Expression of cyclooxygenase-2 (COX-2) in non-neoplastic and neoplastic vulvar epithelial lesions

EP4 as a Negative Prognostic Factor in Patients with Vulvar Cancer

New prognostic factors and targeted therapies are urgently needed to improve therapeutic outcomes in vulvar cancer patients and to reduce therapy related morbidity. Previous studies demonstrated the important role of prostaglandin receptors in inflammation and carcinogenesis in a variety of tumor entities. In this study, we aimed to investigate the expression of EP4 in vulvar cancer tissue and its association with clinicopathological data and its prognostic relevance on survival. Immunohistochemistry was performed on tumor specimens of 157 patients with vulvar cancer treated in the Department of Obstetrics and Gynecology, Ludwig-Maximilian-University of Munich, Germany, between 1990 and 2008. The expression of EP4 was analyzed using the well-established semiquantitative immunoreactivity score (IRS) and EP4 expression levels were correlated with clinicopathological data and patients' survival. To specify the tumor-associated immune cells, immunofluorescence double staining was performed on tissue samples. In vitro experiments including 5-Bromo-2'-Deoxyuridine (BrdU) proliferation assay and 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromid (MTT) viability assay were conducted in order to examine the effect of EP4 antagonist L-161,982 on vulvar carcinoma cells. EP4 expression was a common finding in in the analyzed vulvar cancer tissue. EP4 expression correlated significantly with tumor size and FIGO classification and differed significantly between keratinizing vulvar carcinoma and nonkeratinizing carcinoma. Survival analysis showed a significant correlation of high EP4 expression with poorer overall survival (p = 0.001) and a trending correlation between high EP4 expression and shorter disease-free survival (p = 0.069). Cox regression revealed EP4 as an independent prognostic factor for overall survival when other factors were taken into account. We could show in vitro that EP4 antagonism attenuates both viability and proliferation of vulvar cancer cells. In order to evaluate EP4 as a prognostic marker and possible target for endocrinological therapy, more research is needed on the influence of EP4 in the tumor environment and its impact in vulvar carcinoma.

Assessment of promising protein markers for vulva cancer

OBJECTIVES

To validate the results of a previous study with the tissue microarray technology showing that cyclooxygenase 2 (COX-2) overexpression and absent caspase 3 expression are associated with poor disease-specific survival in univariate analysis.

METHODS

The study group comprised 80 consecutive patients with vulva cancer treated in the period from 1999 to 2003 in a university hospital. A tissue microarray with 3 tumor tissue cores per patient was constructed and stained with antibodies against COX-2, caspase 3, epidermal growth factor receptor, p16 INK4, cyclin D1, and Ki-67. The impact of the expression of these protein markers and selected clinicopathologic variables on disease-specific as well as disease-free survival was measured. Cox proportional hazard model was used for both univariate and multivariate analyses.

RESULTS

In multivariate analysis, lymph node metastases and strong COX-2 expression were related to disease-free (hazard ratio [HR], 8.33, 95% confidence interval [CI], 2.97-23.36; P < 0.001; and HR, 6.42; 95% CI, 2.33-17.72; P < 0.001) and disease-specific survival (HR, 6.04; 95% CI, 2.12-17.19; P = 0.001; and HR, 5.11; 95% CI, 1.82-14.36; P = 0.002). In the present series, no association was found between caspase 3 expression and survival.

CONCLUSION

The prognostic significance of COX-2 overexpression was confirmed. In contrast, in the present series, no relation was found between caspase 3 expression and survival.

COX-2 and Her-2/neu are overexpressed in Paget’s disease of the vulva and the breast: results of a preliminary study

PURPOSE

Paget's disease (PD) of the breast as well as the vulva is a rare condition that accounts for about 4% of breast neoplasms and 1% of vulvar malignancies. Recurrent disease after breast and vulvar surgery might be a challenge. To evaluate relevant molecules therapeutically, tissue from mammary and vulvar PD lesions was investigated immunohistochemically.

METHODS

Histopathologic samples from 11 patients with mammary PD and eight patients with vulvar PD were stained with antibodies against estrogen and progesterone receptors, HER-2/neu and COX-2 followed by semiquantitative evaluation of the staining results.

RESULTS

All tested mammary lesions as well as seven out of eight vulvar PD were negative for estrogen and progesterone receptors. Strong membranous staining for HER-2/neu (Score 3) was seen in all cases. Six out of 8 vulvar and 10 out of 11 mammary PD showed COX-2 overexpression.

CONCLUSIONS

PD of the breast and vulva are negative for estrogens and progesterons, therefore, anti-hormonal therapy is not indicated. The high frequency of Her-2/neu and COX-2 overexpression, however, suggests that these molecules could be therapeutically relevant in patients with PD. These results require further investigation.

The role of angiogenesis and COX-2 expression in the evolution of vulvar lichen sclerosus to squamous cell carcinoma of the vulva

OBJECTIVES

We aimed to determine whether premalignant changes in vulvar lichen sclerosus (LS) could be identified by analysing markers of angiogenesis and the expression of the enzyme cyclooxygenase-2 (COX-2).

METHODS

Eight cases of histologically diagnosed vulvar LS, which showed an evolution to carcinoma of the vulva histologically documented, were compared to 10 cases of vulvar LS, for which follow-up information was available for at least 9 years, and to 10 cases of LS adjacent to squamous cell carcinoma (SCC) of the vulva. The microvessel density (MVD), and the expression of vascular endothelial growth factor (VEGF) and of COX-2 were analysed.

RESULTS

Difference of MVD between unchanged LS cases and LS cases evolving to SCC and LS adjacent to SCC cases was statistically significant (P=0.008, Wilcoxon Mann-Whitney test). Difference of VEGF and COX-2 expression between unchanged LS cases and LS cases evolving to SCC and LS adjacent to SCC cases were statistically significant (P=0.007 and P=0.01, respectively; Fisher's exact test).

CONCLUSIONS

Our study addresses the possibility that immunohistochemical studies may add information to permit the identification of LS as a precursor lesion that has a greater potential to evolve into SCC. These data may identify characteristics of vulvar LS disclosing alterations that indicate the further development to cancer; therefore, it may allow the identification of a group of LS patients who need a careful follow-up and adjunctive biopsies.

Cyclooxygenase 2 expression in cervical intraepithelial neoplasia and vulvar cancer

OBJECTIVE

The purpose of this study is to describe the expression of cyclooxygenase (COX) 2 cervical intraepithelial neoplasia (CIN) and vulvar cancer specimens.

MATERIALS AND METHODS

Archived tissues from 21 cases including 6 cases negative for CIN (no CIN), 71 low-grade (CIN 1) diseases, 8 high-grade (CIN 2, 3) diseases, and 14 vulvar cancer cases were examined. Immunohistochemistry was evaluated in COX-2 expression in tissue using an isoform-specific COX-2 polyclonal antibody. Specimens were assigned an immunohistochemical score for intensity of staining and the percent of cells stained. The slides were scored by 2 independent pathologists and compared across histological categories.

RESULTS

A greater proportion of cells were stained in specimens with high-grade CIN (p = 0.01). Staining intensity was not statistically different among the 3 groups. Higher scores were found for vulvar cancer as compared with normal vulva (p = 0.01).

CONCLUSIONS

The increase in COX-2 in cervical cancer precursors may provide a potential target for prevention studies.

Identification of potential prognostic markers for vulvar cancer using immunohistochemical staining of tissue microarrays

The aim of this study is to determine immunohistochemical markers with prognostic significance for disease-specific survival in patients with squamous cell cancer of the vulva. The study material consisted of slides and paraffin blocks of 50 vulvectomy specimens. A tissue microarray was constructed and stained with 16 antibodies. The impact of lymph node metastases, size of tumor, vascular space involvement, and the marker expression on disease-specific survival was calculated. In univariate analysis lymph node metastases, tumor size more than 4 cm, vascular space involvement, strong cyclooxygenase 2 expression, and absent Caspase 3 expression were significantly associated with disease-specific survival. In a multivariate analysis, poor disease-specific survival is independently associated with absent Caspase 3 expression (hazard ratio, 0.2; 95% confidence interval, 0.04-0.97; P = 0.045). Five-year survival was 86% in patients with tumors positive for Caspase 3 (n = 20) and drops to 64% in patients with Caspase 3-negative tumors (n = 30). In this test set, cyclooxygenase 2 and Caspase 3 seem to be immunohistochemical markers with prognostic significance for vulva cancer. The results have to be validated.

Cyclooxygenase-2 expression in cervical intraepithelial neoplasia III and squamous cell cervical carcinoma, and its correlation with clinicopathologic variables

The objective of the study was to compare cyclooxygenase-2 (COX-2) expression in cervical intraepithelial neoplasia III (CIN III) and squamous cell carcinoma (SCC) of the cervix, and its correlation with clinicopathologic factors of SCC with a review of the available literature. This study included 25 patients with CIN III and 67 patients with stage I-IIa SCC. All patients in the SCC group were treated with radical hysterectomy plus pelvic and para-aortic lymphadenectomy and postoperative chemoradiotherapy based on their histopathologic risk factors. Immunohistochemical analysis was performed on paraffin-embedded sections with COX-2 antibody. COX-2 expression in the SCC group was significantly higher than in the CIN III group (55.2% [37/67] vs 24% [6/25]; P= 0.008). Significantly higher expression of COX-2 was observed in patients with lymphovascular space invasion (LVSI) compared to patients without LVSI (61.9% [34/55] vs 33.3% [3/9]; P= 0.02). Additionally, patients with tumor sizes >4 cm had significantly higher COX-2 expression than patients with tumor sizes <4 cm (65.9% [27/41] vs 39% [10/26] P= 0.028). There was no significant relationship with respect to COX-2 expression and parametrial involvement, lymph node metastasis, recurrences, and survival. In multivariate analysis, LVSI was the only statistically significant determinant for COX-2 expression (P= 0.024; OR = 2.35; 95% CI = 1.1-4.9). Our results and a review of the literature both suggest that COX-2 expression may have a role in the development and progression of CIN III and it is related to some clinicopathologic variables of cervical carcinoma. Further studies are needed to clarify the role of COX-2 inhibitors in the management of CIN and SCC.

Medical treatment of vulvar squamous cell hyperplasia

OBJECTIVE

To evaluate symptomatic response and recurrence rates of graduated topical fluorinated corticosteroid in patients with vulvar squamous cell hyperplasia.

METHODS

Nine hundred seventy-six patients with biopsy-proven vulvar squamous cell hyperplasia from 1990 to 2003 were reviewed in this retrospective study. All patients were treated with graduated topical fluorinated corticosteroid. Data were obtained from hospital records. Symptomatic remission and recurrence rates were noted following six months local therapy.

RESULTS

The mean age was 42.55+/-10.93 (15-85). The remission rate was 93.8% in six months. The remission rate was non-significantly higher in postmenopausal patients than that in their premenopausal counterpart (94.9% vs 93.0%, p=0.15). The disease recurred in 6.9% of patients. Of the patients that suffered recurrence 47.5% had persistent disease initially. The patients with following factors older ages (>40 years), postmenopausal period had significantly higher recurrence rates. Four patients with recurrent disease and six patients with persistent disease in the form of vulvar intraepithelial neoplasia I-II or atypical squamous hyperplasia, were treated with skinning vulvectomy.

CONCLUSION

Corticosteroid in the treatment of vulvar squamous cell hyperplasia yielded excellent response rates. In the evaluation of patients without symptomatic relief, the first step should be a vulvar biopsy to exclude the presence of atypical components.

Aberrant expression of alpha-dystroglycan in cervical and vulvar cancer

OBJECTIVES

Cervical and vulvar cancers develop through well-defined precursor lesions but their exact pathogenesis is still unknown. The dystroglycan complex is a transmembrane glycoprotein that forms a continuous link from the extracellular matrix to the actin cytoskeleton. Deregulated expression of dystroglycan has been reported in human malignancies and related to tumor differentiation and aggressiveness. In this study, expression of dystroglycan was evaluated in the multistep cervical and vulvar tumorigenesis.

METHODS

Expression of the dystroglycan complex was evaluated by immunostaining in lesions representing different stages of vulvar and cervical tumorigenesis using a monoclonal antibody which recognizes carbohydratic epitopes on the alpha-dystroglycan subunit.

RESULTS

alpha-dystroglycan was constantly detected in normal cervical epithelium with a mean percentage of positive cells higher than 80%. A progressive significant reduction in the mean percentage of positive cells was observed in low (67%) and high grade SIL (14%) and in invasive carcinomas (2.6%) of the cervix. In cancers, no differences were observed in terms of percentage of positive cells when cases were stratified according with either tumor grade or stage. A progressive significant reduction in the mean percentage of positive cells was also observed from normal vulvar epithelium (90%) to VIN1 (66%), VIN2 (28%) and invasive vulvar carcinomas (22%). No significant decrease in the alpha-dystroglycan staining was observed in squamous cell hyperplasia lesions (85%) while lichen sclerosus displayed a percentage of positive cells (47%) significantly lower than normal epithelium.

CONCLUSIONS

Detection of alpha-dystroglycan is frequently lost in human cervical and vulvar tumorigenesis and further studies are warranted to verify whether evaluation of this molecule might serve as marker of risk progression of preneoplastic lesions and to better understand its significance in terms of cancer development.

Prediction of lymph node metastases in vulvar cancer: a review

The aim of this study was to review the literature on currently available non- and minimally-invasive diagnostic methods and analysis of primary tumor characteristics for prediction of inguinofemoral lymph node metastases in patients with primary squamous cell carcinoma of the vulva. We used the English language literature in PubMed and reference lists from selected articles. Search terms included vulvar carcinoma, prognosis, lymph node metastases, ultrasound, computer tomography, magnetic resonance imaging, positron emission tomography, and sentinel lymph node. No study type restrictions were imposed. Currently no noninvasive imaging techniques exist that are able to predict lymph node metastases with a high enough negative predictive value. A depth of invasion < or =1 mm is the only histopathologic parameter that can exclude patients for complete inguinofemoral lymphadenectomy. No other clinicopathologic parameter allows exclusion of lymph node metastases with a high enough negative predictive value. The minimally invasive sentinel node procedure is a promising technique for selecting patients for complete lymphadenectomy, but its safety has not been proven yet.

Expression of the CDK inhibitor p27kip1 and oxidative DNA damage in non-neoplastic and neoplastic vulvar epithelial lesions

Vulvar cancer represents an important medical problem worldwide whose incidence is increasing at an alarming rate in young females. Several factors have been linked to vulvar cancer development, but its exact pathogenesis remains to be determined. Vulvar tumorigenesis proceeds through intermediate dysplastic lesions, known as vulvar intraepithelial neoplasias, frequently associated with non-neoplastic epithelial disorders of the vulva, such as lichen sclerosus and squamous cell hyperplasia. In this study, the expression of the CDK inhibitor p27Kip1 and the extent of endogenous oxidative DNA damage were evaluated in vulvar specimens, including normal tissues, lichen sclerosus, squamous cell hyperplasia, vulvar intraepithelial neoplasias and invasive squamous cell carcinomas. We found that p27Kip1 was constantly expressed in normal vulvar epithelium cells while a progressive significant reduction in the percentage of p27Kip1-positive cells was observed in vulvar intraepithelial neoplasias (77%) and in invasive carcinomas (64%). Mean percentage of positive cells in invasive carcinomas, but not in vulvar intraepithelial neoplasias, was also significantly lower than squamous cell hyperplasia lesions (78%) while lichen sclerosus displayed a percentage of positive cells (45%) significantly lower than both vulvar intraepithelial neoplasias and invasive carcinomas. 8-hydroxydeoxyguanosine (8-OHdG) is considered a sensitive biomarker for oxidative stress. We observed a progressive significant increase in the levels of 8-OHdG and in the percentage of positive cells from normal vulvar epithelium to vulvar intraepithelial neoplasias (25%) and to invasive carcinomas (64%). Squamous cell hyperplasia displayed an intermediate percentage of positive cells comparable to vulvar intraepithelial neoplasias 2 but significantly higher than vulvar intraepithelial neoplasias 1 and lower than invasive carcinomas. Lichen sclerosus staining was significantly lower than carcinomas but higher than vulvar intraepithelial neoplasias and squamous cell hyperplasia. These results demonstrate that expression of p27Kip1 is downregulated while oxidative DNA damage increases from early non-neoplastic epithelial alterations through vulvar intraepithelial neoplasias to invasive vulvar carcinomas. Thus, both parameters might play an important role in the development of this cancer and their study might contribute to our understanding of human vulvar carcinogenesis.

Cyclooxygenase-2 (COX-2) Immunostaining Does Not Correlate With the Degree of Vulvar Neoplasia

OBJECTIVE

The cyclooxygenase-2 (COX-2) enzyme is up-regulated in inflammatory and neoplastic conditions. In the last decade, its biological role has been investigated in various pre-invasive and invasive cancers with the hope that it can serve as a target for cancer prevention and treatment.

METHODS

We evaluated the expression of COX-2 in vulvar biopsies to determine its relationship to the degree of dysplasia. COX-2 expression was studied by immunohistochemistry in 62 consecutive vulvar biopsies divided into four diagnostic groups. Group 1 included inflamed vulva (n = 14); group 2, vulvar intraepithelial neoplasia (VIN) I and VIN II (n = 20); group 3, VIN III and carcinoma in situ (n = 18); and group 4, invasive squamous cell carcinoma (n = 10). Representative sections were immunostained using polyclonal anti-COX-2 antibodies at concentration 1:25 without pretreatment. Immunostaining was scored according to the proportion of positive epithelial cells in the vulvar mucosa as 0 (no positive cells), 1(< 5% positive), 2 (6-50% positive), or 3 (> 50% positive).

RESULTS

Mean immunostaining scores were 1.6, 1.4, 0.7, and 1.2 for groups 1, 2, 3, and 4, respectively. Scores were different between the groups (chi(2) = 9.908, P = 0.019) as shown by Cochran-Mantel-Haenszel statistical analysis (modified ridit scores), but did not correlate with age or the degree of dysplasia. The strongest staining for COX-2 was in the inflammatory group.

CONCLUSION

COX-2 staining in inflamed, dysplastic, and malignant vulvar epithelium is variable but, as shown in this study, does not correlate with the degree of vulvar dysplasia or malignancy.