Progesterone receptor status is a significant prognostic variable of progression-free survival in advanced epithelial ovarian cancer

Contribution of Immunohistochemistry in Prognostic Assessment of Epithelial Ovarian Carcinoma – Review of the Literature I

Epithelial ovarian carcinoma is worldwide the sixth most common female cancer, and this malignancy carries the highest mortality among all gynecological cancers. The high mortality is due mostly to the fact that the tumor is frequently diagnosed late, in advanced stage, as the early disease is often asymptomatic and no effective screening methods are available. The most important prognostic factors in ovarian carcinoma are the stage, size of residual tumor following surgery, presence of ascites, age and the general condition of the patient, tumor histology, and, in patients with early disease, also the grade of the tumor. Large number of studies on prognostic and predictive factors in epithelial ovarian carcinoma has been published, often with contradictory results. The most intensely studied prognostic factors are those for expression of hormonal receptors, for tumor proliferation activity (mainly by antigen Ki-67 and topoisomerase IIα), the markers of apoptosis (p53, p21, mdm2, bcl-2 and other proteins), or other oncoproteins (particularly HER-2/neu).

Prognostic value of progesterone receptor expression in ovarian cancer: a meta-analysis

Objective

While a prognosis value of progesterone receptor (PR) in ovarian cancer has been reported in some publications, controversial data were presented by different reports. In order to address the disagreement of progesterone receptor in ovarian cancer survival, we conducted this meta-analysis.

Methods

Relevant articles on progesterone receptor and ovarian cancer prognosis were identified via a thorough search of PubMed, Embase and Cochrane Central. Hazard ratios (HR) and 95% confidence interval (CI) were extracted from studies on overall survival (OS) and disease-free survival (DFS)/progress-free survival (PFS)/recurrence-free survival (RFS).

Result

A total of 28 eligible studies containing 5685 patients were collected for analysis. It was found that progesterone receptor positivity was significantly associated with favorable overall survival (OS) (HR = 0.86, 95% CI = 0.78 to 0.95, P = 0.002) and disease-free survival (DFS)/progress-free survival (PFS)/recurrence-free survival (RFS) (HR = 0.75, 95% CI = 0.61 to 0.93, P = 0.008) of ovarian cancer patients. Subgroup analysis showed that progesterone receptor expression was associated with a favorable prognosis of unclassified ovarian cancer, European origin, and immunohistochemical detection method.

Conclusion

Progesterone receptor expression can be used as a favorable prognostic predictor in ovarian cancer managements.

Active FOXO1 Is a Key Determinant of Isoform-Specific Progesterone Receptor Transactivation and Senescence Programming

Progesterone promotes differentiation coupled to proliferation and prosurvival in the breast, but inhibits estrogen-driven growth in the reproductive tract and ovaries. Herein, it is demonstrated, using progesterone receptor (PR) isoform-specific ovarian cancer model systems, that PR-A and PR-B promote distinct gene expression profiles that differ from PR-driven genes in breast cancer cells. In ovarian cancer models, PR-A primarily regulates genes independently of progestin, while PR-B is the dominant ligand-dependent isoform. Notably, FOXO1 and the PR/FOXO1 target gene p21 (CDKN1A) are repressed by PR-A, but induced by PR-B. In the presence of progestin, PR-B, but not PR-A, robustly induced cellular senescence via FOXO1-dependent induction of p21 and p15 (CDKN2B). Chromatin immunoprecipitation (ChIP) assays performed on PR isoform-specific cells demonstrated that while each isoform is recruited to the same PRE-containing region of the p21 promoter in response to progestin, only PR-B elicits active chromatin marks. Overexpression of constitutively active FOXO1 in PR-A-expressing cells conferred robust ligand-dependent upregulation of the PR-B target genes GZMA, IGFBP1, and p21, and induced cellular senescence. In the presence of endogenous active FOXO1, PR-A was phosphorylated on Ser294 and transactivated PR-B at PR-B target genes; these events were blocked by the FOXO1 inhibitor (AS1842856). PR isoform-specific regulation of the FOXO1/p21 axis recapitulated in human primary ovarian tumor explants treated with progestin; loss of progestin sensitivity correlated with high AKT activity.

IMPLICATIONS

This study indicates FOXO1 as a critical component for progesterone signaling to promote cellular senescence and reveals a novel mechanism for transcription factor control of hormone sensitivity.

Progesterone action in breast, uterine, and ovarian cancers

Progesterone and progesterone receptors (PRs) are essential for the development and cyclical regulation of hormone-responsive tissues including the breast and reproductive tract. Altered functions of PR isoforms contribute to the pathogenesis of tumors that arise in these tissues. In the breast, progesterone acts in concert with estrogen to promote proliferative and pro-survival gene programs. In sharp contrast, progesterone inhibits estrogen-driven growth in the uterus and protects the ovary from neoplastic transformation. Progesterone-dependent actions and associated biology in diverse tissues and tumors are mediated by two PR isoforms, PR-A and PR-B. These isoforms are subject to altered transcriptional activity or expression levels, differential crosstalk with growth factor signaling pathways, and distinct post-translational modifications and cofactor-binding partners. Herein, we summarize and discuss the recent literature focused on progesterone and PR isoform-specific actions in breast, uterine, and ovarian cancers. Understanding the complexity of context-dependent PR actions in these tissues is critical to developing new models that will allow us to advance our knowledge base with the goal of revealing novel and efficacious therapeutic regimens for these hormone-responsive diseases.

Progesterone receptors induce FOXO1-dependent senescence in ovarian cancer cells

Loss of nuclear progesterone receptors (PR) and low circulating progesterone levels are associated with increased ovarian cancer (OC) risk. However, PR are abundantly expressed in a significant percentage of serous and endometrioid ovarian tumors; patients with PR+ tumors typically experience longer progression-free survival relative to those with PR-null tumors. The molecular mechanisms of these protective effects are poorly understood. To study PR action in OC in the absence of added estrogen (i.e., needed to induce robust PR expression), we created ES-2 OC cells stably expressing vector control or GFP-tagged PR-B (GFP-PR). Progestin (R5020) stimulation of ES-2 cells stably expressing GFP-PR induced cellular senescence characterized by altered cellular morphology, prolonged survival, senescence-associated β-galactosidase activity, G1 cell cycle arrest and upregulation of the cell cycle inhibitor, p21, as well as the Forkhead-box transcription factor, FOXO1; these results repeated in unmodified ER+/PR+ PEO4 OC cells. PR-B and FOXO1 were detected within the same PRE-containing regions of the p21 upstream promoter. Knockdown of p21 resulted in molecular compensation via FOXO1-dependent upregulation of numerous FOXO1 target genes (p15, p16, p27) and an increased rate of senescence. Inhibition of FOXO1 (with AS1842856) or stable FOXO1 knockdown inhibited progestin-induced p21 expression and blocked progestin-induced senescence. Overall, these findings support a role for PR as a tumor suppressor in OC cells, which exhibits inhibitory effects by inducing FOXO1-dependent cellular senescence. Clinical "priming" of the PR-FOXO1-p21 signaling pathway using PR agonists may provide a useful strategy to induce irreversible cell cycle arrest and thereby sensitize OC cells to existing chemotherapies as part of combination "two-step" therapies.

Survival of women with ovarian carcinomas and borderline tumors is not affected by estrogen and progesterone receptor status

Objective

To examine the patterns of estrogen receptor (ER) and progesterone receptor (PR) expression in borderline ovarian tumors (BOTs) and ovarian carcinomas. We also assessed the disease-free survival (DFS) and overall survival (OS) in women with ovarian carcinoma, in relation to ER and/or PR expression.

Methods

We examined ER/PR expression in 38 BOTs and 172 ovarian carcinomas removed from patients treated at the State University of Campinas-UNICAMP (Brazil), from 1993 to 2008 and followed for up to 60 months using tissue microarray-based immunohistochemistry.

Results

Twenty-eight (73.7%) mucinous and 10 (26.3%) serous BOTs were included. Ovarian carcinomas consisted mainly of 79 (46.0%) serous, 44 (25.5%) mucinous, 17 (9.8%) endometrioid, 10 (5.8%) clear-cell types. There was no significant difference of the ER/PR expression between BOT and ovarian carcinoma (p=0.55 for ER alone, 0.90 for PR alone, and 0.12 for combined expression). The level of ER/PR expression in BOTs was significantly higher in serous than in mucinous tumors (p<0.01). In carcinomas, ER/PR was higher in serous tumors than in mucinous (p<0.01) and clear cell tumors (p=0.02), and higher in endometrioid tumors than in mucinous tumors (p<0.01). DFS was affected neither by the clinical characteristics nor by combined steroid receptor status. OS was found to be significantly worse (p<0.01) only in women with stages II-IV tumors and those with residual disease after surgery (p<0.01).

Conclusion

Overall, serous and endometrioid tumors were predominantly ER/PR positive, whereas mucinous and clear-cell tumors were preponderantly ER/PR negative. DFS and OS were not affected by ER/PR expression.

Evaluation of a hormone receptor-positive ovarian carcinoma subtype with a favourable prognosis by determination of progesterone receptor and oestrogen receptor 1 mRNA expression in formalin-fixed paraffin-embedded tissue

AIMS

In vitro and epidemiological studies indicate an essential role for progesterone in the aetiology and progression of ovarian carcinoma. The aim of this study was to examine the prognostic role of progesterone receptor (PR) protein and mRNA expression.

METHODS AND RESULTS

PR expression was examined by immunohistochemistry (n=143) and kinetic reverse transcription-polymerase chain reaction (RT-PCR) from formalin-fixed and paraffin-embedded tissue (n=55). PR mRNA and protein expression correlated (P<0.0001). PR mRNA was a positive predictor for overall and progression-free survival (P=0.0005 and P<0.0001, respectively). Protein expression was also prognostic (P=0.015 and P=0.0011, respectively), whereas only PR mRNA retained its prognostic value on multivariate analysis (P=0.04). PR mRNA was still a positive prognostic marker among oestrogen receptor 1 (ESR1) mRNA-positive tumours (P=0.0007) and survival was best in patients with PR- and ESR1-positive phenotypes (P=0.0155 and P=0.0016, respectively).

CONCLUSION

Expression of PR and ESR1 defines a subgroup of ovarian carcinomas with a favourable prognosis. PR and ESR1 mRNA expression analysis is a sensitive, quantitative and easy-to-perform high-throughput analytical tool for the identification of this subgroup and could be predictive in clinical trials focused on patients with potential benefit from hormonal treatment.

Correlation Between Immunohistochemical Biomarkers Expression and Prognosis of Ovarian Carcinomas in Tunisian Patients

Background

Ovarian cancer is the leading cause of death from gynaecological malignancies. Newer biological prognostic factors and predictors of response to therapy are needed. Our study was designed to evaluate the expression of p53, Bcl-2, Estrogen receptor (ER) and Progesterone receptor (PR) in ovarian carcinoma and to compare it with other prognostic parameters such as age, FIGO stage, size of residual tumor, histological type and grade.

Methods

This is a retrospective study conducted in the department of pathology at Sfax University Hospital. Confirmed 57 cases of ovarian carcinoma were reviewed in the period between January 1995 and December 2006. We used immunohistochemistry to evaluate the expression of p53, Bcl-2, ER and PR receptors and Chi-Square and Student test to correlate immunohistochemical findings with some prognostic parameters of ovarian carcinoma.

Results

The percentage of expression of p53, Bcl-2, ER and PR was 73,7; 47,4; 35,1 and 33,3 % respectively. p53 overexpression correlated with an advanced FIGO stage (p = 0,026) and presence of ascitis (p < 10^-4). The expression of PR was associated with an early stage (FIGO I and II), a non serous histologic type and a low tumour grade (p = 0,045; 0,010 and 0,036 respectively). No correlation was found between Bcl-2 and ER and prognostic parameters. Survival analysis revealed that Bcl-2 status, FIGO stage, presence of ascites, peritoneal cytology, and residual disease were significant predictive factors of survival.

Conclusion

p53 expression correlates with a worse prognosis in epithelial ovarian cancer, whereas Bcl-2 expression is related to a better outcome. For hormonal status, expression of PR is found to be an independent indicator of favourable prognosis. These results should be supported by more and larger studies.

Prognosis and hormone receptor status in older and younger patients with advanced-stage papillary serous ovarian carcinoma

OBJECTIVE

Prior studies have suggested that patients diagnosed with ovarian cancer at an older age have worse outcomes. However, few studies have examined whether differing patterns of protein expression in tumors in older patients correlate with this poorer prognosis. We investigated the correlation of age with prognosis and the significance of hormone receptor status in younger versus older patients through construction of a clinically-annotated high-density tissue microarray (HTMA) composed of stage III and IV papillary serous ovarian cancer cases.

METHODS

Two cohorts of patients (age > or =65 and < or =55 at diagnosis) were identified retrospectively from ovarian carcinoma pathology cases reviewed at our institution between 1999 and 2005. An HTMA was constructed from 148 eligible cases, and clinical data were abstracted through chart and database review.

RESULTS

No difference in survival was observed between younger and older patients. Patients > or =70 years had decreased survival on univariate, but not multivariate, analysis. ER was significantly more likely (p=0.01) and PR significantly less likely (p=0.02) to be expressed in older patients. Neither ER nor PR independently correlated with survival in the overall study population.

CONCLUSIONS

Patients with advanced-stage papillary serous ovarian cancer > or =65 years of age at diagnosis have a similar survival as patients < or =55 years. Hormone receptor status differs significantly between the two age groups, and in the younger patient cohort, there is a trend towards longer overall survival for ER/PR positive tumors. These results suggest that ovarian cancer in younger patients differs biologically from that in older patients.

Expressions of estrogen and progesterone receptors in epithelial ovarian cancer: a clinicopathologic study

Although estrogen (ER) and progesterone (PR) receptors are well recognized as important prognostic indicators of breast and endometrial cancers, their clinical significance in epithelial ovarian cancer is not clear with the limited data from only few immunohistochemical studies. The aim of this study was to evaluate the expressions of ER and PR in patients with epithelial ovarian cancer who were treated in our institution during the period 1996 to 2003. Their associations with clinicopathologic factors of age, stage, histologic subtypes, and grade and their prognostic role to survivals were also examined. Among 106 subjects included in the study, ER and PR expressions were found in 39.6% and 33.0%, respectively, with the corresponding highest expression in serous and endometrioid carcinomas. Estrogen receptor expression had a significant association with age older than 60 years, non-clear cell carcinomas, and high-grade tumors, whereas PR expression showed a significant association with non-clear cell carcinomas and a better response to first-line chemotherapy. Progesterone receptor expression was a favorable prognostic factor to both progression-free and overall survivals from univariable but not multivariable analyses. Expression of ER or any combination of ER/PR subgroups did not have a significant impact on survivals.

Estradiol attenuates EGF-induced rapid uPAR mobilization and cell migration via the G-protein-coupled receptor 30 in ovarian cancer cells

Epidermal growth factor (EGF) stimulates proliferation and migration in ovarian cancer cells, and high tumor expression of the EGF system correlates with poor prognosis. Epidermal growth factor upregulates urokinase plasminogen activator receptor (uPAR) on the cell surface via 3 distinct mechanisms: rapid mobilization of uPAR from detergent-resistant domains, increased mRNA, and decreased degradation. G-protein-coupled receptor 30 (GPR30) is a newly identified membrane estrogen receptor (ER).The objective of this study was to explore the effects of 17beta-estradiol (E(2)) on uPAR expression and cell migration in ovarian cancer cells and further to identify the ER involved.We used 7 ovarian cancer cell lines, cell migration assay, cellular binding of (125)I-uPA, cellular degradation of (125)I-uPA/PAI-1 complex, enzyme-linked immunosorbent assay for uPAR, solid-phase enzyme immunoassay for ERalpha, and quantitative polymerase chain reaction. Estradiol attenuates the stimulatory effect of EGF on cell migration and uPAR expression. Specifically, E(2) reduces the very rapid increase of detergent extractable uPAR, which occurs within minutes of EGF stimulation and probably represents mobilization of uPAR from detergent-resistant domains such as lipid rafts. Estradiol influenced neither the amount of uPAR mRNA nor the rate of uPAR degradation or solubilization. The nuclear ER antagonists ICI 182780 and tamoxifen, which are GPR30 agonists, as well as the specifically constructed GPR30 agonist G1, mimicked the effect of E(2) on uPAR expression and cell migration. OVCAR-3 cells express mRNA for GPR30.Estradiol attenuates EGF-induced mobilization of ligated uPAR from detergent-resistant domains and subsequent migration in ovarian cancer cells. The response to various ER ligands indicates that this effect is mediated via the membrane ER GPR30.

Induction of senescence by progesterone receptor-B activation in response to cAMP in ovarian cancer cells

OBJECTIVE

Progesterone receptor (PR) expression is a favorable prognostic marker in ovarian cancer. We previously demonstrated that the induction of PR-B by treatment with cAMP was associated with G0/G1 arrest of the cell cycle and growth inhibition in NIH 3T3 cells. In this study, we examined the effect of cAMP treatment on cell growth in Ras-transformed NIH3T3 cells and ovarian cancer cells.

METHODS

1) The levels of PR-B and cell cycle associated proteins (p21, p27 and Rb) following treatment with cAMP in the Ras-transformed NIH3T3 cells (K12V) and ovarian cancer cell lines (SKOV cells) were investigated by Western blots. 2) The effects of PR overexpression following treatment with cAMP or after infection of an adenovirus expressing PR-B on cell growth and tumorigenicity in a soft agar culture were examined.

RESULTS

1) Treatment with cAMP increased PR-B and p27 levels in K12V cells and inhibited cell growth by inducing premature senescence. Induction of senescence was specific to the transformed cells. 2) In SKOV cells, treatment with cAMP induced PR-B, p27 and p21 expression, reduced the level of phosphorylated Rb, caused accumulation of cells in the G0/G1 fraction of the cell cycle, and induced senescence. 3) Both anchorage-dependent and -independent SKOV cell growths were inhibited by cAMP treatment. 4) Induction of both the expression and transcriptional activity of PR-B is critical for the induction of senescence and suppression of tumorigenicity.

CONCLUSION

Treatment of cAMP, through activation of PR-B, induced senescence and suppressed tumorigenicity in ovarian cancer cells.

Regulation of ovarian cancer cell viability and sensitivity to cisplatin by progesterone receptor membrane component-1

CONTEXT

Progesterone (P4) influences ovarian cancer cells by an unknown mechanism.

OBJECTIVE

The objective was to determine whether P4 acts through progesterone receptor membrane component-1 (PGRMC1) in ovarian cancers.

DESIGN, SETTING AND PATIENTS

Archival tissue and cDNA provided by OriGene were used for expression studies. In vitro experiments were conducted with Ovcar-3 cells.

MAIN OUTCOME MEASURES

PCR, Western blot, and immunohistochemistry were used to measure expression of PGRMC1 and nuclear progesterone receptor (PGR). PGRMC1's role in regulating the viability of ovarian cancers was assessed by overexpressing PGRMC1, depleting PGRMC1 using small interfering RNA, and attenuating PGRMC1's action with a blocking antibody. Apoptosis was determined by 4',6'-diamino-2-phenylindole staining.

RESULTS

PGRMC1 mRNA increased and PGR mRNA decreased in advanced stages of ovarian cancer. Unlike PGR, PGRMC1 was expressed in virtually every cancer cell within the tumor. A similar relationship between PGRMC1 and PGR was observed in Ovcar-3 cells. In these cells P4 suppressed apoptosis induced by either serum withdrawal or cisplatin (CDDP). Moreover, in the presence of P4, the following occurs: 1) overexpression of PGRMC1 reduces the effectiveness of CDDP, 2) depletion of PGRMC1 with small interfering RNA enhances the effects of CDDP, and 3) PGRMC1 antibody treatment increases the apoptotic response to CDDP.

CONCLUSIONS

These findings indicate that PGRMC1 plays an important role in promoting ovarian cancer cell viability and that attenuating PGRMC1's action makes the ovarian cancer cells more sensitive to CDDP. These data suggest that targeted depletion of PGRMC1 could be useful as an adjunct to CDDP therapy.

Significantly greater expression of ER, PR, and ECAD in advanced-stage low-grade ovarian serous carcinoma as revealed by immunohistochemical analysis

A 2-tier system that classifies ovarian serous carcinoma (OSC) as low grade or high grade is gaining acceptance. Women with low-grade OSC generally have higher 5-year survival rates than do women with high-grade OSC. We examined the expression of various markers to further understand the molecular differences between low-grade and high-grade OSCs: the potential therapeutic targets or prognostic markers Her-2/neu, estrogen receptor, and progesterone receptor (PR); the metastasis-associated markers cyclin D1 (BCL1), E-cadherin, matrix metalloproteinase (MMP) 2, and MMP-9; and the cell proliferation-associated markers BCL1, Ki-67 antigen (Ki-67), and p53. For this immunohistochemical analysis, we used paraffin-embedded specimens from 47 patients with advanced-stage low-grade OSC and from 49 patients with advanced-stage high-grade OSC. Our results showed that low-grade tumors expressed significantly higher levels of estrogen receptor, PR, and E-cadherin than did high-grade tumors, suggesting the involvement of gonadal steroid hormones, especially in the pathogenesis of low-grade OSC; the PR positivity was also observed in the stromal component of these low-grade tumors. On the other hand, high-grade tumors trended toward increased expression of MMP-9, BCL1, p53, and Ki-67, and robust MMP-9 positivity was observed in the stromal component of these high-grade tumors. These differences may lead to the development of different therapeutic strategies for women with either the low-grade or the high-grade form of OSC.

Ovarian cancer survival and polymorphisms in hormone and DNA repair pathway genes

We evaluated the association between 21 polymorphisms in hormone and DNA repair pathway genes and survival among 454 Australian women diagnosed with invasive epithelial ovarian cancer. The cohort was followed for mortality using personal identifiers which were linked to state cancer registry records and the Australian National Death Index. The mean follow-up time after ovarian cancer diagnosis was 4.63 years (all women) and 8.07 years for the censored group (those alive or dead from non-ovarian cancer causes). Two hundred and eighty-eight (63%) ovarian cancer deaths occurred during the follow-up period. No association was observed for the vast majority of polymorphisms, but there was suggestive evidence for altered risk of ovarian cancer death associated with the CYP17 5'UTR C allele (HR 1.30; 95% CI=1.02-1.68, p= 0.04), and for the SRD5A2 V89L C allele (HR 0.79; 95% CI=0.62-1.01, p=0.06). These results are interesting given tentative evidence that both of these variants are also associated with increased predisposition to ovarian cancer in our extended Australian study, and in other published studies. However, given the marginal significance of these associations and the large number of tests performed, independent replication will be necessary to validate these novel findings.

Estrogen-induced loss of progesterone receptor expression in normal and malignant ovarian surface epithelial cells

While estrogens are suspected risk factors for epithelial ovarian cancer (OCa), progesterone (P4) has been shown to exert protective effects. The biological actions of P4 in target cells are mediated by progesterone receptors (PRs) that exist principally as A- and B-isoforms. We observed overexpression of PR-A and PR-B protein in two lines of OCa cells when compared to two lines of nontumorigenic, normal human ovarian surface epithelial (HOSE) cells. Treatment of HOSE or OCa cells with estrone or 17beta-estradiol at 10(-8) M for a period of 72 h induced significant loss of PR-A and PR-B mRNA and protein expression, with the regulation primarily controlled at the transcriptional level. In contrast, breast cancer cells (line MCF-7) exposed to estrogens upregulated PR-A and PR-B expression. Of significance, both the inhibitory and stimulatory actions of estrogens were blocked by the specific ER-antagonist ICI 182,780 (ICI, 10(-5) M), confirming estrogen specificity. Co-treatment of estrogen-exposed HOSE, OCa, and MCF-7 cell lines with inhibitors of type 1- and type 2-17beta hydroxysteroid dehydrogenase did not affect the previously observed changes in PR expression, suggesting that the action of each estrogen is direct and not mediated via conversion to its metabolic counterpart. Green fluorescence protein (GFP)-PR-A and GFP-PR-B were localized in the cytoplasmic compartment of untreated HOSE cells and translocated to the nucleus after P4 treatment, while both chimera PRs resided in the nuclei of OCa cells in a ligand-independent manner. In OCa cell cultures, P4 (10(-6) M), but not RU486 (10(-5) M), induced apoptosis that was blocked by co-treatment with the antiprogestin but enhanced by co-treatment with ICI. In sharp contrast, P4 induced proliferation, while ICI and RU486 caused cell death in MCF-7 cells. In conclusion, this study is first to demonstrate estrogens as negative regulators of PR expression in HOSE/OCa cells and to provide a mechanistic basis upon which to explain the antagonism of estrogens on the anti-OCa action of progestins. It also raises the possibility of using progestin and ICI as a combinational therapy for OCa treatment.

Expression of progesterone receptor is a favorable prognostic marker in ovarian cancer

OBJECTIVE

Receptors for estrogen (ER), progesterone (PR), or androgen (AR) are predictive and prognostic markers of malignancy of multiple endocrine organs, including endometrial and breast cancer. However, the role of ERs, PRs, or ARs in the carcinogenesis of ovarian cancer, another sex hormone-dependent malignancy, is still controversial despite numerous studies that have attempted to determine their role. The disagreement in the findings may result from the fact that the numbers of tumor samples in studies have been small and that different immunohistochemical methods have been used that can introduce variation in the scoring of the histology. We therefore examined the pattern of expression of ERs, PRs, and ARs in a large number of samples of primary ovarian carcinoma by using a tissue microarray technique.

METHODS

We constructed a tissue microarray with 322 samples of primary ovarian carcinoma obtained at surgery performed at The University of Texas M. D. Anderson Cancer Center between 1990 and 2000. Immunohistochemistry studies were performed by using the immunoperoxidase technique against primary antibodies (ER, PR, and AR).

RESULTS

ERs, PRs, and ARs were differently expressed in different histotypes of ovarian cancer: ERs were expressed in 77.3% of all cases but more highly expressed in serous and endometrioid types; PRs were expressed in 26.2% of all cases but most highly expressed in the endometrioid type < 64.2%; and ARs were expressed in 43.7% of all cases but were most highly expressed in serous (47.5%) carcinomas. Of particular importance, the expression of PRs, but not ERs or ARs, was associated with better survival (P < 0.0001) in univariate and multivariate analyses.

CONCLUSIONS

The PR is an independent marker, with its overexpression associated with a favorable prognosis in women with ovarian cancer.

Expression of EBAG9/RCAS1 is associated with advanced disease in human epithelial ovarian cancer

Oestrogen receptor-binding fragment associated gene 9, EBAG9, is an oestrogen-responsive gene that was identified in MCF-7 human breast carcinoma cell line. It is identical to RCAS 1, a cancer cell surface antigen possibly involved in immune escape. In the present study, we examined the expression of EBAG9/RCAS1 in human epithelial ovarian cancer using immunohistochemistry, immunoblotting and reverse transcription–polymerase chain reaction (RT–PCR). A total of 90 epithelial ovarian cancer cases were examined immunohistochemically by means of the antibodies for EBAG9 and ERα. The correlation between EBAG9 immunoreactivity and clinicopathological parameters was examined. mRNA expression of EBAG9 and ERα were evaluated by RT–PCR in 22 cases. The expression for EBAG9 and ERα was examined by immunoblotting in 12 ovarian cancer cell lines. EBAG9 immunoreactivity was detected in the surface and cytoplasm of carcinoma cells in 46 out of 90 cases (51.1%). EBAG9 expression was significantly higher in serous histology (P=0.0402) and advanced disease (P=0.0206). No significant relationship was detected between EBAG9 immunoreactivity and overall survival (P=0.689). There was a highly significant correlation between EBAG9 and ER immunoreactivity (P<0.0001). The EBAG9 mRNA was detected in 20 out of 22 cases. In all of the cases that were positive for ERα mRNA, they were also positive for EBAG9 mRNA. Immunoreactive band corresponding to EBAG9 was detected in 11 out of 12 of ovarian cancer cell lines, and was consistent with ERα expression. In conclusion, the wide distribution of EBAG9 and its relation to advanced disease suggest that this protein may play important roles in epithelial ovarian cancer.

Analysis of potential prognostic factors in 111 patients with ovarian cancer

The aim of this study was to assess the correlation of survival with clinical, surgical, histopathological, and biochemical parameters in patients with ovarian cancer. Age, surgical and histopathological data, the concentrations of estrogen and progesterone receptors, Her-2 neu, p53, U-PA, PAI-1, and Cathepsin D, DNA-and S-phase indexes of 111 ovarian cancer patients have been analyzed and correlated to survival. Progesterone receptors were correlated with prolonged survival. FIGO staging at the time of diagnosis is an independent prognostic factor for the patient's survival. Endometrioid and serous ovarian cancers have a better prognosis than mucinous and clear cell ovarian cancers. Survival of optimally debulked patients was substantially longer than that of not optimally debulked patients. This study shows, that an accurate clinical and surgical staging with an according histopathological assessment combined with optimal cytoreduction is of importance for the prognosis of ovarian cancer patients.

Differential expression of progesterone receptor isoforms A and B in the normal ovary, and in benign, borderline, and malignant ovarian tumors

Human epithelial ovarian neoplasm is well-known to be sex steroid-related, but the possible biological significance of progesterone actions in these tumors remains controversial. In this study, we examined the differential expression patterns of the two progesterone receptor (PR) isoforms, PRA and PRB, using immunohistochemistry and real-time quantitative RT-PCR in normal and neoplastic ovarian tissues, and in cell lines derived from a normal ovarian surface epithelium and an ovarian epithelial carcinoma in order to further elucidate the possible involvement of progesterone in the development of ovarian neoplasms. The median H scores for PR isoforms in normal (n = 8), benign (n = 10), borderline (n = 8) and malignant (n = 24) ovarian tissues were as follows; PRA: 194.0, 171.0, 49.5, 0 (P < 0.05), and PRB: 175.0, 180.5, 251.5, 168.5, respectively. In ovarian cancer cell lines (OVCAR-3 and Caov-3), the PRB / PRAB mRNA ratio was increased by 17beta-estradiol, both time- and dose-dependently. However, this ratio was unaltered following the addition of 17beta-estradiol in a normal ovarian epithelial cell line (NOV-31). Immunoblotting analysis demonstrated that PRB protein expression was markedly up-regulated in OVCAR-3, whereas the PRA and PRB isoforms both appeared to be increased in NOV-31. These results suggest that down-regulation of PRA is associated with the development of ovarian epithelial carcinoma.

Ovarian surface epithelium: biology, endocrinology, and pathology

The epithelial ovarian carcinomas, which make up more than 85% of human ovarian cancer, arise in the ovarian surface epithelium (OSE). The etiology and early events in the progression of these carcinomas are among the least understood of all major human malignancies because there are no appropriate animal models, and because methods to culture OSE have become available only recently. The objective of this article is to review the cellular and molecular mechanisms that underlie the control of normal and neoplastic OSE cell growth, differentiation, and expression of indicators of neoplastic progression. We begin with a brief discussion of the development of OSE, from embryonic to the adult. The pathological and genetic changes of OSE during neoplastic progression are next summarized. The histological characteristics of OSE cells in culture are also described. Finally, the potential involvement of hormones, growth factors, and cytokines is discussed in terms of their contribution to our understanding of the physiology of normal OSE and ovarian cancer development.

Progesterone receptor isoforms A and B in human epithelial ovarian carcinoma: immunohistochemical and RT-PCR studies

Human epithelial ovarian carcinoma is well-known as a sex steroid-dependent neoplasm, but the possible biological significance of progesterone receptor (PR) in this cancer remains controversial. Recently, two isoforms of human PR, PRA and PRB, have been characterized and different functional characteristics have been reported for these two isoforms. We therefore examined immunohistochemistry (107 cases) and reverse transcription-polymerase chain reaction (RT-PCR) (16 cases) for PRA, PRB, and oestrogen receptor-a (ER-a). Labeling indices (LI) for PRA and PRB were 2.4 and 43.6, respectively, and the difference was statistically significant. PRB LI, but not PRA LI, as well as performance status, stage, and residual tumour turned out to be independent prognostic factors following multivariate analysis. There was also a significant correlation between ER-a LI and PRB LI (r = 0.595, P < 0.0001), suggestive of a possible interaction between these two receptors. RT-PCR also detected the expression of PR isoform transcripts in the same pattern as was observed with immunohistochemistry. Results of these studies indicate that PRA and PRB both mediate distinct pathways of progesterone action in ovarian carcinoma. Moreover, it is important to examine PRB LI as a prognostic factor in the cases of human epithelial ovarian carcinoma.

Steroid hormone receptors and long term survival in invasive ovarian cancer

BACKGROUND

Steroid hormone receptors are important determinants of prognosis and predictive behavior in tumor tissues of several origins. Since their role in ovarian cancer is still controversial, we investigated the prevalence and prognostic impact of the estrogen (ER) and progesterone (PR) receptors and combinations (ER+PR+, ER+PR-, ER-PR+, and ER-PR-) in a comparably large number of patients with a long clinical follow-up.

METHODS

The present analysis included 186 patients with invasive ovarian carcinomas treated at the Department of Obstetrics and Gynecology of the Justus-Liebig-University Giessen between 1982 and 1996, the follow-up lasting up to 15.8 years (median 2.4 yrs). The expression of ER and PR was assessed by immunohistochemistry using alkaline phosphatase antialkaline phosphatase in microwave pretreated, formalin fixed, and paraffin embedded specimens of the primary tumors and was evaluated semiquantitatively using a standardized immunoreactive scoring system. Receptor expression and combinations were compared to clinical, histologic and prognostic factors, the tumor proliferation, and the clinical outcome.

RESULTS

Kaplan-Meier survival analyses supported the favorable prognostic value of PR and its level of expression in ovarian carcinomas. Especially the ER-PR+ combination, which accounted for 10.2% of all tumors, showed a significantly superior prognosis when compared with all other combinations (survivors 15 of 19 vs. 67 of 167, log rank P = 0.009) and was associated with early stage, low ascites quantity, and higher tumor differentiation. Five-year survival rates were 13/16 (81.3%) for ER-PR+ tumors versus 58/128 (45.3%) for all other steroid hormone receptor combinations. Residual analysis proved the results.

CONCLUSIONS

The determination of steroid hormone receptor status offers additional prognostic information in ovarian carcinomas. Especially the ER-PR+ phenotype predicts a favorable tumor biology and long term survival, probably reflecting functional effects on tumor proliferation, differentiation, and cellular apoptosis.