial of cyclophosphamide+cisplatin versus paclitaxel+cisplatin, and provided a tumor block through the companion protocol GOG-9404 were eligible. ERBB2 amplification was examined using fluorescence in situ hybridization (FISH) with probes for ERBB2 and the centromere of chromosome 17 (CEP17).

RESULTS

ERBB2 amplification, defined as >2 copies of ERBB2/CEP17, was a rare event in EOC with 7% (9/133) of women exhibiting between 2.2 and 33.7 copies of ERBB2/CEP17, and was not associated with patient age, race, GOG performance status, stage, cell type, grade, measurable disease status, volume of ascites, tumor response or disease status post-chemotherapy. Women with >2 verses < or =2 copies of ERBB2/CEP17 did not have a reduced risk of disease progression (hazard ratio [HR]=0.56; 95% confidence interval [CI]=0.27-1.16; p=0.120) or death (HR=0.57; 95% CI=0.26-1.23; p=0.152), and ERBB2 amplification was not an independent prognostic factor for PFS or OS. ERBB2 amplification, defined as >4 copies of ERBB2/nuclei, was observed in 9% (12/133) of women with levels ranging from 4.2 to 49.2 copies of ERBB2/nuclei, and was associated with older age and volume of ascites, but not with the other clinical covariates or outcome.

CONCLUSION(S)

ERBB2 amplification is a rare event and has no predictive or prognostic value in suboptimally-resected, advanced stage EOC treated with platinum-based combination chemotherapy.

In-labeled KCCYSL peptide as an imaging probe for ErbB-2-expressing ovarian carcinomas

Aberrant expression of ErbB-2, a member of the epidermal growth factor family of receptors, has been implicated in the formation of various malignancies including ovarian cancer. The objective of this study was to determine if the bacteriophage (phage) display-selected ErbB-2 targeting peptide, KCCYSL, once radiolabeled with (111)In would serve as a tumor targeting and Single Photon Emission Computed Tomography (SPECT/CT) imaging agent in a mouse model of human ovarian carcinoma expressing ErbB-2. The KCCYSL peptide was synthesized with a chelator 1,4,7,10-tetra-azacyclododecane-N,N',N",N"'-tetraacetic acid (DOTA), and a Gly-Ser-Gly (GSG) spacer between DOTA and amino terminus of the peptide and radiolabeled with (111)InC1(3). In vitro cell binding studies indicated that (111)In-DOTA-GSG-KCCYSL bound to cultured ovcar-3 carcinoma cells. Biodistribution studies in scid mice bearing human ovcar-3 tumor xenografts revealed a tumor uptake of 0.50 ± 0.05 percent injected dose per gram (%ID/g) at 1 h, and 0.39 ± 0.1 %ID/g at 2 h. Blocking studies with non-radiolabeled counterpart indicated a partial inhibition (41%) (P = 0.04) in tumor uptake of (111)In-DOTA-GSG-KCCYSL. In vivo tumor uptake of (111)In-DOTA-GSG-KCCYSL was clearly evident through SPECT/CT images after 2 h post injection. These studies suggest the potential of this peptide as a radiopharmaceutical for imaging of ErbB-2-expressing ovarian tumors.

Clinical implications of the ErbB/epidermal growth factor (EGF) receptor family and its ligands in ovarian cancer

The ERBB or EGF receptor (EGFR) proto-oncogene family, which consists of four structurally-related transmembrane receptors (i.e., EGFR, ErbB2, ErbB3, and ErbB4), plays an etiological role in the molecular pathogenesis of cancer and is a key therapeutic target in many types of cancer, including ovarian cancer. These ErbB/EGF receptor tyrosine kinases play important physiologic roles in cell proliferation, survival, adhesion, motility, invasion, and angiogenesis. It is, therefore, not surprising that gene amplification, genetic mutation, and altered transcription/translation result in aberrant ErbB/EGF receptor expression and/or signal transduction, contributing to the development of malignant transformation. Clinically, the diagnostic, prognostic, and theragnostic significance of any single ErbB receptor and/or ErbB ligand is controversial, but generally, ErbB receptor overexpression has been correlated with poor prognosis and decreased therapeutic responsiveness in ovarian cancer patients. Thus, anticancer agents targeting ErbB/EGF receptors hold great promise for personalized cancer treatment. Yet, challenges remain in designing prospective clinical trials to assess the clinical utility of ErbB receptors and their ligands to diagnose cancer; to predict progression-free and overall survival, therapeutic responsiveness, and disease recurrence; and to monitor treatment responsiveness. Here, we review the tissue expression and serum biomarker studies that have evaluated the diagnostic, prognostic, and theragnostic utility of ErbB/EGF receptors, their circulating soluble isoforms (sEGFR/sErbBs), and their cognate ligands in ovarian cancer patients.

Prognostic, predictive and therapeutic implications of HER2 in invasive epithelial ovarian cancer

The HER2 oncogene encodes a transmembrane protein partially homologous to epidermal growth factor receptor. This oncogene has been studied mainly in breast cancer where it has prognostic, predictive and therapeutic target value. The expression of HER2 in epithelial ovarian cancer has been less studied. HER2 expression can be determined through IHC, FISH, CISH and ELISA among other tests, with reported positivity frequencies of overexpression varying from 1.8% to 76%. In some studies HER2 overexpression has been associated with advanced stages, poorly differentiated tumors, resistance to chemotherapy and shortened survival. Although trastuzumab is able to produce a low response rate as a single agent in pretreated ovarian cancer patients with overexpression of HER2, its usefulness is limited due to the low frequency of strong expression. To date there is not enough bases for assessment and HER2-based therapies in epithelial ovarian cancer.

Conservative surgery for borderline ovarian tumors: a review

OBJECTIVE

Borderline tumor of the ovary is an epithelial tumor with a low rate of growth and a low potential to invade or metastasize. This review will outline the most recent information regarding the molecular pathogenesis, pathology, fertility and tumor recurrence rate after conservative management of young women with early-stage borderline ovarian tumors.

METHODS

We performed a MEDLINE literature search of relevant clinical trials for the scope of this review that evaluated conservative treatment of borderline ovarian tumors for young women with low-stage disease who wish to preserve their fertility.

RESULTS

Recently, investigators have begun to identify subsets of patients with a worse prognosis, such as patients with aneuploid tumors. A number of oncogenes are under investigation to determine their role in the pathogenesis of borderline ovarian tumors. Previous studies have suggested the safety of conservative surgery with unilateral salpingo-oophorectomy or cystectomy for patients with stage I borderline ovarian tumors. Laparoscopic treatment of adnexal masses has proved to be a safe and effective diagnostic and therapeutic tool in the hands of experienced laparoscopists. For women who are treated conservatively, follow-up is important. Surgery remains the most effective therapy for later stage lesions. Adjuvant therapy for advanced stage of borderline ovarian tumors remains controversial.

CONCLUSION

Conservative management of borderline ovarian tumors is an appropriate therapeutic option for young women with early-stage lesions who wish to preserve their childbearing potential. Available data indicate that in these patients fertility, pregnancy outcome and survival remain excellent.

TP53 status determines clinical significance of ERBB2 expression in ovarian cancer

ERBB2 expression has been found in 19 to 44% of ovarian carcinomas; however, its predictive value has not been demonstrated, and trastuzumab has not found clinical application in ovarian cancer patients. We evaluated clinical significance of ERBB2 expression in relation to TP53 accumulation in ovarian carcinoma patients treated with platinum-based regimens. Immunohistochemical analysis with CB11 and a novel NCL-CBE356 antibody (against the internal and external domains of ERBB2, respectively) was performed on 233 tumours (FIGO stage IIB—IV); the US Food and Drug Administration-approved grading system with 0 to 3+ scale was used for evaluation, and the results were analysed by the Cox and logistic regression models. In all, 42% of the tumours expressed (category 1+, 2+ or 3+) either CB11 or CBE356 or both (CB11/CBE356 parameter). Associations between ERBB2 expression and clinical factors were observed only if tumours with staining category 1+ were grouped together with tumours showing staining categories 2+ and 3+. CB11/CBE356 parameter had a better predictive value than CB11 alone. CB11/CBE356 expression was negatively associated with platinum sensitivity (PS) in the TP53(−) group (P=0.022) and with disease-free survival (DFS) in the TP53(+) group (P=0.009). Our results may suggest that trastuzumab should be given postoperatively to patients with TP53(−)/ERBB2(+) ovarian carcinomas to enhance PS, and after completion of chemotherapy to patients with complete remission and TP53(+)/ERBB2(+) carcinomas to extend DFS time (in total to 30.4% of all patients analysed). Thus, novel criteria for ovarian cancer patient inclusion for clinical trials with trastuzumab should be considered and tested.

HER-2 and cancer antigen 125 evaluation in ovarian borderline tumors by immunohistochemistry and fluorescence in situ hybridization

The study determined the expression of cancer antigen (CA) 125 and HER-2 in 45 borderline ovarian tumors (BOTs) and investigated the correlation of these biologic markers with histologic type, clinical stage, and outcome. The level of CA 125 protein was assessed using DAKO's M-11 clone antibody in immunohistochemistry (IHC) assays (Carpinteria, CA). The HER-2 protein expression was assessed in IHC assays using the HercepTest (DAKO), and the HER-2 gene copy number per cell was investigated through fluorescence in situ hybridization (FISH) assays using VYSIS' PathVysion DNA Probe (Downers Grove, IL). Expression of the CA 125 protein was detected in 49% of the samples (22 out of 45 tumors) and significantly associated with the serous histologic type. However, CA 125 expression did not associate with clinical stage or outcome. Protein overexpression or gene amplification of HER-2 was not found. However, abnormal FISH results were detected in 16% (seven out of 45 patients) of specimens comprising extranumerary copies of HER-2 and/or chromosome 17 per cell. Abnormal FISH results were found to be independent of CA 125 expression and histologic type whereas they positively associate with advanced clinical stage. Our data show that HER-2 is not altered in BOTs, and the presence of aneusomy for chromosome 17 and HER-2 may predict tumor progression.

Overexpression of HER-2/neu is not a risk factor in ovarian clear cell adenocarcinoma

OBJECTIVE

To evaluate the significance of the expression of HER-2/neu as a prognostic factor, we retrospectively examined its overexpression rates chiefly in ovarian clear cell adenocarcinoma (CCA) and their relationships with FIGO stage, lymph node metastasis, and prognosis.

METHODS

In addition to 90 specimens of CCA (stage I, 52; stage II, 7; stage III, 28; stage IV, 3) obtained between 1987 and 2002, 19 specimens of serous adenocarcinoma (S), 19 specimens of mucinous adenocarcinoma (M), and 19 specimens of endometrioid adenocarcinoma (E) collected at initial surgery were studied. The expression of HER-2/neu was immunohistologically scored on a scale of 0 to 3+ according to the HercepTest scoring system, and 2+ and 3+ were regarded as overexpression. The relationship between HER-2/neu overexpression and outcome was evaluated by the Kaplan-Meier method and the log-rank test. The relationship with advanced-stage cancer was analyzed by Fisher's exact test. The relationships with lymph node metastasis and histologic types were compared by the t test.

RESULTS

The rate of HER-2/neu overexpression in CCA was 45.6% (0, 1+, 2+, and 3+ in 14, 35, 36, and 5 cases, respectively), and no differences in the overexpression rate were noted among histologic types: 52.7% in S, 42.1% in M, and 26.4% in E. In CCA, no association was observed between HER-2/neu overexpression and cumulative survival rate (P = 0.5708), FIGO stage (P = 0.5147), or lymph node metastasis (P = 0.3624).

CONCLUSION

The absence in CCA of an association between HER-2/neu overexpression and outcome, stage, or lymph node metastasis indicates that HER-2/neu overexpression is not a prognostic risk factor.

Pathophysiological Dynamics of Human Ovarian Surface Epithelial Cells in Epithelial Ovarian Carcinogenesis

Epithelial ovarian cancer is responsible for almost half of all the deaths from female genital tract tumors. Major impediments to the clinical treatment of this disease are the relatively asymptomatic progression and a lack of knowledge regarding defined precursor or malignant lesions. Most epithelial ovarian cancers are thought to arise from the transformation of ovarian surface epithelial cells, a single continuous layer of flat-to-cuboidal mesothelial cells surrounding the ovary. To improve our understanding of the pathogenesis of epithelial ovarian cancer, it is necessary to study the biological characteristics of normal ovarian surface epithelial cells. However, this approach has been hampered by the inability to purify and culture such human cells. During the past decade, procedures to isolate and culture human ovarian surface epithelial cells have been developed, and, subsequently, using viral oncogenes, several immortalized cells have been established. This new experimental system is being employed to improve our understanding of the genetic changes leading to the initiation of epithelial ovarian cancer and to identify events in the cancer's development. This review mainly describes the biological dynamics of ovarian surface epithelial cells in the pathogenesis of epithelial ovarian cancer, focusing on humans and excluding small animal models.

Molecular similarities between primary peritoneal and primary ovarian carcinomas

The objective of this paper was to characterize expression patterns of biologic markers to distinguish papillary serous peritoneal carcinoma (PPC) from papillary serous ovarian carcinoma (POC). Immunohistochemical analysis of HER-2/neu, p53, bcl-2, and nm23-H1 expression was performed on archival paraffin-embedded tissues. Antigen expression was compared at ovarian and extra-ovarian sites. Thirty-two PPC cases were compared to 18 POC cases. Mean age, stage, grade, and survival outcome were comparable between the two groups. Antigen expression patterns were not significantly different between PPC and POC for the four markers studied. In all cases, nm23-H1 was expressed. Conversely, bcl-2 was expressed at only a single tissue site in three of 32 (9.4%) PPC cases and in one of 18 (5.6%) POC cases. Eleven of 32 (34.4%) PPC cases overexpressed HER-2/neu, vs. four of 18 (22.2%) POC cases. P53 staining results were positive in 23 of 32 (71.9%) PPC and 13 of 18 (72.2%) POC cases. Intrapatient antigen expression was identical at primary and metastatic tumor sites in 50% of the POC and 48.4% of the PPC cases. We conclude that PPC and POC have a comparable immunohistochemical phenotype for these four molecular markers, which is reflected by their similar clinical courses.

Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators

BACKGROUND

The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.

METHODS

245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."

RESULTS

Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.

CONCLUSION

Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."

Expression and function of EGF-related peptides and their receptors in gynecological cancer--from basic science to therapy

EGF-related peptides and their receptors play an important, but not fully understood role, both, in epithelial physiology and pathophysiology but also in human tumor carcinogenesis and tumor behavior, respectively. Overexpression of EGF-related growth factors from normal epithelium to carcinomas has been demonstrated for several human tissues such as breast, endometrium, cervix and ovary. Additionally, the differential overexpression of EGFR or erb B-2 in various malignancies has already proven to be efficacious in stratifying patients with respect to a poor prognosis. These data suggest that EGF-related growth factors, erb B receptors or signaling proteins that function either upstream or downstream from these receptors may represent novel targets for selective tumor therapy. In the future, conventional chemotherapy regimes will ultimately be wedded to more biologically-oriented therapies. One important target for these novel therapeutic approaches in solid tumors will be the EGF-related growth factors and their receptors.

Borderline tumors of the ovary: a clinico-pathologic and immunohistochemical study of 54 cases

OBJECTIVE

To study EGF-R, HER-2/neu (p185), p53, Mib-1 (Ki-67), Bax, Bcl-2, ras expression and ploidy in borderline tumors of the ovary by assessing their frequency, and relationship to histologic type, tumor recurrence and survival.

METHODS

Fifty-four patients with borderline tumors were followed 3-140 months (median: 38 months). Paraffin-embedded sections were stained using monoclonal antibodies against EGF-R, HER-2/neu (p185), p53, Mib-1 (Ki-67), Bax, Bcl-2, and ras. The immunohistochemical findings were correlated to histologic subtype, tumor recurrence, and survival.

RESULTS

Positivity for EGF-R was found in 24% (13/54), in 22% (12/54) p185 was positive, 9% (5/54) of tumors were p53-positive, Mib-1 (Ki-67)-positivity was demonstrable in 46% (25/54). Expression of Bax, Bcl-2, and ras was found in 37% (20/54), 28% (15/54) and in 7% (4/54) of the cases, respectively.

CONCLUSION

The data demonstrate expression of EGF-R, p185/HER-2/neu, p53, Mib-1 (Ki-67), Bax, Bcl-2, and ras in a subgroup of patients with ovarian borderline tumors. Further studies to evaluate their prognostic value are warranted.

c-erbB-2 oncoprotein assay in ovarian carcinoma and its clinical correlation with prognostic factors

Overexpression of the c-erbB-2 oncoprotein has been detected in human adenocarcinoma of the breast, cervix and salivary gland, in all of which an association between the overexpression of the c-erbB-2 and a poor prognosis of the disease has been reported. However, the prognostic role of c-erbB-2 oncoprotein in ovarian carcinoma remains controversial. We measured c-erbB-2 oncoprotein with an enzyme-linked immunosorbent assay (ELISA). Patients with invasive ovarian cancer were found to have significantly higher median c-erbB-2 oncoprotein expression than patients with either benign ovarian cyst (P = 0.002) or control groups (P = 0.001). Overexpression of c-erbB-2 oncoprotein was found in seven (21.9%) of 32 epithelial ovarian cancers. Our results suggest that quantitative analysis of c-erbB-2 oncoprotein may be used to define the prognostic significance of ovarian carcinoma.

Coexpression of the HER-2 gene product, p185HER-2, and epidermal growth factor receptor, p170EGF-R, on epithelial ovarian cancers and normal tissues

Monoclonal antibodies (MAbs) and immunoconjugates reactive with different antigens expressed by neoplastic cells can inhibit tumor growth. Use of these agents in combination with one another or with chemotherapy can exert additive or synergistic cytotoxicity against tumor cells. An augmented therapeutic activity with favorable therapeutic index might be attained when coexpression is observed on tumor cells, but not in normal tissues. In this study frozen sections of 19 ovarian cancers (2 stage I, 10 stage III, 2 stage IV, and 5 recurrent), as well as 29 normal tissues, were evaluated by immunohistochemistry using 11 distinct MAbs against HER-2/p185 and 2 antibodies against EGF-R/p170 to assess coexpression of these receptors. HER-2/p185 expression was detected in 5 to 100% of ovarian cancers and 0 to 50% of normal ovarian epithelia, depending on the antibody used. EGF-R/p170 expression was detected in approximately 70% of cancers and 40% of normal ovaries by both antibodies. Coexpression of p185 and p170 was observed in 47-68% of ovarian cancers and 9-18% of normal ovarian epithelial specimens depending upon the combination of antibodies used. Staining of 273 specimens from 29 normal tissues indicated that coexpression of HER-2 and EGF-R is rare. Normal tissues that coexpressed both receptors in > or =50% of the cases included cervix, endometrium, esophagus, skin, and prostate. These data confirm that HER-2 and EGF-R are more frequently expressed in advanced ovarian cancers than in normal ovarian epithelium and a significant fraction of these tumors coexpress both HER-2 and EGF-R.

Histopathology and molecular biology of ovarian epithelial tumors

Carcinogenesis in the ovary presents special features related to that organ. First, the preinvasive or even invasive lesions are difficult to detect, which explains why most cases are diagnosed at an advanced stage. Second, the group of tumors of low malignant potential (borderline tumors) are still a controversial category of ovarian lesions. Finally, familial ovarian tumors represent an interesting hereditary model of carcinogenesis at the molecular level. Flow cytometry and immunohistochemistry for proliferative markers or oncogenes provide important prognostic information in patients with ovarian tumors. Molecular data, such as loss of heterozygosity at specific genetic loci, also have been correlated with prognosis. Clonality studies in patients with multiple ovarian/pelvian lesions analyzing chromosome X inactivation patterns and genetic deletions or mutations have contributed to the understanding of the origin of these lesions. New technologies to study gene expression patterns, such as cDNA library construction and DNA microarray technologies, are being applied to study histologic phases of tumor progression, such as normal, preinvasive, and tumor tissues. It is hoped that these studies will contribute important information not only for a better understanding of the process of carcinogenesis, but also for assessing the biology and behavior of individual tumors, determining patient prognosis, and eventually influencing therapy.

Human ovarian cancer of the surface epithelium

Epidemiologic studies have shown that the risk of cancer in the ovarian surface epithelium is decreased by factors that suppress ovulation, whereas uninterrupted ovulation has been associated with increased risk. This suggests that ovulation may play a critical role in ovarian carcinogenesis. More recently, molecular studies have demonstrated alterations in specific oncogenes and tumor suppressor genes in ovarian cancers. Overexpression of the HER-2/neu oncogene occurs in approximately 30% of ovarian cancers and correlates with poor survival. Although mutation of the K-ras oncogene has been found in some mucinous ovarian cancers, mutations in this gene appear to be more common in borderline ovarian tumors. Amplification of c-myc occurs in approximately 30% of ovarian cancers and is more frequently seen in serous cancers. Mutation of the p53 tumor suppressor gene, with resultant overexpression of mutant p53 protein, occurs in 50% of stage III/IV and 15% of stage I/II ovarian cancers. Most p53 mutations in ovarian cancers are transitions, which suggests that they arise spontaneously rather than due to exogenous carcinogens. In contrast to the acquired genetic alterations described above that are a feature of sporadic ovarian cancers, 5-10% of ovarian cancers probably arise due to inherited genetic defects. Recently, the BRCA1 tumor suppressor gene has heen identified and shown to be responsible for most cases of hereditary ovarian cancer. Further studies are needed to augment our understanding of the molecular pathogenesis of ovarian cancer.

p53 and HER-2/neu overexpression in ovarian borderline tumors

OBJECTIVE

To study p53 and HER-2/neu expression in borderline ovarian tumors (BLOT) by assessing their frequency, coexpression, and relationship to histologic type, FIGO stage, tumor recurrence, and survival.

METHODS

Forty-two patients with confirmed BLOT (25 serous, 13 mucinous, and 4 seromucinous) were followed for 1.5 to 14 years (mean, 6.3). Thirty (71%) patients had FIGO stage I and 12 (29%) had FIGO stage III disease. Paraffin-embedded sections from the 42 BLOT, 5 normal ovaries, and 10 benign ovarian cystadenomas were stained using monoclonal antibodies against human p53 (DAKO-p53, DAKO, Denmark) and HER-2/neu (C-erB-2, Triton, Parkway, CA). Positive staining was semiquantitated depending on the number of positively stained tumor cells. p53 and HER-2/neu overexpressions were correlated to each other, to histologic subtype, stage, tumor recurrence, and survival.

RESULTS

None of the patients had tumor recurrence. The 5- and 10-year disease-free survival was 100%. None of the normal ovaries or ovarian cystadenomas demonstrated overexpression of p53 or HER-2/neu. Ten (24%) BLOT demonstrated overexpression of p53 and 9 (21%) demonstrated overexpression of HER-2/neu. HER-2/neu overexpression was significantly greater in stage III than in stage I tumors (P = 0.0157). Seromucinous BLOT demonstrated significantly greater p53 overexpression compared with other histologic subtypes (P = 0.030). Coexpression of p53 and HER-2/neu occurred in 4 patients (9.5%). There was no significant correlation between the overexpression of p53 and HER-2/neu (P = 0.180) and no significant relationship between p53 and HER-2/neu overexpression and the presence of microinvasion, ability to perform optimal cytoreductive surgery, tumor recurrence, or survival.

CONCLUSIONS

p53 and HER-2/neu overexpression occurred in about 20-25% of BLOT overall and more commonly in seromucinous and advanced stage tumors. Coexpression occurred in 9.5% of the cases with no significant correlation between the expression of p53 and HER-2/neu.

Molecular genetic events in the development and progression of ovarian cancer in humans

Ovarian tumor development is characterized by specific clinical and pathological features that provide an interesting model of carcinogenesis: first, the pre-invasive and even invasive lesions are difficult to detect; second, a group of cases with a known familial predilection constitute an important heredltary model of carcinogenesis; and third, the category of morphologically borderline ovarian tumors (tumors of low malignant potential) poses several unanswered questions such as: what histologic criteria should be used for their diagnosis; what is their natural history; and what is their molecular relationship to invasive tumors? Recently, molecular studies have contributed to a better understanding of the biology of these tumors, their behavior in vivo, and their response to therapy. This article summarizes the most recent molecular advances.

p53 alterations are predictive of chemoresistance and aggressiveness in ovarian carcinomas: a molecular and immunohistochemical study

Chemotherapeutic management of ovarian cancers is a difficult task as these neoplasms show significant differences in chemosensitivity, even if they share identical clinicopathological features. The present study was undertaken to investigate the prognostic and predictive role of p53 alterations in ovarian cancer. To this end, using different technical approaches, i.e. genetic and immunohistochemical analyses, we analysed a series of 68 ovarian neoplasms including 15 low malignant potential (LMP) tumours and 53 invasive carcinomas. We never observed p53 abnormalities in LMP tumours. p53 alterations were present only in invasive ovarian carcinomas, and they were detected much more frequently in tumours characterized by high histological grade (P = 0.01) and advanced-stage disease (P = 0.006 and P = 0.05 for gene mutations and protein expression respectively). For 33 patients with invasive ovarian cancer, information was available concerning response to cisplatin-based chemotherapy. A strong correlation (P = 0.001) has emerged between p53 alterations and response to chemotherapy; only one (14%) of seven patients who had a pathological complete response to antiblastic drugs showed p53 aberrations, whereas 18 (82%) of 22 cases with partial response and all of the four non-responsive patients scored positive for p53 abnormalities. We also observed that patients with p53 mutations had a significantly shorter progression-free survival than patients with p53-negative tumours (P = 0.05). Taken together, our results strongly suggest that in epithelial ovarian malignancies tumours showing p53 aberrations are significantly less sensitive to chemotherapy and more aggressive than those with functional p53. Thus, a routine analysis of this gene could have profound implications for the treatment of ovarian cancer.

Oncogenes in gynecologic oncology

Advances in molecular biology have facilitated the recent investigation of gynecological malignancies. The presence of certain oncogenes within gynecological tumors indicates that transformation may be associated with genetic alteration of normal regulatory processes. This paper reviews several oncogenes that have been implicated in the transformation of gynecological tissues.

Borderline ovarian tumors

Borderline tumor of the ovary (BOT) is an epithelial tumor with a low rate of growth and a low potential to invade or metastasize. This tumor often is associated with a significantly better prognosis than epithelial ovarian cancer. Most tumors are either serous or mucinous in histology and present as early stage lesions. However, stage III lesions with peritoneal implants are not uncommon. Patients with early stage lesions have an excellent prognosis. Patients with higher stage lesions have a worse prognosis. Long-term follow-up of patients with BOT is required since the tumor can recur up to 20 years after the initial diagnosis. Recently, investigators have begun to identify subsets of patients with a worse prognosis, such as patients with aneuploid tumors. Treatment for early stage lesions is surgical and conservative surgery can be accomplished successfully in younger patients who desire to maintain fertility. Treatment for later stage lesions has been approached in a variety of ways. All approaches initially begin with maximal cytoreductive surgery. Studies suggest that early stage disease should be managed with surgery alone. Conflicting results on the usefulness of adjuvant therapy for patients with later stage disease have been obtained. At this time, the usefulness of adjuvant therapy for advanced disease remains undetermined. Further understanding of the basis of the disease and analysis of specific higher risk subsets might identify patients in whom adjuvant therapy could be tested in the setting of controlled clinical trials.

Expression of cell regulatory proteins in ovarian borderline tumors

BACKGROUND

Tumors of borderline malignancy are still a controversial subgroup of ovarian neoplasms. The expression of several cell regulatory proteins was studied to characterize the molecular phenotype of these tumors, and to compare them with their benign and malignant counterparts.

METHODS

Specimens from 22 patients with tumors of borderline malignancy (11 serous and 11 mucinous tumors), 12 patients with benign tumors, and 16 patients with invasive ovarian carcinomas were evaluated for expression of epidermal growth factor receptor (EGFR), HER-2/neu, PTP1B, and p53 by immunohistochemical techniques.

RESULTS

One or both of the tyrosine kinase growth factor receptors EGFR and HER-2/neu was expressed by 42% of benign, 59% of borderline, and 81% of malignant ovarian tumors. EGFR was expressed in a significantly greater fraction of malignant lesions (69%) than borderline lesions (18%) (P< 0.004). EGFR expression was not observed among the 11 mucinous borderline tumors. HER-2/neu was expressed by 50% of borderline tumors and was not a marker for malignancy. The tyrosine phosphatase PTP1B was expressed by a similar fraction of benign (17%), borderline (27%), and malignant (19%) tumors. The number of cases studied precluded correlation of kinase and phosphatase activity. However, among 12 tumors with PTP1B expression, 9 also expressed EGFR or HER-2/neu. Overexpression of p53 was observed only in malignant serous tumors and was not found in malignant mucinous, borderline, or benign lesions.

CONCLUSIONS

Either EGFR or HER-2/neu was detected in a majority of borderline cancers. PTP1B was present only in a minority of these cancers. Frankly malignant serous lesions differed from borderline and benign tumors with regard to expression of EGFR and overexpression of p53.

An evaluation of prognostic factors in advanced ovarian cancer

A summary is presented of currently available prognostic factors in advanced ovarian cancer of the common epithelial types. The emphasis is on the most promising clinical, classical pathological, biochemical, immunohistochemical, molecular biological and quantitative pathological factors.

c-erbB-2 and p53 expression in fallopian tube carcinoma

BACKGROUND

Carcinoma of the fallopian tube is a rare gynecologic malignancy. Its histologic appearance and patterns of spread are similar to those of epithelial ovarian cancer. Alterations in the gene products of c-erbB-2 (HER-2/neu) and p53 are found commonly in ovarian tumors and may have prognostic relevance. The authors sought to determine whether tubal cancers are biologically similar to ovarian cancer with respect to the expression of these two molecular markers.

METHODS

A cohort of 43 patients with fallopian tube cancer was studied. Immunohistochemical staining for c-erbB-2 and p53 was performed on pretreatment tissue blocks. Clinical information was available for all patients, with a median follow-up of 9 years. Clinicopathologic correlations were made.

RESULTS

Nine patients had Stage I disease, 11 had Stage II disease, 18 had Stage III disease, and 5 had Stage IV disease, with a median survival was 65 months. c-erbB-2 overexpression was found in 11 cases (25.6%), and p53 positivity was noted in 26 cases (60.5%). Log rank survival curves showed no association between staining for c-erbB-2 or p53 expression and clinical outcome. A multivariate analysis identified patient age older than 65 years (P = 0.05) and Stage III or IV disease (P = 0.0065) as the only variables that predicted poor outcome.

CONCLUSIONS

Fallopian tube cancers are similar to ovarian cancer with respect to the proportion of tumors with abnormal expression of c-erbB-2 and p53. The authors could not demonstrate that these two molecular markers had prognostic relevance in this disease, but the size of their cohort was limited. However, the potential prognostic relevance of c-erbB-2 and p53 expression in tubal cancers should be pursued in a larger cohort.

Overexpression of c-erbB-2 in epithelial ovarian cancer. Prognostic value and relationship with response to chemotherapy

BACKGROUND

Overexpression of the c-erbB-2 protein has been reported in tumors from approximately 25% of patients with epithelial ovarian cancer. However, its clinical significance has not been well established.

METHODS

Overexpression of the c-erbB-2 protein was studied by immunohistochemistry in paraffin-embedded tumor tissue from 106 patients with ovarian cancer.

RESULTS

Tumors from 23 patients (21.7%) had c-erbB-2 overexpression. The percentage of tumors with overexpression was higher in those with Stages III/IV disease (29.2%) compared with those with Stages I/II disease (5.9%) (P = 0.057), in patients with residual tumor greater than 2 cm after initial surgery (37.2%) compared with those with tumor less than 2 cm (9.5%) (P = 0.01), and in patients who failed to respond to chemotherapy with carboplatin and cyclophosphamide (75%) compared with those who responded (18.6%) (P = 0.0043). No correlation was found between c-erbB-2 expression with age, the degree of differentiation, or the histologic subtype. Median survival of the 23 patients with protein overexpression was 62 weeks, whereas 75% of the 83 patients without overexpression were alive at 123 weeks (P = 0.0000). Of the patients with advanced stage disease (III/IV), survival was also lower in those presenting with overexpression (60 weeks) compared with those without expression (75% alive at 93 weeks) (P = 0.0000). Multivariate analysis of possible prognostic factors showed that c-erbB-2 overexpression and residual tumor greater than 2 cm resulted in a worsening of survival rates.

CONCLUSION

c-erbB-2 overexpression in tumors from patients with ovarian cancer resulted in a poorer prognosis than for patients whose tumors did not have overexpression.

CSF-1 and its receptor in ovarian, endometrial and breast cancer

The aim of this report is to review the role of CSF-1 and its receptor in neoplasms of the breast and female reproductive tract. Expression and function of CSF-1 and its receptor were studied in tumours of the human breast, ovary and endometrium. CSF-1 and its receptor, initially implicated as essential to normal monocyte development and trophoblastic implantation, have been more recently shown to be expressed by carcinomas of the breast, ovary and endometrium where activation of the receptor by ligand produced either by the tumour cells or by stromal elements stimulates tumour cell invasion by a urokinase-dependent mechanism. Breast carcinomas express wild-type CSF-1 receptors at levels comparable to those observed in trophoblast and monocytes. Ovarian and endometrial carcinomas express significantly lower levels of wild-type, functional CSF-1Rs while ovarian carcinomas also express unusual transcripts which diverge from the wild-type CSF-1R transcript in their 5' extracellular and other sequences. Tumour cell expression of CSF-1R is under the control of several steroid hormones (glucocorticoids and progestins) and tumour cell CSF-1 expression appears to be regulated by other hormones, some of which are involved in normal lactogenic differentiation. In addition, tumour cells often produce CSF-1 at such high levels that CSF-1 spills into the extracellular fluid and circulation. Measurements of circulating levels of CSF-1 have proved useful in patients with ovarian, endometrial and breast carcinoma patients both for disease detection and monitoring of response to breast carcinoma patients both for disease detection and monitoring of response to therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Expression of c-erbB-2, c-myc, and c-ras oncoproteins, insulin-like growth factor receptor I, and epidermal growth factor receptor in ovarian carcinoma

AIMS

To assess whether the overexpression of five dominant oncogene encoded proteins is crucial to the pathogenesis of ovarian carcinoma and whether this provides any useful prognostic information.

METHODS

The expression of the insulin-like growth factor 1 receptor (ILGFR 1), epidermal growth factor receptor (EGFR), and the c-erbB-2, c-ras, and c-myc products was studied by multiparameter flow cytometry in 80 patients with epithelial ovarian cancer for whom long term follow up was available.

RESULTS

Overexpression of ILGFR 1, EGFR, c-erbB-2, c-ras and c-myc was found in, respectively, nine of 80 (11%), 10 of 80 (12%), 19 of 80 (24%), 16 of 80 (20%) and 28 of 80 (35%) ovarian carcinomas. The levels of expression of ILGFR 1, EGFR, c-erbB-2 and c-ras were significantly higher in the tumours of patients with recurrent or persistent disease after chemotherapy than in the tumours of patients at initial presentation (p < 0.02). Multivariate analysis showed that residual tumour (p < 0.001), FIGO stage (p = 0.002), EGFR overexpression (p = 0.030) and previous chemotherapy (p = 0.034) were independent variables for predicting survival.

CONCLUSIONS

Overexpression of these oncoproteins only occurs in a small proportion of ovarian carcinomas but may have an important role in the progression of the disease.

Pathogenesis of ovarian cancers

OBJECTIVE

To review our current understanding of the molecular genetic events involved in the development of epithelial ovarian cancers.

METHODS

Molecular biologic techniques have been used to examine the role of growth-stimulatory genes (oncogenes) and -inhibitory genes (tumor suppressors) in ovarian cancer.

RESULTS

A number of different peptide growth factors and their receptors are expressed by normal and malignant ovarian epithelial cells. However, the role, if any, of growth factors in ovarian carcinogenesis or maintenance of the transformed phenotype remains unknown. Amplification and overexpression of the HER-2/neu and c-myc oncogenes occur in a significant fraction of epithelial ovarian cancers (20-30%). Overexpression of HER-2/neu has correlated with poor survival in some studies, whereas c-myc amplification is more common in serous cancers. Mutation of the K-ras oncogene frequently occurs in borderline ovarian tumors, but is less common in invasive epithelial ovarian cancers. Mutation of the p53 tumor suppressor gene occurs in approximately half of advanced (stage III/IV) ovarian cancers and in 15% of early (stage IA/IB) cases. Most recently, preliminary studies have focused on the role of other tumor suppressor genes, cyclins, WAF1, and DNA mismatch repair genes.

CONCLUSIONS

An understanding of the molecular events involved in the pathogenesis of epithelial ovarian cancer is beginning to evolve. Improvements in early diagnosis, treatment, and prevention of this deadly disease are dependent on further progress in this area.

Prevalence and significance of HER-2/neu expression in early epithelial ovarian cancer

BACKGROUND

Although expression of the HER-2/neu oncogene may be of some prognostic importance in advanced ovarian cancer, its role in early-stage disease has not been established. The current study examined the prevalence and significance of HER-2/neu expression in early epithelial ovarian cancer.

METHODS

The authors analyzed the expression of HER-2/neu on frozen tumor specimens from 40 patients with early epithelial ovarian cancer using the indirect immunoperoxidase technique with monoclonal antibodies that detect epitopes on the extracellular domain of the HER-2/neu protein. All patients underwent comprehensive surgical staging. HER-2/neu expression was graded as negative, weak, moderate (1+ to 2+), or strong (3+). Complete clinical data and long-term follow up were available for all patients.

RESULTS

The distribution of patients by stage was as follows: Stage IA, 6; IB, 0; IC, 14; IIA, 4; IIB, 6; IIC, 10. The mean patient age was 53 years. Fourteen patients had serous tumors; nine, endometrioid; eight, clear cell; eight, mucinous; and one, undifferentiated. Intratumoral heterogeneity of HER-2/neu expression was observed with most specimens. In eight specimens (20%), some areas of the tumor showed strong (3+) expression, beyond the level that can be seen in normal ovarian epithelium. Twenty-eight specimens (70%) showed moderate (1+ to 2+) staining, whereas four specimens (10%) showed negative or weak staining. At a mean follow-up time among surviving patients of 32 months, 15 patients (37%) have had cancer recurrence. No statistically significant relationship was found between HER-2/neu expression and survival, disease-free survival, stage, or grade. A significant increase was found in 3+ expression of HER-2/neu in clear cell tumors.

CONCLUSION

Consistent HER-2/neu overexpression occurs infrequently in early ovarian cancer, making it unlikely that such overexpression is a general early event in ovarian carcinogenesis. HER-2/neu expression does not appear to be a strong prognostic marker in early epithelial ovarian cancer.

Activation of c-erbB-2 and prognosis in ovarian carcinoma. Comparison with histologic type, grade, and stage

BACKGROUND

Prior reports suggested that measuring c-erbB-2 activation in ovarian carcinomas might be valuable in predicting prognosis. The authors attempted to confirm these studies while specifically excluding tumors of low malignant potential.

METHODS

The clinical and pathologic significance of c-erbB-2 oncogene activation was assessed in 56 ovarian carcinomas, none of which met histologic criteria for tumor of low malignant potential.

RESULTS

By using an immunohistochemical technique previously validated in molecular studies, c-erbB-2 oncogene overexpression was identified in 10 of the 56 carcinomas but did not correlate with histologic type, histologic grade, International Federation of Gynecology and Obstetrics (FIGO) stage, or prognosis. Adverse prognostic factors included histologic type (serous carcinoma), high grade, and high stage (FIGO Stages III and IV). Grade and stage were highly correlated with each other and were more important prognostic indicators than histologic type.

CONCLUSION

Measuring c-erbB-2 activation in ovarian carcinomas may not be of practical value in predicting prognosis when tumors of low malignant potential are excluded.

Prognostic significance of HER-2/neu expression in advanced epithelial ovarian cancer: a multivariate analysis

OBJECTIVE

We tested the hypothesis that there is prognostic significance to the level of expression of the protooncogene HER-2/neu in advanced ovarian cancer, as prior studies have suggested.

STUDY DESIGN

We determined expression of HER-2/neu by immunohistochemistry, with monoclonal antibody 9G6 and the indirect immunoperoxidase technique, on frozen tumor specimens from 105 patients with stage III or IV epithelial ovarian cancer. All patients were treated at Memorial Sloan-Kettering Cancer Center, and no patient was lost to follow-up. Median follow-up among surviving patients is 34 months. HER-2/neu expression was scored as negative, weak, 1+, 2+, or 3+. The staining pattern of normal ovarian epithelium was scored negative to 1+. Multivariate analysis was performed to evaluate the prognostic significance of HER-2/neu expression.

RESULTS

Twenty-five of the 105 patients (24%) showed strong membrane staining (3+); the other tumor specimens showed weaker membrane staining or no immunoreactivity. There was no correlation of HER-2/neu expression with any of a variety of clinical factors, including stage, grade, cell type, and residual tumor. No significant survival difference was found between patients with levels of staining intensity similar to those of normal ovarian epithelium and those with increased expression (3+). Median survival times were 36 and 27 months, respectively, for the two groups (95% confidence intervals 29 to 45 and 18 to 39 months). Multivariate analysis of possible prognostic factors showed that HER-2/neu overexpression conferred a marginal worsening of survival (p = 0.09) for the subgroup of patients in whom a negative surgical reassessment was not achieved after chemotherapy.

CONCLUSION

HER-2/neu expression does not appear to be an important prognostic factor in patients with advanced epithelial ovarian cancer.