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Němejcová K, Šafanda A, Kendall Bártů M, Michálková R, Švajdler M, Shatokhina T, Laco J, Matěj R, Méhes G, Drozenová J, Hausnerová J, Špůrková Z, Náležinská M, Dundr P. An extensive immunohistochemical analysis of 290 ovarian adult granulosa cell tumors with 29 markers. Virchows Arch 2024:10.1007/s00428-024-03854-0. [PMID: 38904760 DOI: 10.1007/s00428-024-03854-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2024] [Revised: 06/10/2024] [Accepted: 06/13/2024] [Indexed: 06/22/2024]
Abstract
The current knowledge about the immunohistochemical features of adult granulosa cell tumor (AGCT) is mostly limited to the "traditional" immunohistochemical markers of sex cord differentiation, such as inhibin, calretinin, FOXL2, SF1, and CD99. Knowledge about the immunohistochemical markers possibly used for predictive purpose is limited. In our study, we focused on the immunohistochemical examination of 290 cases of AGCT classified based on strict diagnostic criteria, including molecular testing. The antibodies used included 12 of the "diagnostic" antibodies already examined in previous studies, 10 antibodies whose expression has not yet been examined in AGCT, and 7 antibodies with possible predictive significance, including the expression of HER2, PD-L1, CTLA4, and 4 mismatch repair (MMR) proteins. The results of our study showed expression of FOXL2, SF1, CD99, inhibin A, calretinin, ER, PR, AR, CKAE1/3, and CAIX in 98%, 100%, 90%, 78%, 45%, 41%, 94%, 82%, 26%, and 9% of AGCT, respectively. GATA3, SATB2, napsin A, MUC4, TTF1, and CD44 were all negative. PTEN showed a loss of expression in 71% of cases and DPC4 in 4% of cases. The aberrant staining pattern (overexpression) of p53 was found in 1% (3/268) of cases, 2 primary tumors, and 1 recurrent case. Concerning the predictive markers, the results of our study showed that AGCT is microsatellite stable, do not express PD-L1, and are HER2 negative. The CTLA4 expression was found in almost 70% of AGCT tumor cells.
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Affiliation(s)
- Kristýna Němejcová
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Studničkova 2, 12800, Prague 2, Czech Republic.
| | - Adam Šafanda
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Studničkova 2, 12800, Prague 2, Czech Republic
| | - Michaela Kendall Bártů
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Studničkova 2, 12800, Prague 2, Czech Republic
| | - Romana Michálková
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Studničkova 2, 12800, Prague 2, Czech Republic
| | - Marián Švajdler
- Šikl's Department of Pathology, The Faculty of Medicine and Faculty Hospital in Pilsen, Charles University, Pilsen, Czech Republic
| | - Tetiana Shatokhina
- Department of Oncological Pathology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
| | - Jan Laco
- The Fingerland Department of Pathology, Charles University Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Charles University, Prague, Czech Republic
| | - Radoslav Matěj
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Studničkova 2, 12800, Prague 2, Czech Republic
- Department of Pathology, 3rd Faculty of Medicine, Charles University, University Hospital Královské Vinohrady, 10034, Prague, Czech Republic
- Department of Pathology and Molecular Medicine, Third Faculty of Medicine, Charles University, Thomayer University Hospital, Prague, Czech Republic
| | - Gábor Méhes
- Department of Pathology, Faculty of Medicine, University of Debrecen, 4032, Debrecen, Hungary
| | - Jana Drozenová
- Department of Pathology, 3rd Faculty of Medicine, Charles University, University Hospital Královské Vinohrady, 10034, Prague, Czech Republic
| | - Jitka Hausnerová
- Department of Pathology, University Hospital Brno and Medical Faculty, Masaryk University, Brno, Czech Republic
| | - Zuzana Špůrková
- Department of Pathology, Bulovka University Hospital, Prague, Czech Republic
| | - Monika Náležinská
- Division of Gynecologic Oncology, Department of Surgical Oncology, Masaryk Memorial Cancer Institute and Medical Faculty of Masaryk University, Brno, Czech Republic
| | - Pavel Dundr
- Department of Pathology, First Faculty of Medicine, Charles University and General University Hospital in Prague, Studničkova 2, 12800, Prague 2, Czech Republic
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Salarzaei M, van de Laar RLO, Ewing-Graham PC, Najjary S, van Esch E, van Beekhuizen HJ, Mustafa DAM. Unraveling Differences in Molecular Mechanisms and Immunological Contrasts between Squamous Cell Carcinoma and Adenocarcinoma of the Cervix. Int J Mol Sci 2024; 25:6205. [PMID: 38892393 PMCID: PMC11172577 DOI: 10.3390/ijms25116205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/18/2024] [Accepted: 05/31/2024] [Indexed: 06/21/2024] Open
Abstract
This study aims to refine our understanding of the inherent heterogeneity in cervical cancer by exploring differential gene expression profiles, immune cell infiltration dynamics, and implicated signaling pathways in the two predominant histological types of cervix carcinoma, Squamous Cell Carcinoma (SCC) and Adenocarcinoma (ADC). Targeted gene expression data that were previously generated from samples of primary cervical cancer were re-analyzed. The samples were grouped based on their histopathology, comparing SCC to ADC. Each tumor in the study was confirmed to be high risk human papilloma virus (hrHPV) positive. A total of 21 cervical cancer samples were included, with 11 cases of SCC and 10 of ADC. Data analysis revealed a total of 26 differentially expressed genes, with 19 genes being overexpressed in SCC compared to ADC (Benjamini-Hochberg (BH)-adjusted p-value < 0.05). Importantly, the immune checkpoint markers CD274 and CTLA4 demonstrated significantly higher expression in SCC compared to ADC. In addition, SCC showed a higher infiltration of immune cells, including B and T cells, and cytotoxic cells. Higher activation of a variety of pathways was found in SCC samples including cytotoxicity, interferon signaling, metabolic stress, lymphoid compartment, hypoxia, PI3k-AKT, hedgehog signaling and Notch signaling pathways. Our findings show distinctive gene expression patterns, signaling pathway activations, and trends in immune cell infiltration between SCC and ADC in cervical cancer. This study underscores the heterogeneity within primary cervical cancer, emphasizing the potential benefits of subdividing these tumours based on histological and molecular differences.
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Affiliation(s)
- Morteza Salarzaei
- Department of Gynaecologic Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands (H.J.v.B.)
| | - Ralf L. O. van de Laar
- Department of Gynaecologic Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands (H.J.v.B.)
| | - Patricia C. Ewing-Graham
- Department of Pathology and Clinical Bioinformatics, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands
| | - Shiva Najjary
- Department of Pathology and Clinical Bioinformatics, The Tumor Immuno-Pathology Laboratory, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands;
| | - Edith van Esch
- Department of Gynecology and Obstetrics, Catharina Ziekenhuis Eindhoven, Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands;
| | - Heleen J. van Beekhuizen
- Department of Gynaecologic Oncology, Erasmus MC Cancer Institute, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands (H.J.v.B.)
| | - Dana A. M. Mustafa
- Department of Pathology and Clinical Bioinformatics, The Tumor Immuno-Pathology Laboratory, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD Rotterdam, The Netherlands;
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Yao Y, Wang Y, Ye L, Lu B, Lu W. Invasive stratified mucin-producing carcinoma (ISMC) of the cervix: a clinicopathological and molecular analysis of 59 cases with special emphasis on histogenesis and potential therapeutic targets. Histopathology 2024; 84:315-324. [PMID: 37735961 DOI: 10.1111/his.15051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 08/29/2023] [Accepted: 09/01/2023] [Indexed: 09/23/2023]
Abstract
AIMS This study aimed to better characterize the clinical and molecular features in invasive stratified mucin-producing carcinoma (ISMC), an uncommon aggressive subtype of endocervical adenocarcinoma (EAC). METHODS AND RESULTS We recruited 59 ISMC for clinicopathological analysis, immunohistochemistry (n = 56), and targeted next-generation sequencing (n = 17). Our cases contained 29 pure and 30 mixed-type ISMC. Five patients developed local recurrence at 6-32 months (median: 13 months), and died of disease at 16-55 months (median: 16 months). Pure and mixed-type ISMC showed no significant difference in overall survival and tumour relapse (P > 0.05) except larger tumour size in the pure-type (P = 0.009). Compared to the usual-type EAC (n = 217), ISMsC were more frequently associated with large tumour size (P = 0.003), advanced FIGO stage (P = 0.017), lymph node metastasis (P = 0.022), Silva pattern C (P < 0.001), and poor overall survival and short tumour recurrence. SOX2 expression was observed in 82.1% (46/56) ISMC, substantially higher than p63 expression (P < 0.001), while positive SOX17 was present in 3.6% (2/56) cases. PD-L1 was positive in 41/56 ISMC (73.21%) (combined positive score: range: 1-92, median: 22). Three ISMC patients (17.65%) had PIK3CA mutations, while one each (5.88%) patient harboured an ERBB2, TP53, STK11, and PTEN mutation, respectively. CONCLUSION We conclude that ISMC is clinically more aggressive than the usual-type EAC. ISMC may originate from cervical reserve cells with bidirectional differentiation. PD-L1 overexpression and the molecular profiles raise the possibility that a subset of ISMC patients may benefit from anti-PD-L1 immunotherapy and other targeted therapy, such as mTOR inhibitor and T-DM1.
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Affiliation(s)
- Yeli Yao
- Department of Gynecologic Oncology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Yan Wang
- Department of Surgical Pathology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Lei Ye
- Department of Surgical Pathology, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Bingjian Lu
- Department of Surgical Pathology, Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang Province, Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Zhejiang Provincial Key Laboratory of Precision Diagnosis and Therapy for Major Gynecological Diseases, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Weiguo Lu
- Department of Gynecologic Oncology, Center for Uterine Cancer Diagnosis & Therapy Research of Zhejiang Province, Zhejiang Provincial Clinical Research Center for Obstetrics and Gynecology, Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, China
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Tu M, Xu J. Advances in immunotherapy for gynecological malignancies. Crit Rev Oncol Hematol 2023:104063. [PMID: 37385307 DOI: 10.1016/j.critrevonc.2023.104063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 05/21/2023] [Accepted: 06/25/2023] [Indexed: 07/01/2023] Open
Abstract
To date, surgery, chemotherapy and radiotherapy are mainly used to treat or remove gynecological malignancies. However, these approaches have their limitations when facing complicated female diseases such as advanced cervical and endometrial cancer (EC), chemotherapy-resistant gestational trophoblastic neoplasia and platinum-resistant ovarian cancer. Instead, immunotherapy, as an alternative, could significantly improve prognosis of those patients receiving traditional treatments, with better antitumor activities and possibly less cellular toxicities. Its' development is still not fast enough to meet the current clinical needs. More preclinical studies and larger-scale clinical trials are required. This review aims to introduce the landscape and up-to-date status of immunotherapy against gynecological malignancies, with a discussion of the challenges and future direction.
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Affiliation(s)
- Mengyan Tu
- Women's Reproductive Health Laboratory of Zhejiang Province, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang, China
| | - Junfen Xu
- Department of Gynecologic Oncology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou 310006, Zhejiang, China.
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Yu L, Lanqing G, Huang Z, Xin X, Minglin L, Fa-hui L, Zou H, Min J. T cell immunotherapy for cervical cancer: challenges and opportunities. Front Immunol 2023; 14:1105265. [PMID: 37180106 PMCID: PMC10169584 DOI: 10.3389/fimmu.2023.1105265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 02/27/2023] [Indexed: 05/15/2023] Open
Abstract
Cancer cellular immunotherapy has made inspiring therapeutic effects in clinical practices, which brings new hope for the cure of cervical cancer. CD8+T cells are the effective cytotoxic effector cells against cancer in antitumor immunity, and T cells-based immunotherapy plays a crucial role in cellular immunotherapy. Tumor infiltrated Lymphocytes (TIL), the natural T cells, is approved for cervical cancer immunotherapy, and Engineered T cells therapy also has impressive progress. T cells with natural or engineered tumor antigen binding sites (CAR-T, TCR-T) are expanded in vitro, and re-infused back into the patients to eradicate tumor cells. This review summarizes the preclinical research and clinical applications of T cell-based immunotherapy for cervical cancer, and the challenges for cervical cancer immunotherapy.
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Affiliation(s)
- Lingfeng Yu
- School of Basic Medical Sciences, Tianjin Medical University, Tianjin, China
| | - Gong Lanqing
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ziyu Huang
- School of Arts and Sciences, Brandeis University, Boston, MA, United States
| | - Xiaoyan Xin
- School of Arts and Sciences, Brandeis University, Boston, MA, United States
| | - Liang Minglin
- School of Arts and Sciences, Brandeis University, Boston, MA, United States
| | - Lv Fa-hui
- Department of Obstetrics and Gynecology, The Second People’s Hospital of Hefei, Hefei, Anhui, China
| | - Hongmei Zou
- Department of Obstetrics, Qianjiang Central Hospital, Qianjiang, Hubei, China
| | - Jie Min
- Department of Obstetrics and Gynecology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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The Premetastatic Lymph Node Niche in Gynecologic Cancer. Int J Mol Sci 2023; 24:ijms24044171. [PMID: 36835583 PMCID: PMC9959967 DOI: 10.3390/ijms24044171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/06/2023] [Accepted: 02/15/2023] [Indexed: 02/22/2023] Open
Abstract
It has been suggested that a primary tumor can "prepare" the draining of lymph nodes to "better accommodate" future metastatic cells, thus implying the presence of a premetastatic lymph node niche. However, this phenomenon remains unclear in gynecological cancers. The aim of this study was to evaluate lymph-node draining in gynecological cancers for premetastatic niche factors, such as myeloid-derived suppressor cells (MDSCs), immunosuppressive macrophages, cytotoxic T cells, immuno-modulatory molecules, and factors of the extracellular matrix. This is a monocentric retrospective study of patients who underwent lymph-node excision during their gynecological-cancer treatment. In all, 63 non-metastatic pelvic or inguinal lymph nodes, 25 non-metastatic para-aortic lymph nodes, 13 metastatic lymph nodes, and 21 non-cancer-associated lymph nodes (normal controls) were compared for the immunohistochemical presence of CD8 cytotoxic T cells, CD163 M2 macrophages, S100A8/A9 MDSCs, PD-L1+ immune cells, and tenascin-C, which is a matrix remodeling factor. PD-L1-positive immune cells were significantly higher in the control group, in comparison to the regional and distant cancer-draining lymph nodes. Tenascin-C was higher in metastatic lymph nodes than in both non-metastatic nodes and control lymph nodes. Vulvar cancer-draining lymph nodes showed higher PD-L1 values than endometrial cancer and cervical cancer-draining lymph nodes. Endometrial cancer-draining nodes had higher CD163 values and lower CD8 values, compared to vulvar cancer-draining nodes. Regarding regional draining nodes in low- and high-grade endometrial tumors, the former showed lower S100A8/A9 and CD163 values. Gynecological cancer-draining lymph nodes are generally immunocompetent, but vulvar cancer draining nodes, as well as high-grade endometrial cancer draining nodes, are more susceptible to harboring premetastatic niche factors.
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Li Y, Shen F, Tan Q, Chen Y, Gu Y. Research Progress of Immuno-Inhibitory Receptors in Gynecological Cervical Cancer. Technol Cancer Res Treat 2023; 22:15330338231208846. [PMID: 37908109 PMCID: PMC10621300 DOI: 10.1177/15330338231208846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 09/03/2023] [Accepted: 10/02/2023] [Indexed: 11/02/2023] Open
Abstract
The mortality rate of cervical cancer is the highest among female malignant tumors and seriously threatens women's lives and health. Persistent high-risk human papillomavirus (HPV) infection is the leading cause of cervical cancer, which provides the basis for immunotherapy. In recent years, owing to progress in targeted therapy and immunotherapy, the survival time of patients with cervical cancer has been significantly extended. However, effective treatments for advanced, recurrent, and metastatic cancers are lacking. "Tumor immunotherapy" has been described as a viable option for tumor therapy but the efficacy of immunotherapy for cervical cancer has only been demonstrated in phase I or II clinical trials. Immune checkpoint inhibitors (ICIs) have shown promising clinical results particularly for treating recurrent and advanced cervical cancer, however, they remain inadequate in some patients. Immune checkpoint is the target of immunotherapy. Therefore, the identification of novel therapeutic targets is essential. In this paper, the structure, expression, function, biological effect of immune inhibitory receptors (IRs) and related clinical studies were reviewed, in order to further explore the application potential of these immune checkpoints and apply them to the future clinical treatment of cervical cancer.
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Affiliation(s)
- Yang Li
- Jiangsu Institute of Clinical Immunology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
- Department of Gynecology and obstetrics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Fangrong Shen
- Department of Gynecology and obstetrics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Qingqing Tan
- Department of Gynecological Oncology, The Affiliated Changzhou Maternal and Child Health Care Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Youguo Chen
- Department of Gynecology and obstetrics, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yanzheng Gu
- Jiangsu Institute of Clinical Immunology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
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Ge Y, Zhang Y, Zhao KN, Zhu H. Emerging Therapeutic Strategies of Different Immunotherapy Approaches Combined with PD-1/PD-L1 Blockade in Cervical Cancer. Drug Des Devel Ther 2022; 16:3055-3070. [PMID: 36110399 PMCID: PMC9470119 DOI: 10.2147/dddt.s374672] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 07/28/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Yanjun Ge
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Yuchen Zhang
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
| | - Kong-Nan Zhao
- School of Basic Medical Science, Wenzhou Medical University, Wenzhou, People’s Republic of China
- Australian Institute for Bioengineering and Nanotechnology, The University of Queensland, St Lucia, Queensland, Australia
| | - Haiyan Zhu
- Department of Gynecology, Shanghai First Maternity and Infant Hospital, Tongji University School of Medicine, Shanghai, People’s Republic of China
- School of Basic Medical Science, Wenzhou Medical University, Wenzhou, People’s Republic of China
- Correspondence: Haiyan Zhu, Shanghai First Maternity and Infant Hospital, No. 2699 Gaokexi Road, Shanghai, 200092, People’s Republic of China, Tel +86 13758465255, Email
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Zhou F, Chen H, Li M, Strickland AL, Zheng W, Zhang X. The Prognostic Values of HPV Genotypes and Tumor PD-L1 Expression in Patients With HPV-associated Endocervical Adenocarcinoma. Am J Surg Pathol 2022; 46:300-308. [PMID: 35175967 PMCID: PMC8860210 DOI: 10.1097/pas.0000000000001800] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Despite the well-established pathogenic effect of high-risk human papillomavirus (hrHPV) genotypes on endocervical adenocarcinomas (ECAs), the prognostic values of hrHPV genotypes and their association with other prognostic variables have not been established. We categorized 120 usual-type human papillomavirus-associated (HPVA) ECA cases into 3 species groups (HPV16+, HPV18/45+, and other genotypes+) based on the hrHPV status. The clinical-stage, invasion patterns (Silva), and programmed death ligand-1 (PD-L1) expression were compared among genotype groups. In addition, log-rank test and Kaplan-Meier survival curves were used to compare progression-free survival (PFS) among different patient groups. A total of 120 ECA cases with positive hrHPV tests were included in this study. Among them, 51 (42.5%) were positive for HPV16, 50 (41.7%) were positive for HPV18 or 18/45, 9 (7.5%) were positive for other hrHPV genotypes (not including HPV16/18/45). Our data showed patients had no significant difference in clinical stages (P=0.51), invasion patterns (P=0.55), and PFS (P=0.59) across genotype groups. Overall, a relatively high prevalence of PD-L1 expression was observed in HPVA ECAs (25% by tumor proportion score [TPS] and 55% by a combined positive score [CPS]). Using TPS, 19.6% (10/51) HPV16+ cases, 32.0% (16/50) cases of HPV18 or 18/45+ cases, and 22.2% (2/9) cases of other genotypes+ cases demonstrated PD-L1 positivity. No significant difference in PD-L1 expression was seen across genotype groups (P=0.35). PD-L1 expression in tumors with patterns B and C was significantly higher than in those with pattern A (P=0.00002). Patients with PD-L1-positive tumors by either CPS or TPS showed significantly poorer PFS than those with PD-L1-negative tumors (CPS, P=0.025; TPS, P=0.001). Our data support that HPV genotypes have no prognostic value in HPVA ECAs, while PD-L1 expression serves as a negative prognostic marker in HPVA ECAs and implies an unfavorable outcome.
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Affiliation(s)
- Feng Zhou
- Department of Pathology, Zhejiang University School of Medicine Women’s Hospital, Hangzhou
| | - Hao Chen
- Department of Pathology, University of Texas Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Meiping Li
- Department of Pathology, Shaoxing Maternity and Child Health Care Hospital, Shaoxing, Zhejiang Province, China
| | - Amanda L. Strickland
- Department of Pathology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Wenxin Zheng
- Department of Pathology, University of Texas Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Xiaofei Zhang
- Department of Pathology, Zhejiang University School of Medicine Women’s Hospital, Hangzhou
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Programme death ligand 1 expressions as a surrogate for determining immunotherapy in cervical carcinoma patients. PLoS One 2022; 17:e0263615. [PMID: 35139126 PMCID: PMC8827435 DOI: 10.1371/journal.pone.0263615] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 01/22/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The programme death ligand1 and its receptor (PD-1/PD-L1) interaction is a target for blockage by immunotherapy that uses the body's own immune system. Some studies show that PD-L1 expressing tumours are also more aggressive with poor prognosis. This study evaluated the immunohistochemical expression of PD-L1 in uterine cervical carcinomas. Women with cervical cancer would benefit from its use as a marker in therapy and prognosis. METHODS Hospital-based cross-sectional retrospective study was conducted. The study materials included 183 archived formalin fixed and paraffin embedded (FFPE) tissue blocks with histological diagnosis of cervical carcinoma diagnosed in our facility within a five-year period (January 2012 and December 2016) that met the study criteria. Data were extracted from records in the Department and immunohistochemistry was done using polyclonal antibodies to PD-L1 (GTX104763, Genetex). Obtained data were analysed using SPSS version 23. P < 0.05 was considered significant. RESULTS A hundred and eighty-three cases of cervical cancer were studied. PD-L1 was positive in 57.4% of all cases. The diffuse pattern of staining was the major pattern accounting for 88.5% of positive cases. Poorly differentiated cervical carcinomas are less likely to express PD-L1. Within the histologic types, the squamous cell carcinomas expressed PD-L1 in 58.7%, and 50% of adenocarcinomas were positive. PD-L1 was not expressed in all cases of adenoid cystic carcinomas and basaloid squamous cell carcinomas. CONCLUSION A significant population of cervical carcinoma expresses PD-L1 by immunohistochemistry. PD-L1 prevalence is lower amongst the poorly differentiated cancers compared to other grades.
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PD-L1: Can it be a biomarker for the prognosis or a promising therapeutic target in cervical cancer? Int Immunopharmacol 2021; 103:108484. [PMID: 34954558 DOI: 10.1016/j.intimp.2021.108484] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 12/12/2021] [Accepted: 12/15/2021] [Indexed: 12/24/2022]
Abstract
Cervical cancer is one of the most common in the female genital tract and remains a leading cause that threatens the health and lives of women worldwide, although preventive vaccines and early diagnosis have reduced mortality. While treatment by operation and chemoradiotherapy for early-stage patients achieve good outcomes, the great majority of cervical cancers caused by the human papilloma virus (HPV) make immunotherapy realizable for patients with advanced and recurrent cervical cancer. To date, some clinical trials of checkpoint immunotherapy in cervical cancer have indicated significant benefits of programmed cell death-1/programmed cell death-ligand 1 (PD-1/PD-L1) inhibitors, providing strong evidence for PD-1/PD-L1 as a therapeutic target. In this review article, we discuss the role of PD-L1 and the application of PD-L1 inhibitors in cervical cancer, with the aim of providing direction for future research.
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Chen L, Yang F, Feng T, Wu S, Li K, Pang J, Shi X, Liang Z. PD-L1, Mismatch Repair Protein, and NTRK Immunohistochemical Expression in Cervical Small Cell Neuroendocrine Carcinoma. Front Oncol 2021; 11:752453. [PMID: 34745983 PMCID: PMC8566736 DOI: 10.3389/fonc.2021.752453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/05/2021] [Indexed: 12/11/2022] Open
Abstract
Background Cervical small cell neuroendocrine carcinoma (SCNC) is a rare and aggressive disease that lacks a standard treatment strategy or effective methods of targeted therapy. PD-L1 inhibitors for DNA mismatch repair system-deficient (dMMR) tumors and neurotrophin receptor tyrosine kinase (NTRK) inhibitors offer potential pan-cancer treatments. Methods Immunohistochemistry was employed as the main detection method, and any NTRK positive cases, identified by immunohistochemistry, were further submitted for evaluation by fluorescence in situ hybridization (FISH) and real-time polymerase chain reaction (RT-PCR) methods. Results Forty-six patients were enrolled. Positive PD-L1 expression was seen in 22 of the 43 patients (51.16%) with an average combined positive score of 6.82. PD-L1-positive patients were more likely to have a higher proliferation rate in the tumor, and they experienced less recurrence and death (p = 0.048 and 0.033, respectively) compared with the patients with negative PD-L1 expression. However, in the multivariate analysis, none of the clinical parameters was associated with the expression of PD-L1. There was no association between PD-L1 expression and disease recurrence or overall survival in the Kaplan-Meier analysis. All cases were found to be MMR-stable and lacked NTRK gene fusion. However, pan-Trk expressed in 14 (32.56%) of the 43 tested cases, but FISH and RT-PCR failed to confirm any positive fusion signals in IHC-positive cases. Conclusions PD-L1 may be an effective therapeutic target for cervical SCNC. Cervical SCNC is a MMR-stable tumor and lacks NTRK gene fusion. IHC isn’t a reliable method in the detection of NTRK gene fusion in cervical SCNC.
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Affiliation(s)
- Longyun Chen
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fan Yang
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ting Feng
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Shafei Wu
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kaimi Li
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Junyi Pang
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaohua Shi
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhiyong Liang
- Department of Pathology, State Key Laboratory of Complex Severe and Rare Disease, Molecular Pathology Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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13
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Khalifa R, Elsese N, El-Desouky K, Shaair H, Helal D. Immune checkpoint proteins (PD-L1 and CTLA-4) in endometrial carcinoma: prognostic role and correlation with CD4 +/CD8 + tumor infiltrating lymphocytes (TILs) ratio. J Immunoassay Immunochem 2021; 43:192-212. [PMID: 34697997 DOI: 10.1080/15321819.2021.1981377] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Developing the prognostic aspects of endometrial carcinoma through shedding light on immune check point proteins (PD-L1 and CTLA-4) together with Tumor-Infiltrating Lymphocytes (TILs) may help finding new targets for immunotherapy, especially for advanced cases. This study aimed to study the immunohistochemical expression of PD-L1 and CTLA-4 in correlation with tumor infiltrating lymphocytes (TILs) in series of endometrial carcinomas. CTLA-4 showed notably higher frequency of expression in the studied cases than PD-L1. However, both showed significant association across different histopathological subtypes. PD-L1 immunohistochemical expression in studied endometrial carcinomas was significantly associated with low CD4+/CD8+ratio, high tumor grades, presence of lymph node metastasis and higher tumor stage. CTLA-4 immunohistochemical expression in studied endometrial carcinomas was significantly associated with low CD4+/CD8+ ratio and high tumor grades but not with tumor stage. Both PD-L1 & CTLA-4 are expressed in subset of endometrial carcinomas with more prevalence of the latter. Both immune checkpoint proteins have significant correlation with different prognostic clinicopathological parameters together with TILs (CD4 & CD8 and their ratio). Increased activated cytotoxic T lymphocytes and PD-L1 expression in endometrial carcinomas may suggest identification of patients' subset of tumors that can be candidates for treatment with immunotherapy.
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Affiliation(s)
- Rana Khalifa
- Department of pathology, Faculty of Medicine, Pathology, Tanta University, Tanta, Egypt
| | - Nawal Elsese
- Department of pathology, Faculty of Medicine, Pathology, Tanta University, Tanta, Egypt
| | - Karima El-Desouky
- Department of pathology, Faculty of Medicine, Pathology, Tanta University, Tanta, Egypt
| | - Hassan Shaair
- Department of pathology, Faculty of Medicine, Pathology, Tanta University, Tanta, Egypt
| | - Duaa Helal
- Department of pathology, Faculty of Medicine, Pathology, Tanta University, Tanta, Egypt
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14
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Choi S, Kim SW, Kim HS. Invasive Stratified Mucin-producing Carcinoma (ISMC) of the Uterine Cervix: Clinicopathological and Molecular Characteristics With Special Emphasis on the First Description of Consistent Programmed Death-ligand 1 (PD-L1) Over-expression. Cancer Genomics Proteomics 2021; 18:685-698. [PMID: 34479920 DOI: 10.21873/cgp.20290] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 07/30/2021] [Accepted: 08/03/2021] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND/AIM Invasive stratified mucin-producing carcinoma (ISMC) of the uterine cervix has been reported to be more aggressive than other subtypes of endocervical adenocarcinoma. We investigated the clinicopathological and molecular characteristics of eight ISMCs. PATIENTS AND METHODS We reviewed the electronic medical records and pathology slides of eight patients with ISMC and conducted programmed death-ligand 1 (PD-L1) immunostaining and targeted sequencing. RESULTS The patients were between 31 and 54 years. Six tumors were pure ISMCs, and two showed co-existing squamous cell carcinoma and usual-type endocervical adenocarcinoma. Lymph node metastases were detected in three cases. Three patients developed distant metastases to the adnexa, lungs, inguinal lymph nodes, and small intestine. Two patients experienced disease progression, and three developed postoperative local recurrences. All tumors showed PD-L1 over-expression, with a mean combined positive score of 73.8 (range=30-100). One tumor harbored erb-b2 receptor tyrosine kinase 2 amplification. CONCLUSION ISMC of the uterine cervix exhibits a high risk of recurrence, metastasis, and resistance to chemoradiation therapy. PD-L1 over-expression was consistently observed in all ISMCs. This finding raises the possibility that patients with ISMC may benefit from PD-L1 immunotherapy.
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Affiliation(s)
- Sangjoon Choi
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - So-Woon Kim
- Department of Pathology, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul, Republic of Korea
| | - Hyun-Soo Kim
- Department of Pathology and Translational Genomics, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea;
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15
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Chen L, Lucas E, Zhang X, Liu Q, Zhuang Y, Lin W, Chen H, Zhou F. Programmed death-ligand 1 expression in human papillomavirus-independent cervical adenocarcinoma and its prognostic significance. Histopathology 2021; 80:338-347. [PMID: 34455625 DOI: 10.1111/his.14552] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 12/26/2022]
Abstract
AIMS In the 2020 World Health Organization classification of female genital tumours, endocervical adenocarcinomas (ECAs) are subclassified into human papillomavirus (HPV)-associated (HPVA) and HPV-independent (HPVI) groups on the basis of their distinct aetiologies and clinical behaviours. The aim of this study was to investigate programmed death-ligand 1 (PD-L1) expression and its prognostic value in HPVI ECA and HPVA ECA, and compare these between the two entities. METHODS AND RESULTS A total of 93 ECAs accessioned between 2013 and 2020 were selected for further analysis, including 48 usual-type HPVA ECAs and 45 HPVI ECAs. Then, we evaluated PD-L1 expression in whole tissue sections of these cases by using the tumour proportion score (TPS) and the combined positive score (CPS). Heterogeneous PD-L1 expression was observed in both HPVI ECAs and usual-type HPVA ECAs. However, no significant difference in PD-L1 expression was seen among different histological types of ECA when either the CPS or the TPS was used. Gastric-type ECA (GEA) was associated with higher clinical stage (P = 0.001), worse progression-free survival (PFS) (P = 0.008) and worse overall survival (OS) (P = 0.02) than usual-type HPVA ECA and non-GEA HPVI ECA. When the TPS was used, PD-L1-positive GEA was associated with significantly worse PFS (P = 0.03) and OS (P = 0.015) than PD-L1-negative GEA. CONCLUSIONS Our data show frequent PD-L1 expression in HPVI ECAs, supporting the potential role of the programmed cell death protein 1/PD-L1 pathway as a therapeutic target for these tumours. Our data also support PD-L1 as a negative prognostic marker associated with a potentially unfavourable outcome for GEAs.
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Affiliation(s)
- Lili Chen
- Department of Oncology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang Province, China
| | - Elena Lucas
- Department of Pathology, University of Texas Southwestern Medical Center, USA.,Department of Pathology, Parkland Hospital, Dallas, TX, USA
| | - Xiaofei Zhang
- Department of Pathology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang Province, China
| | - Qin Liu
- Department of Pathology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang Province, China
| | - Yalin Zhuang
- Department of Oncology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang Province, China
| | - Wanrun Lin
- Department of Pathology, University of Texas Southwestern Medical Center, USA
| | - Hao Chen
- Department of Pathology, University of Texas Southwestern Medical Center, USA.,Department of Pathology, Parkland Hospital, Dallas, TX, USA
| | - Feng Zhou
- Department of Pathology, Zhejiang University School of Medicine Women's Hospital, Hangzhou, Zhejiang Province, China
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16
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Song F, Jia M, Yu S, Cao L, Sun PL, Gao H. PD-L1 expression and immune stromal features in HPV-independent cervical adenocarcinoma. Histopathology 2021; 79:861-871. [PMID: 34156708 DOI: 10.1111/his.14435] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 06/16/2021] [Accepted: 06/19/2021] [Indexed: 12/16/2022]
Abstract
AIMS Human papilloma virus (HPV)-independent cervical adenocarcinoma (CA) is usually diagnosed at an advanced stage, while the therapeutic options are limited. Therefore, effective treatment options are required. The programmed cell death 1 (PD-1) inhibitor pembrolizumab has been approved for the treatment of patients with recurrent or metastatic cervical squamous cell carcinoma expressing PD-ligand 1 (PD-L1). However, no data regarding PD-L1 expression in HPV-independent CA are available. Thus, we evaluated the association between PD-L1 expression and the clinicopathological characteristics and survival of patients with HPV-independent CA. METHODS We evaluated PD-L1, mismatch repair (MMR) protein expression and the immune stromal features of 44 patients with HPV-independent CA. PD-L1 expression was defined as a combined positive score (CPS) ≥1 and a tumour proportion score (TPS) ≥1%. RESULTS PD-L1 expression was observed in 14 cases (31.8%) with CPS ≥1 and 12 cases (27.3%) with TPS ≥1%. PD-L1 expression, based on either the CPS or the TPS, was associated with a high tumour-infiltrating lymphocyte percentage (CPS = P < 0.001; TPS = P < 0.001). Patients with a PD-L1 CPS ≥1 showed worse progression-free survival and overall survival than PD-L1-negative patients (P = 0.004 and P = 0.023, respectively). Forty-two cases demonstrated intact MMR expression and two cases demonstrated loss of MSH2/MSH6. CONCLUSIONS Our data demonstrated that PD-L1 was expressed in HPV-independent CA, especially in clear cell carcinoma, and that PD-L1 expression is a negative prognostic marker. Our data support the role of PD-L1 in HPV-independent CA and its potential as an immunotherapeutic target.
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Affiliation(s)
- Fuqin Song
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Meng Jia
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Shili Yu
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Lanqing Cao
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Ping-Li Sun
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
| | - Hongwen Gao
- Department of Pathology, The Second Hospital of Jilin University, Changchun, Jilin, China
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17
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Rivera-Colon G, Chen H, Molberg K, Niu S, Strickland AL, Castrillon DH, Carrick K, Gwin K, Lea J, Zheng W, Lucas E. PD-L1 Expression in Endocervical Adenocarcinoma: Correlation With Patterns of Tumor Invasion, CD8+ Tumor-infiltrating Lymphocytes, and Clinical Outcomes. Am J Surg Pathol 2021; 45:742-752. [PMID: 33298732 DOI: 10.1097/pas.0000000000001633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Programmed death-1 ligand (PD-L1) expression has been used as a predictive marker for response to immune checkpoint inhibitors and has been reported to have prognostic value. Its prevalence and significance in endocervical adenocarcinoma (ECA) remain underinvestigated. We evaluated PD-L1 expression and CD8+ tumor-infiltrating lymphocyte density in whole tissue sections of 89 ECAs. PD-L1 expression was observed in 68% of ECAs by combined positive score (CPS, cutoff 1) and 29% of ECAs by tumor proportion score (TPS, cutoff 1%). Using CPS, PD-L1 expression was seen in 11%, 78%, and 72% of pattern A, B, and C tumors, respectively, with significantly higher expression in tumors with destructive-type invasion (B and C) (P=0.001 [A vs. B], 0.0006 [A vs. C], 0.0002 [A vs. B+C]). Using TPS, no significant difference in PD-L1 expression was seen between tumors with different invasion patterns (0%, 22%, and 32% in tumors with pattern A, B, and C, respectively; P=0.27 [A vs. B], 0.053 [A vs. C], 0.11 [A vs. B+C]). PD-L1-positive ECAs demonstrated significantly higher CD8+ tumor-infiltrating lymphocyte density (CPS: P=0.028; TPS: P=0.013) and worse progression-free survival when compared with PD-L1-negative ECAs (CPS: hazard ratio [HR]=4.253 vs. 0.235, P=0.025; TPS: HR=4.98 vs. 0.2; P=0.004). When invasion patterns were separately assessed, pattern C tumors similarly showed worse progression-free survival in PD-L1-positive tumors (CPS: HR=6.15 vs. 0.16, P=0.045; TPS: HR=3.78 vs. 0.26, P=0.027). In conclusion, our data show frequent PD-L1 expression in ECA with destructive-type invasion, supporting the role of the PD-1/PD-L1 pathway as a therapeutic target for these tumors. Our data also support PD-L1 as a negative prognostic marker associated with a potentially unfavorable outcome.
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Affiliation(s)
| | - Hao Chen
- Departments of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Kyle Molberg
- Departments of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Shuang Niu
- Departments of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Amanda L Strickland
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Diego H Castrillon
- Departments of Pathology
- Obstetrics and Gynecology
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Kelley Carrick
- Departments of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Katja Gwin
- Departments of Pathology
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Jayanthi Lea
- Obstetrics and Gynecology
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center
| | - Wenxin Zheng
- Departments of Pathology
- Obstetrics and Gynecology
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
| | - Elena Lucas
- Departments of Pathology
- Harold C. Simmons Comprehensive Cancer Center, UT Southwestern Medical Center
- Department of Pathology, Parkland Hospital, Dallas, TX
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18
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Venkatas J, Singh M. Nanomedicine-mediated optimization of immunotherapeutic approaches in cervical cancer. Nanomedicine (Lond) 2021; 16:1311-1328. [PMID: 34027672 DOI: 10.2217/nnm-2021-0044] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Cervical cancer shows immense complexity at the epigenetic, genetic and cellular levels, limiting conventional treatment. Immunotherapy has revolutionized nanomedicine and rejuvenated the field of tumor immunology. Although several immunotherapeutic approaches have shown favorable clinical responses, their efficacies vary, with subsets of patients benefitting. The success of cancer immunotherapy requires the enhancement of cytokines and antitumor effector cell production and activation. Recently, the feasibility of nanoparticle-based cytokine approaches in tumor immunotherapy has been highlighted. Immunotherapeutic nanoparticle-based platforms form a novel strategy enabling researchers to co-deliver immunomodulatory agents, target tumors, improve pharmacokinetics and minimize collateral toxicity to healthy cells. This review looks at the potential of immunotherapy and nanotechnologically enhanced immunotherapeutic approaches for cervical cancer.
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Affiliation(s)
- Jeaneen Venkatas
- Nano-Gene & Drug Delivery Group, Discipline of Biochemistry, School of Life Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, KwaZulu-Natal, South Africa
| | - Moganavelli Singh
- Nano-Gene & Drug Delivery Group, Discipline of Biochemistry, School of Life Sciences, University of KwaZulu-Natal, Private Bag X54001, Durban, 4000, KwaZulu-Natal, South Africa
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19
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Patel MV, Shen Z, Rodriguez-Garcia M, Usherwood EJ, Tafe LJ, Wira CR. Endometrial Cancer Suppresses CD8+ T Cell-Mediated Cytotoxicity in Postmenopausal Women. Front Immunol 2021; 12:657326. [PMID: 33968059 PMCID: PMC8103817 DOI: 10.3389/fimmu.2021.657326] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 04/06/2021] [Indexed: 12/19/2022] Open
Abstract
Endometrial cancer is the most common gynecological cancer. To investigate how it suppresses host immune function, we isolated CD8+ T cells from endometrial endometroid carcinomas and adjacent non-cancerous endometrium and determined if the tumor environment regulates cytotoxic capacity. Endometrial carcinomas had increased numbers of CD8+ T cells compared to adjacent non-cancerous endometrium. Tumor CD8+ T cells expressed significantly less granzyme A (GZA), B (GZB), and PD-1 than those in adjacent non-cancerous tissues and also had significantly lower cytotoxic killing of allogeneic target cells. CD103-CD8+ T cells, but not CD103+CD8+ T cells, from both adjacent and tumor tissue were primarily responsible for killing of allogeneic target cells. Secretions recovered from endometrial carcinoma tissues suppressed CD8+ cytotoxic killing and lowered perforin, GZB and PD-1 expression relative to non-tumor CD8+ T cells. Furthermore, tumor secretions contained significantly higher levels of immunosuppressive cytokines including TGFβ than non-tumor tissues. Thus, the tumor microenvironment suppresses cytotoxic killing by CD8+ T cells via the secretion of immunosuppressive cytokines leading to decreased expression of intracellular cytolytic molecules. These studies demonstrate the complexity of CD8+ T cell regulation within the endometrial tumor microenvironment and provide a foundation of information essential for the development of therapeutic strategies for gynecological cancers.
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Affiliation(s)
- Mickey V. Patel
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Zheng Shen
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Marta Rodriguez-Garcia
- Department of Immunology, Tufts University School of Medicine, Boston, MA, United States
| | - Edward J. Usherwood
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
| | - Laura J. Tafe
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Charles R. Wira
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Lebanon, NH, United States
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20
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Carrero YN, Callejas DE, Mosquera JA. In situ immunopathological events in human cervical intraepithelial neoplasia and cervical cancer: Review. Transl Oncol 2021; 14:101058. [PMID: 33677234 PMCID: PMC7937982 DOI: 10.1016/j.tranon.2021.101058] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 02/22/2021] [Indexed: 12/15/2022] Open
Abstract
Neoplasia of the cervix represents one of the most common cancers in women. Clinical and molecular research has identified immunological impairment in squamous intraepithelial cervical lesions and cervical cancer patients. The in-situ expression of several cytokines by uterine epithelial cells and by infiltrating leukocytes occurs during the cervical intraepithelial neoplasia and cervical cancer. Some of these cytokines can prevent and others can induce the progression of the neoplasm. The infiltrating leukocytes also produce cytokines and growth factors relate to angiogenesis, chemotaxis, and apoptosis capable of modulating the dysplasia progression. In this review we analyzed several interleukins with an inductive effect or blocking effect on the neoplastic progression. We also analyze the genetic polymorphism of some cytokines and their relationship with the risk of developing cervical neoplasia. In addition, we describe the leukocyte cells that infiltrate the cervical uterine tissue during the neoplasia and their effects on neoplasia progression.
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Affiliation(s)
- Yenddy N Carrero
- Facultad de Ciencias de la Salud. Carrera de Medicina, Universidad Técnica de Ambato, Ambato, Ecuador.
| | - Diana E Callejas
- Departamento de Ciencias Biológicas, Facultad de Ciencias de la Salud, Universidad Técnica de Manabí, Portoviejo, Ecuador.
| | - Jesús A Mosquera
- Instituto de Investigaciones Clínicas Dr. Américo Negrette. Facultad de Medicina, Universidad del Zulia. Maracaibo, Venezuela.
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21
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Schepisi G, Casadei C, Toma I, Poti G, Iaia ML, Farolfi A, Conteduca V, Lolli C, Ravaglia G, Brighi N, Altavilla A, Martinelli G, De Giorgi U. Immunotherapy and Its Development for Gynecological (Ovarian, Endometrial and Cervical) Tumors: From Immune Checkpoint Inhibitors to Chimeric Antigen Receptor (CAR)-T Cell Therapy. Cancers (Basel) 2021; 13:840. [PMID: 33671294 PMCID: PMC7922040 DOI: 10.3390/cancers13040840] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/10/2021] [Accepted: 02/14/2021] [Indexed: 12/24/2022] Open
Abstract
Gynecological tumors are malignancies with both high morbidity and mortality. To date, only a few chemotherapeutic agents have shown efficacy against these cancer types (only ovarian cancer responds to several agents, especially platinum-based combinations). Within this context, the discovery of immune checkpoint inhibitors has led to numerous clinical studies being carried out that have also demonstrated their activity in these cancer types. More recently, following the development of chimeric antigen receptor (CAR)-T cell therapy in hematological malignancies, this strategy was also tested in solid tumors, including gynecological cancers. In this article, we focus on the molecular basis of gynecological tumors that makes them potential candidates for immunotherapy. We also provide an overview of the main immunotherapy studies divided by tumor type and report on CAR technology and the studies currently underway in the area of gynecological malignancies.
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Affiliation(s)
- Giuseppe Schepisi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Chiara Casadei
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Ilaria Toma
- Clinical Oncology, Arcispedale Sant’Anna University Hospital, 44124 Ferrara, Italy;
| | - Giulia Poti
- Istituto Dermopatico dell’Immacolata, IDI IRCCS, 00167 Rome, Italy;
| | - Maria Laura Iaia
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
- Medical Oncology Unit 1, University of Genoa, Ospedale Policlinico San Martino IRCCS, 16132 Genoa, Italy
| | - Alberto Farolfi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Vincenza Conteduca
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Cristian Lolli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Giorgia Ravaglia
- Unit of Biostatistics and Clinical Trials, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy;
| | - Nicole Brighi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Amelia Altavilla
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Giovanni Martinelli
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
| | - Ugo De Giorgi
- Department of Medical Oncology, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Via P. Maroncelli 40, 47014 Meldola, Italy; (C.C.); (M.L.I.); (A.F.); (V.C.); (C.L.); (N.B.); (A.A.); (G.M.); (U.D.G.)
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22
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Qin R, Cao L, Ye C, Wang J, Sun Z. A novel prognostic prediction model based on seven immune-related RNAs for predicting overall survival of patients in early cervical squamous cell carcinoma. BMC Med Genomics 2021; 14:49. [PMID: 33588862 PMCID: PMC7885601 DOI: 10.1186/s12920-021-00885-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 01/25/2021] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND In this study, we aimed to mine immune-related RNAs expressed in early cervical squamous cell carcinoma to construct prognostic prediction models. METHODS The RNA sequencing data of 309 cervical squamous cell carcinoma (CSCC) cases, including data of individuals with available clinical information, were obtained from The Cancer Genome Atlas (TCGA) database. We included 181 early-stage CSCC tumor samples with clinical survival and prognosis information (training dataset). Then, we downloaded the GSE44001 gene expression profile data from the National Center for Biotechnology Information Gene Expression Omnibus (validation dataset). Gene ontology annotation and the Kyoto Encyclopedia of Genes and Genomes pathway analyses were used to analyze the biological functions of differentially expressed immune-related genes (DEIRGs). We established protein-protein interactions and competing endogenous RNA networks using Cytoscape. Using the Kaplan-Meier method, we evaluated the association between the high- and low-risk groups and the actual survival and prognosis information. Our univariate and multivariate Cox regression analyses screened for independent prognostic factors. RESULTS We identified seven prognosis-related signature genes (RBAKDN, CXCL2, ZAP70, CLEC2D, CD27, KLRB1, VCAM1), the expression of which was markedly associated with overall survival (OS) in CSCC patients. Also, the risk score of the seven-gene signature discripted superior ability to categorize CSCC patients into high-risk and low-risk groups, with a observablydifferent OS in the training and validation datasets. We screened two independent prognostic factors (Pathologic N and prognostic score model status) that correlated significantly by univariate and multivariate Cox regression analyses in the TCGA dataset. To further explore the potential mechanism of immune-related genes, we observed associated essential high-risk genes with a cytokine-cytokine receptor interaction. CONCLUSIONS This study established an immune-related RNA signature, which provided a reliable prognostic tool and may be of great significance for determining immune-related biomarkers in CSCC.
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Affiliation(s)
- Rui Qin
- Department of Obstetrics and Gynecology, The Third Hospital of Jilin University, No 126, Xiantai Street, Changchun, Jilin, 130033, People's Republic of China
| | - Lu Cao
- Department of Obstetrics and Gynecology, The Third Hospital of Jilin University, No 126, Xiantai Street, Changchun, Jilin, 130033, People's Republic of China
| | - Cong Ye
- Department of Obstetrics and Gynecology, The Third Hospital of Jilin University, No 126, Xiantai Street, Changchun, Jilin, 130033, People's Republic of China
| | - Junrong Wang
- Department of Obstetrics and Gynecology, The Third Hospital of Jilin University, No 126, Xiantai Street, Changchun, Jilin, 130033, People's Republic of China.
| | - Ziqian Sun
- Department of Obstetrics and Gynecology, The Third Hospital of Jilin University, No 126, Xiantai Street, Changchun, Jilin, 130033, People's Republic of China.
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23
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Guo L, Hua K. Cervical Cancer: Emerging Immune Landscape and Treatment. Onco Targets Ther 2020; 13:8037-8047. [PMID: 32884290 PMCID: PMC7434518 DOI: 10.2147/ott.s264312] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 07/13/2020] [Indexed: 12/24/2022] Open
Abstract
Immune cells are essential for defending the body’s balance and have increasingly been implicated in controlling tumor growth. In cervical cancer (CC), the immune landscape is extensively connected with human papillomavirus (HPV) status. Recent insights from studies have revealed that as a result of infection with HPV, immune cell populations such as lymphocytes or monocytes change during carcinogenesis. Immune therapy, in particular checkpoint inhibitors, those targeting PD-1 or PD-L1, has shown promising efficacy. This article reviews the immune landscape and immunotherapy of CC.
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Affiliation(s)
- Luopei Guo
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, People's Republic of China
| | - Keqin Hua
- Obstetrics and Gynecology Hospital of Fudan University, Shanghai 200011, People's Republic of China.,Shanghai Key Laboratory of Female Reproductive Endocrine Related Diseases, Shanghai 200011, People's Republic of China
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24
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Sancakli Usta C, Altun E, Afsar S, Bulbul CB, Usta A, Adalı E. Overexpression of programmed cell death ligand 1 in patients with CIN and its correlation with human papillomavirus infection and CIN persistence. Infect Agent Cancer 2020; 15:47. [PMID: 32695218 PMCID: PMC7367318 DOI: 10.1186/s13027-020-00312-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 07/12/2020] [Indexed: 01/07/2023] Open
Abstract
Backround HPV causes specific cell-mediated immunity in the cervix. Mononuclear cells such as helper T cells (CD4+), cytotoxic T cells (CD8+), and dendritic cells play a critical role in the initiation of the HPV-specific immune response and destruction of virus-infected cervical epithelial cells. The programmed cell death ligand 1 (PD-L1) gene encodes an immune inhibitory receptor ligand and overexpression of PD-L1 inhibits T-cell activation and cytokine production. The aim of this study was to investigate the expression of PD-L1 in cervical tissue and its correlation with clinicopathological findings. Methods In this cross-sectional study, a total of 94 women who were referred for colposcopy due to abnormal Papanicolaou (PAP) test results and/or HPV positivity were evaluated. The presence of HR-HPV-DNA was analyzed using type- and gene-specific primers along with commercial real-time polymerase chain reaction. The cervical examination was done with a colposcope. Cervical biopsies were obtained from the areas that were evaluated as abnormal during the colposcopy. Histopathological result of cervical biopsies were defined as no intraepithelial neoplasia (CIN 0), mild CIN (CIN I), and moderate-to-high CIN (CIN II-III). All women were classified into four groups based on their HR-HPV positivity and cervical biopsy results: Group I (controls; n = 29), HR-HPV (-) CIN 0; Group II (n = 21), HR-HPV (+) CIN 0; Group III (n = 20), HR-HPV (+) CIN I; and Group IV (n = 24), HR-HPV (+) CIN II-III. A semi-quantitative scoring system was used to evaluate the degree of Ki-67, p16, and PD-L1 immunoreactivity in the cervical tissue samples. Results We found that PD-L1 expression in both mononuclear cells and in cervical epithelial cells gradually increases from the HR-HPV (-), CIN 0 group to the HR-HPV (+), CIN II-III group (p = 0.0003 and p = 0.0394, respectively) and mononuclear PD-L1 expression was correlated with HPV type, initial Pap test results, HPV persistence, and CIN persistence or recurrence (p = 0.0180, p = 0.0109, p = 0.0042, and p = 0.0189, respectively). Moreover, mononuclear PD-L1 expression was also correlated with Ki-67 and p16 immunoreactivity (p = 0.0432 and p = 0.0166, respectively). Epithelial PD-L1 expression was only correlated with HPV type and the presence of HPV persistence (p = 0.0122 and p = 0.0292, respectively). Conclusion During the initial evaluation of the cervical histology results, the assessment of PD-L1 expression-especially in mononuclear cells in cervical tissue samples-may provide more information on the progression of HR-HPV infection and its persistence.
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Affiliation(s)
- Ceyda Sancakli Usta
- Department of Obstetrics and Gynecology, School of Medicine, Balikesir University, Cagis Yerleskesi, Bigadic yolu 17. km pc:10345, Balikesir, Türkiye
| | - Eren Altun
- Department of Pathology, School of Medicine, Balikesir University, Balikesir, Turkey
| | - Selim Afsar
- Department of Obstetrics and Gynecology, Balikesir Ataturk State Hospital, Balikesir, Turkey
| | - Cagla Bahar Bulbul
- Department of Obstetrics and Gynecology, School of Medicine, Balikesir University, Cagis Yerleskesi, Bigadic yolu 17. km pc:10345, Balikesir, Türkiye
| | - Akin Usta
- Department of Obstetrics and Gynecology, School of Medicine, Balikesir University, Cagis Yerleskesi, Bigadic yolu 17. km pc:10345, Balikesir, Türkiye
| | - Ertan Adalı
- Department of Obstetrics and Gynecology, School of Medicine, Balikesir University, Cagis Yerleskesi, Bigadic yolu 17. km pc:10345, Balikesir, Türkiye
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25
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Karpathiou G, Chauleur C, Dal Col P, Dridi M, Hathroubi S, Mobarki M, Peoc'h M. An immunohistochemical analysis of CD3, PD-L1, and CTLA-4 expression in carcinosarcomas of the gynecological tract and their metastases. Pathol Res Pract 2020; 216:153028. [PMID: 32703493 DOI: 10.1016/j.prp.2020.153028] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 05/15/2020] [Accepted: 05/18/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Carcinosarcoma of the gynecological tract is a rare tumor with a dismal prognosis. Its immune micro-environment has not been sufficiently studied. AIM OF THE STUDY To study the immune micro-environment of gynecological carcinosarcomas. MATERIAL AND METHODS Sixty-nine surgical specimens from 37 different patients, including 34 primary tumors and 35 metastases, were immunohistochemically studied for the expression of CD3, PD-L1, and CTLA-4. Clinical and histological features were recorded and correlated with immunohistochemical factors. RESULTS Twenty-two cases involved the uterine corpus, 1 the uterine cervix, and 14 the adnexa. The overall survival ranged from 2 to 156 months, with a median survival of 16 months. CD3 expression was more frequent at the sarcomatous than the carcinomatous component. CTLA-4 expression was higher at the carcinomatous than the sarcomatous component. PD-L1 was negative in all cases studied. Tumor relapse, metastasis presence, metastasis localization, and overall survival did not correlate with CD3 or CTLA-4 expression. CONCLUSION PD-L1 expression is not a feature of gynecological carcinosarcomas, despite a relatively frequent lymphocytic reaction. CTLA-4 expression is sometimes found in these tumors.
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Affiliation(s)
- Georgia Karpathiou
- Department of Pathology, North Hospital, University Hospital of St-Etienne, France.
| | - Celine Chauleur
- Department of Obstetrics and Gynecology, North Hospital, University Hospital of St-Etienne, France
| | - Pierre Dal Col
- Department of Pathology, North Hospital, University Hospital of St-Etienne, France
| | - Maroa Dridi
- Department of Pathology, North Hospital, University Hospital of St-Etienne, France
| | - Sirine Hathroubi
- Department of Pathology, North Hospital, University Hospital of St-Etienne, France
| | - Mousa Mobarki
- Department of Pathology, North Hospital, University Hospital of St-Etienne, France; Department of Pathology, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
| | - Michel Peoc'h
- Department of Pathology, North Hospital, University Hospital of St-Etienne, France
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