Prognostic factors in invasive cervical carcinomas associated with human papillomavirus (HPV). Quantitative data and cytokeratin expression

Positive Linear Relationship between Nucleophosmin Protein Expression and the Viral Load in HPV-Associated Oropharyngeal Squamous Cell Carcinoma: A Possible Tool for Stratification of Patients

Most oropharyngeal squamous cell carcinomas (OPSCCs) are human papillomavirus (HPV)-associated, high-risk (HR) cancers that show a better response to chemoradiotherapy and are associated with improved survival. Nucleophosmin (NPM, also called NPM1/B23) is a nucleolar phosphoprotein that plays different roles within the cell, such as ribosomal synthesis, cell cycle regulation, DNA damage repair and centrosome duplication. NPM is also known as an activator of inflammatory pathways. An increase in NPM expression has been observed in vitro in E6/E7 overexpressing cells and is involved in HPV assembly. In this retrospective study, we investigated the relationship between the immunohistochemical (IHC) expression of NPM and HR-HPV viral load, assayed by RNAScope in situ hybridization (ISH), in ten patients with histologically confirmed p16-positive OPSCC. Our findings show that there is a positive correlation between NPM expression and HR-HPV mRNA (Rs = 0.70, p = 0.03), and a linear regression (r² = 0.55; p = 0.01). These data support the hypothesis that NPM IHC, together with HPV RNAScope, could be used as a predictor of transcriptionally active HPV presence and tumor progression, which is useful for therapy decisions. This study includes a small cohort of patients and, cannot report conclusive findings. Further studies with large series of patients are needed to support our hypothesis.

AgNOR Pleomorphic Count as a Tumor Marker in Cervical Carcinogenesis and Feasibility of Its Introduction in Cervical Cancer Screening Programs to Discriminate High-Risk Cases of Squamous Intraepithelial Lesions of the Cervix

BACKGROUND

AgNOR pleomorphism has been widely used for its diagnostic importance in differentiating premalignant and malignant lesions of different human neoplasms. However, an evaluation of its potential for discriminating cases of high-risk squamous intraepithelial lesions of the cervix (SIL) has been rarely attempted.

AIM

The tumor marker potential of AgNOR pleomorphism counts was assessed by correlating high and low mean counts in low-grade SIL (LSIL) cases with persistence or regression of the lesion and HPV positivity.

MATERIALS AND METHODS

The 115 LSIL cases selected for the study were registered from the ongoing cervical cancer screening of the rural population of Lucknow West. Silver nitrate staining for AgNOR counts and HPV DNA testing were done in all 115 cases.

RESULTS

The AgNOR counts in the 115 LSIL cases revealed low counts in 92 and high counts in 23 cases. Follow-up, available in 107 cases, revealed persistence of the lesion in 21 of the 23 cases with high counts and in 4 of the 84 cases with low counts. HPV positivity showed a strong correlation with high counts. Persistence of LSIL was also more frequent with high AgNOR counts and in HPV-positive cases.

CONCLUSIONS

The study showed a correlation of high mean AgNOR counts with HPV positivity and persistence of LSIL.

Silver-stained nucleolar organizer regions in normal and dysplastic cervical lesions: correlation with DNA ploidy and S-phase fraction by flow cytometry

OBJECTIVES

To investigate the prognostic significance of DNA ploidy and silver-stained nucleolar organizer regions (AgNOR), their relation to the cytological grades of cervical dysplasia and correlation of cells in the S-phase of the cell cycle and DNA ploidy with AgNOR count.

METHODS

Multiparametric DNA flow-cytometric analysis and AgNOR count were performed on cervical smear samples, cytologically diagnosed as normal (n = 196), atypical squamous cells of unknown significance (ASCUS, n = 98) and various grades of cervical dysplasia (n = 127).

RESULTS

Among the cytological grade, aneuploid cases from low-grade squamous intraepithelial lesion (mild) and high-grade squamous intraepithelial lesion (moderate and severe) groups were showing high AgNOR counts (ranges 4.33-5.86 and 5.91-7.42, respectively). Aneuploid cases from the ASCUS group also presented high AgNOR (range 3.72-4.93). The high percentage of cells in the S-phase (>12%) correlated with these 2 parameters in the ASCUS and dysplasia groups. After grouping the cases into those with high (>4.0) and low (<4.0) AgNOR counts, significant correlations in the group with high AgNOR count with DNA ploidy, S-phase and cytological grade were recorded (p < 0.001). Results obtained from follow-up study revealed that cases with aneuploidy, high AgNOR count and S-phase fraction presented with a progressive trend of disease.

CONCLUSIONS

Thus, the study shows that high AgNOR count, S-phase fraction and aneuploid DNA have prognostic significance in the early detection of cervical cancer.

Gene expression profiles in squamous cell cervical carcinoma using array-based comparative genomic hybridization analysis

Our aim was to identify novel genomic regions of interest and provide highly dynamic range information on correlation between squamous cell cervical carcinoma and its related gene expression patterns by a genome-wide array-based comparative genomic hybridization (array-CGH). We analyzed 15 cases of cervical cancer from KangNam St Mary's Hospital of the Catholic University of Korea. Microdissection assay was performed to obtain DNA samples from paraffin-embedded cervical tissues of cancer as well as of the adjacent normal tissues. The bacterial artificial chromosome (BAC) array used in this study consisted of 1440 human BACs and the space among the clones was 2.08 Mb. All the 15 cases of cervical cancer showed the differential changes of the cervical cancer-associated genetic alterations. The analysis limit of average gains and losses was 53%. A significant positive correlation was found in 8q24.3, 1p36.32, 3q27.1, 7p21.1, 11q13.1, and 3p14.2 changes through the cervical carcinogenesis. The regions of high level of gain were 1p36.33-1p36.32, 8q24.3, 16p13.3, 1p36.33, 3q27.1, and 7p21.1. And the regions of homozygous loss were 2q12.1, 22q11.21, 3p14.2, 6q24.3, 7p15.2, and 11q25. In the high level of gain regions, GSDMDC1, RECQL4, TP73, ABCF3, ALG3, HDAC9, ESRRA, and RPS6KA4 were significantly correlated with cervical cancer. The genes encoded by frequently lost clones were PTPRG, GRM7, ZDHHC3, EXOSC7, LRP1B, and NR3C2. Therefore, array-CGH analyses showed that specific genomic alterations were maintained in cervical cancer that were critical to the malignant phenotype and may give a chance to find out possible target genes present in the gained or lost clones.

Morphometric evaluation of nucleolar organizer regions in cervical intraepithelial neoplasia

The objective of this study was to determine whether some morphometric parameters and two different methods of counting AgNOR dots were correlated with the grade of cervical intraepithelial neoplasia. Thirty uterine cervix biopsies (8 cases of cervicitis, 9 CIN I, CIN II and 6 CIN III) were studied. Two methods were used to count AgNOR dots. The first one consisted of counting the number of epithelial cells with 1, 2, 3, 4, or more dots. The second method, based on a computer analysis system, consisted of counting the total number of dots in 100 cells, without considering the number of dots per cell. Using the same computer analysis system, the following parameters were measured: area, diameter, perimeter, roundness and length of each dot. The following parameters were found to be correlated with the grade of intraepithelial neoplasia: 1) number of cells with 1 dot, which decreased with increasing grade of cervical intraepithelial neoplasia; 2) number of cells with 4 dots or more, which increased with increasing grade of cervical intraepithelial neoplasia; 3) total number of dots per 100 cells, which progressively increased with increasing grade of intraepithelial neoplasia. We conclude that counting cells with 4 or more dots is the more trustworthy parameter for distinguishing the grade of cervical intraepithelial neoplasia.

Inflammatory response in cervical intraepithelial neoplasia and squamous cell carcinoma of the uterine cervix

Leukocytic infiltrates are a morphologic feature of most solid tumors, including uterine cervical intraepithelial neoplasia (CIN) and invasive carcinoma. We have studied 50 cases of CIN I, CIN II, CIN III, invasive carcinoma and normal controls in order to evaluate the inflammatory response. Two markers--CD68, a macrophage-specific marker, and ICAM-1, present on leukocytes, blood vessels and epithelial cells--were employed. Results have demonstrated similar inflammatory cell counts in normal, CIN II and CIN III lesions by both markers, and lower counts for CIN I. Invasive carcinomas demonstrated a statistically significant increase in infiltrate density by both CD68 (p < 0.002) and ICAM-1 (p < 0.05). Macrophage density by either marker did not correlate with Human Papillomavirus (HPV) presence, specific type, or evidence of co-infection with several types. We conclude that the inflammatory response to cervical intraepithelial-neoplasia is inadequate. The elevated cell counts in invasive carcinomas may reflect a reaction towards invasion rather than tumor-specific immune response. Depression of inflammation in CIN I lesions may be associated with active viral replication in these lesions.

HPV- and node status in cervical cancer long-term results

OBJECTIVE

To evaluate prognostic significance of HPV-status in cervical cancer and to compare that with the prognostic significance of lymph-node status.

METHODS

Cervical cancer biopsy specimens from primaries and, in surgical cases, from pelvic lymph-nodes too were analysed for the presence of human papillomavirus type 16 DNA-sequences using PCR technique. The management of surgical cases with two exceptions included Wertheim's hysterectomy predominantly with preoperative local radiotherapy and also with postoperative local and external beam radiotherapy depending on the histology. Non-surgical cases were treated with combined local and external radiotherapy to pelvic fields.

RESULTS

Patients have been followed up for an average of 37 months after treatment ranging between 0 and 102 months. The mean progression-free survival time of surgical and non-surgical cases were 43 and 28 months, respectively. Patients with HPV-16 positive biopsies from the cervical primary had an average progression-free survival of 37 months, the same as those with HPV-16 negative cervical biopsies. Those patients who were found to carry HPV-16 DNA in their surgically removed pelvic lymph-nodes had an average of 27 months progression-free survival. The mean progression-free survival among histologically node-positive and node-negative surgical cases were 23 and 42 months, respectively. The mean progression-free survival time of node-positive cases with HPV-16 positive cervical primary was 7.5 months while that of patients with HPV-16 negative cervical biopsy was 38 months. Among histologically node-negative patients, HPV-16 positive and negative cases had an average progression-free survival time of 38 and 46 months, respectively.

CONCLUSIONS

Among those under investigation the most important factors to predict progression-free survival were surgically amenable disease, histologically negative pelvic lymph-nodes and HPV-16 negative cervical biopsies, though this latter one proved significant only among surgical cases.

Prevalence of human papillomavirus 16 and nucleolar organizer region counts in oral exfoliated cells from normal and malignant epithelia

This study was designed to identify the prevalence of human papillomavirus 16 (HPV 16) in oral exfoliated cells from 26 patients with oral cancer and matched healthy volunteers with the use of polymerase chain reaction. In addition, the value of a silver staining technique for nucleolar organizer regions (AgNORs) was also investigated. HPV 16 was detected in 30.8% of the cancer lesions, 26.9% of the unaffected sites, and 15.4% of samples from normal mucosa. AgNOR counts on the same cases were analyzed. Although AgNOR counts are useful in distinguishing between normal and malignant oral exfoliated cells, they provided no additional prognostic information for oral cancer. However, when AgNOR counts were compared with HPV 16-positive and HPV 16-negative counts in cancer lesions, AgNOR counts were higher in HPV-positive lesions. These findings suggest that HPV 16 may play a role in tumor cell proliferation, but it is unlikely to play a significant role alone in the cause of oral cancer. Therefore evidence of HPV 16 infection in oral malignant neoplasms should be cautiously interpreted.

Female genital tract cancer

BACKGROUND

Site-specific cancer frequencies and incidence rates are reported regularly by the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program, but not by histologic type within site. This report reviews data for 160,977 histologically or cytologically confirmed invasive and in situ cancers of the female genital tract.

METHODS

Data were supplied by the SEER program for histologically confirmed cases of uterine corpus, uterine cervix, ovary, vulva, vagina, fallopian tube, and placental cancers diagnosed between 1973 and 1987. Histologic types were reviewed for race, age at diagnosis, incidence, stage, and survival.

RESULTS

There were 89,943 invasive and 71,034 in situ neoplasms. Squamous carcinoma was the most common invasive malignancy of the cervix (77.1%), vulva (74.4%), and vagina (70.8%). Adenocarcinoma was the most frequent malignancy in the uterine corpus (81.5%) and ovary (86.6%), with these percentages reaching 91.6% for corpus and 86.9% for ovary if adenosquamous carcinoma and adenocarcinoma with squamous metaplasia are included. Cervical carcinoma in situ accounted for 91.0% of all in situ cancers. In situ cancers made up 78.5% of all cervical cancers, 35.1% of vaginal cancers, and 50.4% of vulvar cancers.

CONCLUSIONS

There are dominant histologic groups in each female genital tract site that are largely responsible for incidence and survival statistics. Within the groups, however, there are subtypes with differing features. Epidemiologic studies may provide more definite information by considering the effect of these subtypes in examining risk factors.

Expression of cytokeratin 10, 13, and involucrin as prognostic factors in low stage squamous cell carcinoma of the uterine cervix

BACKGROUND

The identification of pretreatment markers with predictive significance for the presence of lymph node metastases and treatment outcome in low stage cancer of the uterine cervix is clinically important. Because the presence of differentiation-related markers varies in this type of cancer, the authors investigated whether loss of these markers is related to a poor clinical course.

METHODS

An indirect immunoperoxidase technique was applied to formalin fixed, paraffin embedded tissue sections of 80 patients with International Federation of Gynecology and Obstetrics Stage IB and IIA primary squamous cell cervical carcinomas for detection of expression of cytokeratin 10 and 13, and involucrin. Comparisons were made of the expression of each of these markers among 40 patients with regional node metastases and 40 age-matched patients with no lymph node metastases. Differences in the frequency of expression of these markers also were analyzed in relation to histopathologic characteristics, recurrence, and survival.

RESULTS

Expression of cytokeratin 10, 13, and involucrin was found in 24, 64, and 53%, respectively, of all patients studied. The authors found no differences between patients with positive regional lymph nodes and those with negative lymph nodes. Expression of cytokeratin 13 and involucrin was associated with tumor grade (P = 0.01). No relationship was found between expression of the markers used and recurrence or survival in the entire group. Within the lymph node-positive group, however, the survival rate of patients with tumors with cytokeratin 13 expression was significantly higher than that of patients with tumors lacking cytokeratin 13 expression (P = 0.02).

CONCLUSION

Expression of cytokeratin 10, 13, or involucrin in the primary tumor is of no predictive value with respect to the presence of regional lymph node metastases in low stage squamous cell cervical cancer. However, cytokeratin 13 expression appears to be of prognostic significance in patients with positive regional lymph nodes.

Nucleolar organizer regions and cervical intraepithelial neoplasia among women with human immunodeficiency virus infection

OBJECTIVE

Our purpose was to evaluate the proliferative activity of cervical intraepithelial neoplasia lesions in human immunodeficiency virus-seropositive women.

STUDY DESIGN

The proliferative activity of cervical intraepithelial neoplasia lesions was measured by nucleolar organizer regions-associated proteins count. Twenty-two biopsy specimens of cervical intraepithelial neoplasia lesions from patients positive for human immunodeficiency virus were compared with 22 matched biopsy specimens obtained from controls negative for the virus.

RESULTS

The mean count of nucleolar organizer regions-associated proteins per cell was 9.5 +/- 3.7 (SD) in human immunodeficiency virus-positive patients and 7.6 +/- 2.8 in human immunodeficiency virus-negative controls (p < 0.0001 by Poisson test of heterogeneity of counts). The difference in counts between the two groups, which was confirmed by log-linear analysis, persisted within each severity stratum of cervical intraepithelial neoplasia and was independent of associated human papillomavirus infection. In human immunodeficiency virus-positive patients log-linear analysis showed that high-grade cervical intraepithelial neoplasia, the presence of human papillomavirus infection, and the severity of human immunodeficiency virus disease were independently correlated with increased nucleolar organizer regions-associated protein counts per cell.

CONCLUSION

The results of this study indicate that the proliferative activity of cervical intraepithelial neoplasia lesions of human immunodeficiency virus-positive patients was increased compared with matched lesions from human immunodeficiency virus-negative women. This finding suggests the possibility of an increased oncogenic progression of cervical intraepithelial neoplasia lesions in human immunodeficiency virus-positive patients.