Vulvo-vaginal epithelial tumors in mares: A preliminary investigation on epithelial-mesenchymal transition and tumor-immune microenvironment

Vulvo-vaginal epithelial tumors are uncommon in mares, and data on the epithelial-to-mesenchymal transition (EMT) and the tumor-immune microenvironment (TIME) are still lacking. This is a study investigating the equus caballus papillomavirus type 2 (EcPV2) infection state as well as the EMT process and the tumor microenvironment in vulvo-vaginal preneoplastic/ benign (8/22) or malignant (14/22) epithelial lesions in mares. To do this, histopathological, immunohistochemical, transcriptomic, in situ hybridization, and correlation analyses were carried out. Immunohistochemistry quantification showed that cytoplasmic E-cadherin and β-catenin expression as well as nuclear β-catenin expression were features of malignant lesions, while benign/preneoplastic lesions were mainly characterized by membranous E-cadherin and β-catenin expression. Despite this, there were no differences between benign and malignant equine vulvo-vaginal lesions in the expression of downstream genes involved in the canonical and noncanonical wnt/β-catenin pathways. In addition, malignant lesions were characterized by a lower number of cells with cytoplasmic cytokeratin expression as well as a slightly higher cytoplasmic vimentin immunolabeling. The TIME of malignant lesions was characterized by more numerous CD204+ M2-polarized macrophages. Altogether, our results support the hypothesis that some actors in TIME such as CD204+ M2-polarized macrophages may favor the EMT process in equine vulvo-vaginal malignant lesions providing new insights for future investigations in the field of equine EcPV2-induced genital neoplastic lesions.

Epithelial-mesenchymal transition (EMT) in vulvar cancer with and without inguinal lymph node involvement

Purpose

Epithelial-mesenchymal transition (EMT) is associated with increased metastatic spread and poor prognosis. Data on vulvar carcinoma are limited.

Methods

Thirty-two cases of squamous cell carcinoma of the vulva (16 with and 16 without inguinal lymph node metastases) and their lymph node deposits were evaluated for immunohistochemical expression of EMT markers (vimentin, cyclin D1, e-cadherin), p16, p53 and Ki-67. Results of EMT-immunostainings were compared to lymph node involvement and expression of p53 and p16. The micro-anatomical staining pattern for EMT markers comparing the tumor center with the front of invasion was analysed in each tumor.

Results

There was no difference in the expression of EMT markers between node negative and node positive tumors. Staining for vimentin and cyclin D1 was seen within tumor cells at the front of invasion in 100 and 84.4% of the tumors, respectively. The majority of cases (68.7%) showed negative or reduced staining for e-cadherin in this micro-anatomical localization. Tumor cells within the lymph node metastases showed positive staining for e-cadherin in 75% and for cyclin D1 in 49% of the cells but were negative for vimentin in 13 out of 16 cases (81.3%). Tumors with aberrant p53 staining represented a non-significant higher vimentin but significantly higher cyclin D1 expression at the front of invasion than those with p53 wild-type pattern.

Conclusion

The present study shows no differences in the expression of EMT markers between node positive and node negative vulvar cancers. The evaluation of immunostaining within the micro-anatomical context indicates that an EMT-phenotype is restricted to the tumor cells at the front of invasion. Paired analyses of vulvar carcinomas and their lymph node deposits suggest mesenchymal-epithelial transition (MET) in the metastatic deposits. Immunohistochemical staining results may suggest that EMT is more prevalent in vulvar cancer with aberrant p53 staining.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00432-021-03715-2.

Immunohistochemical expression of ErbB/HER family proteins in patients with vulvar cancer

OBJECTIVE

To investigate the immunohistochemical (IHC) expression of the ErbB/HER family in primary vulvar squamous cell carcinoma (VSCC).

METHODS

We analyzed a series of 125 patients who were surgically treated for VSCC from January 1980 to June 2016. All cases had lymph node (LN) staging and 80 had LN metastasis. A tissue microarray was built for epidermal growth factor receptor (EGFR), HER2, HER3, and HER4 IHC staining.

RESULTS

In the primary tumor we found positive expressions for EGFR, HER2, HER3, and HER4 in 5%, 0.9%, 0.9%, and 22.8%, respectively. For the LN metastasis, expressions of EGFR and HER4 were positive in 22.2% and 39.1%, respectively. No cases had positive staining for HER2 and HER3 in the LN metastasis. For HER4, positive expression correlated with smaller tumor sizes (P = 0.02). However, positive HER4 was related to adverse prognostic factors such as: histological grade (P = 0.012), presence of lymphovascular space invasion (40.9% vs 16.2%; P = 0.035), and perineural invasion (57.1% vs 16.7%; P = 0.006). Notably, all cases with LN metastasis had positive HER4 in the primary tumor (P < 0.001). ErbB/HER family expression was not related to worse survival.

CONCLUSION

EGFR, HER2, and HER3 were infrequently expressed in VSCC by IHC. HER4 IHC expression was found in 22.8% of cases and was related to adverse prognostic factors.

Assessment of TSPAN Expression Profile and Their Role in the VSCC Prognosis

The role and prognostic value of tetraspanins (TSPANs) in vulvar squamous cell carcinoma (VSCC) remain poorly understood. We sought to primarily determine, at both the molecular and tissue level, the expression profile of the TSPANs CD9, CD63, CD81, and CD82 in archived VSCC samples (n = 117) and further investigate their clinical relevance as prognostic markers. Our studies led us to identify CD63 as the most highly expressed TSPAN, at the gene and protein levels. Multicomparison studies also revealed that the expression of CD9 was associated with tumor size, whereas CD63 upregulation was associated with histological diagnosis and vascular invasion. Moreover, low expression of CD81 and CD82 was associated with worse prognosis. To determine the role of TSPANs in VSCC at the cellular level, we assessed the mRNA levels of CD63 and CD82 in established metastatic (SW962) and non-metastatic (SW954) VSCC human cell lines. CD82 was found to be downregulated in SW962 cells, thus supporting its metastasis suppressor role. However, CD63 was significantly upregulated in both cell lines. Silencing of CD63 by siRNA led to a significant decrease in proliferation of both SW954 and SW962. Furthermore, in SW962 particularly, CD63-siRNA also remarkably inhibited cell migration. Altogether, our data suggest that the differential expression of TSPANs represents an important feature for prognosis of VSCC patients and indicates that CD63 and CD82 are likely potential therapeutic targets in VSCC.

Impact of partnership status on clinical outcomes of patients with vulvar squamous cell carcinoma and performance of sentinel lymph node biopsy

OBJECTIVES

Vulvar squamous cell carcinoma is a rare malignancy and lymph node involvement is the most significant prognostic factor. We aimed to evaluate the association between partnership status and mortality from vulvar squamous cell carcinoma, cancer stage at the time of presentation, and the decision for sentinel lymph node biopsy.

METHODS

The US National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) database was queried and different parameters were evaluated relative to partnership status. A total of 4851 patients with vulvar squamous cell carcinoma, >18 years of age, who presented between January 2010 to December 2015, were analyzed. Kaplan-Meier and Cox regression analyses were used to assess survival and hazard ratio. Multinomial regression analysis and χ² were utilized to evaluate odd ratios and significance of variables.

RESULTS

Most patients were unpartnered (58.5%), including never married (17.7%), divorced (13.8%), or widowed (27%). Partnered patients were mostly Caucasian (88.4%), insured (74%), and presented with stage I disease (57.2%), compared with unpartnered patients (79.1%), (61.7%), and (51.7%), respectively (p<0.01). The mean survival time (months) in partnered patients was longer, compared with unpartnered (p<0.001), and the difference between both groups increased from 9 months at stage I to 24 months at stage IV, which remained independently significant after adjusting the different variables. Cox regression showed that partnered patients had a lower hazard ratio than unpartnered patients (p<0.01). Mortality from vulvar squamous cell carcinoma increased with age at diagnosis, no surgery, and unemployment (p<0.01). Unpartnered patients were the least likely to undergo sentinel lymph node biopsy in early stages, compared with partnered (p<0.01). Univariate Cox regression analysis showed that not performing sentinel lymph node biopsy almost doubled the hazard ratio of vulvar squamous cell carcinoma (p<0.01).

CONCLUSIONS

Partnership status should be considered when counseling patients for vulvar squamous cell carcinoma therapy and when recommending screening and follow-up to optimize patient care.

Widowed status increases the risk of death in vulvar cancer

Aim: To evaluate the effect of marital status on survival of patients with vulvar cancer. Materials & methods: A total of 4001 patients with vulvar cancer were included from the SEER database. Statistical analyses were performed using χ2 test, Kaplan–Meier method, Cox regression proportional hazards and a 1:1 propensity score-matching. Results: The 8-year vulvar cancer-related survival in married, divorced, single and widowed patients were 78.6, 82.2, 78.9 and 61.6%, respectively (p < 0.001). In multivariate analysis, widows patients had significantly worse vulvar cancer survival than the nonwidowed counterparts in unmatched and matched populations. Conclusion: Being widowed is associated with greater risk of vulvar cancer mortality than the nonwidowed counterparts.

MiR-223-5p works as an oncomiR in vulvar carcinoma by TP63 suppression

MiR-223-5p has been previously mentioned to be associated with tumor metastasis in HPV negative vulvar carcinomas, such as in several other tumor types. In the present study, we hypothesized that this microRNA would be important in vulvar cancer carcinogenesis and progression. To investigate this, we artificially mimicked miR-223-5p expression in a cell line derived from lymph node metastasis of vulvar carcinoma (SW962) and performed in vitro assays. As results, lower cell proliferation (p < 0.01) and migration (p < 0.001) were observed when miR-223-5p was overexpressed. In contrast, increased invasive potential of these cells was verified (p < 0.004). In silico search indicated that miR-223-5p targets TP63, member of the TP53 family of proteins, largely described with importance in vulvar cancer. We experimentally demonstrated that this microRNA is capable to decrease levels of p63 at both mRNA and protein levels (p < 0.001, and p < 0.0001; respectively). Also, a significant inverse correlation was observed between miR-223-5p and p63 expressions in tumors from patients (p = 0.0365). Furthermore, low p63 protein expression was correlated with deeper tumor invasion (p = 0.0491) and lower patient overall survival (p = 0.0494). Our study points out miR-223-5p overexpression as a putative pathological mechanism of tumor invasion and a promising therapeutic target and highlights the importance of both miR-223-5p and p63 as prognostic factors in vulvar cancer. Also, it is plausible that the evaluation of p63 expression in vulvar cancer at the biopsy level may bring important contribution on prognostic establishment and in elaborating better surgical approaches for vulvar cancer patients.

An Integrative Approach Uncovers Biomarkers that Associate with Clinically Relevant Disease Outcomes in Vulvar Carcinoma

Vulvar squamous cell carcinoma (VSCC) is a rare disease that has a high mortality rate (∼40%). However, little is known about its molecular signature. Therefore, an integrated genomics approach, based on comparative genome hybridization (aCGH) and genome-wide expression (GWE) array, was performed to identify driver genes in VSCC. To achieve that, DNA and RNA were extracted from frozen VSCC clinical specimens and examined by aCGH and GWE array, respectively. On the basis of the integration of data using the CONEXIC algorithm, PLXDC2 and GNB3 were validated by RT-qPCR. The expression of these genes was then analyzed by IHC in a large set of formalin-fixed paraffin-embedded specimens. These analyses identified 47 putative drivers, 46 of which were characterized by copy number gains that were concomitant with overexpression and one with a copy number loss and downregulation. Two of these genes, PLXDC2 and GNB3, were selected for further validation: PLXDC2 was downregulated and GNB3 was overexpressed compared with non-neoplastic tissue. By IHC, both proteins were ubiquitously expressed throughout vulvar tissue. High expression of GNB3 and low PLXDC2 immunostaining in the same sample was significantly associated with less lymph node metastasis and greater disease-free survival. On the basis of a robust methodology never used before for VSCC evaluation, two novel prognostic markers in vulvar cancer are identified: one with favorable prognosis (GNB3) and the other with unfavorable prognosis (PLXDC2).

IMPLICATIONS

This genomics study reveals markers that associate with prognosis and may provide guidance for better treatment in vulvar cancer. Mol Cancer Res; 14(8); 720-9. ©2016 AACR.

Primary Vulvo-Vaginal Cancers: Trends in Incidence and Mortality in Poland (1999-2012)

BACKGROUND

The aim of this study was to determine the incidence, mortality rates and trends of vulvar and vaginal cancers in Poland.

METHODS

Data were retrieved from the Polish National Cancer Registry. Age-standardised rates (ASRs) of cancer incidence and mortality were calculated by direct standardisation, and joinpoint regression was performed to describe the trends using the average annual percent change (AAPC).

RESULTS

From 1999 to 2012, the number of diagnosed cases of vulvar cancer was 5,958, and the ASRs of incidence varied from 0.99 to 1.18, with a significant trend towards a decrease (AAPC -0.78; p < 0.05). The ASR of mortality varied from 0.39 to 0.62, with a slight but insignificant increase in trend (AAPC 0.72; p > 0.05). The ASR of vaginal cancer incidence varied from 0.21 to 0.31, while the ASR of mortality ranged from 0.09 to 0.22. This study also proved a significantly falling trend in vaginal cancer mortality (AAPC -4.69; p < 0.05) and a decreasing trend in vaginal cancer incidence (AAPC -1.67; p > 0.05).

CONCLUSION

The rarity of vulvar and vaginal cancers as well as the decline in their incidence rates should not discourage further research on the epidemiology and treatment of these conditions.

Could sentinel node mapping of the groin cause extranodal metastasis in vulva cancer?

Groin node lymphadenectomy in vulva cancer carries a substantial risk of morbid sequelae. Sentinel lymph node (SLN) mapping is a valid alternative in patients with squamous cancer of diameter <4 cm and nonsuspicious lymph nodes. SLN are mapped according to the combined technique of radioscintigraphy using technetium-labelled colloid and blue dye. We describe early extranodal recurrence in 2 patients undergoing SLN mapping. They had lymph node metastases at their original dissection. We question whether rapid lymph flow promoted by injection of colloid and dye could cause retrograde flow of cancer cells along the lymphatics draining from the pubis to the groin and extravasation of cancer cells into the dermis since these metastases arose anterior to the pubis and medial to the groin. These recurrence sites were more medial and cephalad than would be expected for skin bridge metastasis. CT imaging shows the metastases are within the dermis. No lymphatic tissue was identified around these subcuticular cancer deposits at repeat resection. Body wall extension occurs in recurrent vulva cancer, but we never saw such an early recurrence when full inguinofemoral lymphadenectomy without SLN was the standard approach. These 2 cases raise a caveat in the application of SLN mapping in vulva cancer, especially when metastasis is detected on SLN as the afferent channels to the lymph nodes may be already blocked or flow impaired by the tumour.

ROCK1 as a novel prognostic marker in vulvar cancer

Background

Vulvar carcinoma is an infrequent tumour, accounting for fewer than 3% of all malignant tumours that affect women, but its incidence is rising in the past few decades. In young women, the manifestation of the vulvar carcinoma is often linked to risk factors such as smoking and HPV infection, but most cases develop in women aged over 50 years through poorly understood genetic mechanisms. Rho-associated coiled-coil-containing protein kinase 1 (ROCK1) has been implicated in many cellular processes, but its function in vulvar cancer has never been examined. In this study, we aimed to determine the prognostic value of ROCK1 gene and protein analysis in vulvar squamous cell carcinoma (VSCC).

Methods

ROCK1 expression levels were measured in 16 vulvar tumour samples and adjacent normal tissue by qRT-PCR. Further, 96 VSCC samples were examined by immunohistochemistry (IHC) to confirm the involvement of ROCK1 in the disease. The molecular and pathological results were correlated with the clinical data of the patients. Sixteen fresh VSCC samples were analyzed by array-based comparative genomic hybridization (aCGH).

Results

In each pair of samples, ROCK1 levels were higher by qRT-PCR in normal tissue compared with the tumour samples (p = 0.016). By IHC, 100% of invasive front areas of the tumour and 95.8% of central tumour areas were positive for ROCK1. Greater expression of ROCK1 was associated with the absence of lymph node metastasis (p = 0.022) and a lower depth of invasion (p = 0.002). In addition, higher ROCK1 levels correlated with greater recurrence-free survival (p = 0.001). Loss of ROCK1 was independently linked to worse cancer-specific survival (p = 0.0054) by multivariate analysis. This finding was validated by IHC, which demonstrated enhanced protein expression in normal versus tumour tissue (p < 0.001). By aCGH, 42.9% of samples showed a gain in copy number of the ROCK1 gene.

Conclusions

ROCK1 is lower expressed in tumour tissue when compared with adjacent normal vulvar epithelia. In an independent sample set of VSCCs, lower expression levels of ROCK1 correlated with worse survival rates and a poor prognosis. These findings provide important information for the clinical management of vulvar cancer.

A Thirty-year Review of Vulvar Cancer in Jamaica, 1978 to 2007

OBJECTIVE

To evaluate the trends in vulvar cancer between 1978 and 2007 in Kingston and St Andrew, Jamaica, with respect to age-standardized rates and histologic types.

METHODS

All cases of vulvar cancer recorded in the Jamaica Cancer Registry from 1978 to 2007 were extracted and analysed for age distribution and histologic type.

RESULTS

There were 78 cases (one person of unknown age) of vulvar cancer recorded over the 30-year period. Sixty per cent of the affected patients were between 50 and 80 years old. The most common histologic type of vulvar malignancy was squamous cell carcinoma (82%). There was a decline in age-standardized incidence rates of both vulvar cancers overall and vulvar squamous cell carcinoma over the 30-year period.

CONCLUSION

Squamous cell carcinoma is the most common vulvar malignancy in the Jamaican population, and affects primarily older women. Despite high prevalence rates of high-risk human papillomavirus infection, no increase in the age-standardized incidence of vulvar squamous cell carcinoma was identified.

EGFR expression in vulvar cancer: clinical implications and tumor heterogeneity

Epidermal growth factor receptor (EGFR) protein expression was assessed by immunohistochemistry (IHC) in 150 cases of invasive vulvar squamous cell carcinoma. In addition, gene copy number status by fluorescence in situ hybridization was performed in a smaller set of samples. Results were correlated with patient's clinical data and prognostic factors. EGFR overexpression (2+ and 3+) was observed on the membrane in 24.66% and 21.33% of all cases, respectively. Higher EGFR expression was associated with depth of invasion (P = .0409) and disease recurrence (P = .0401). Cytoplasm staining was found in 21.33% of the cases and was associated with absence of nodal metastasis (P = .0061) and better survival (P = .0199). Intratumor heterogeneity of EGFR IHC staining was frequently observed (55.33%) and was associated with the presence of nodal metastasis (P = .0207) and tumor invasion (P = .0161). Worse survival outcomes have been demonstrated in tumors with EGFR heterogeneity (P = .0434). EGFR gene status evaluated by fluorescence in situ hybridization did not correlate with protein expression evaluated by IHC. In conclusion, EGFR cytoplasm staining has no link with poorer outcome; still, this pattern of staining is even more related to better prognosis. EGFR heterogeneity of staining correlated with more aggressive tumors, and presented to be an important marker of poor prognosis in vulvar squamous cell carcinoma. The usage of small biopsies or even tissue microarrays for vulvar cancer evaluation should be carefully reconsidered for the assessment of EGFR as the results may be misleading. Protein overexpression may be independent on gene amplification, showing that other molecular mechanisms than copy number variation may regulate protein expression of EGFR in vulvar cancer.

microRNA portraits in human vulvar carcinoma

Unregulated expression of microRNAs is well known and has already been demonstrated in many tumor types. However, in vulvar carcinoma this field has been unknown territory. Our study characterizes microRNA in vulvar tumors through an expression profile of 754 miRNAs, relating this with clinical and anatomopathologic data, and presence of HPV infection. Twenty HPV-negative and 20 HPV-positive samples, genotyped for high-risk HPVs (HPV16, 18, 31, 33) and a pool of seven normal vulvar skin samples were used for the identification of differentially expressed miRNAs by TLDA Quantitative Real Time PCR (qRT-PCR). Twenty-five differentially expressed microRNAs between HPV-positive and HPV-negative groups and 79 differentially expressed on the tumor compared with normal samples were obtained. A network between microRNA expression profiles and putative target mRNAs predicted by target prediction algorithms and previously demonstrated as relevant in vulvar carcinomas, such as TP53, RB, PTEN, and EGFR was constructed. Downregulation of both miR-223-5p and miR-19-b1-5p were correlated with the presence of lymph node metastasis; downregulation of miR-100-3p and miR-19-b1-5p were correlated with presence of vascular invasion; overexpression of miR-519b and miR-133a were associated with advanced FIGO staging. In conclusion, our study demonstrates that microRNAs may be clinically important in vulvar carcinomas and our findings may help for further studies on functional implications of miRNA deregulation in this type of cancer.

Cell cycle suppressor proteins are not related to HPV status or clinical outcome in patients with vulvar carcinoma

Interactions between the cyclin-dependent kinase inhibitors (CDKI) and human papillomavirus (HPV) infection in the pathogenesis of vulvar carcinoma are still incomplete. This study aimed to evaluate the prognostic relevance of these proteins in vulvar cancer. One hundred and thirty-nine patient specimens assembled in a tissue microarray were evaluated for p16, p21, p27, and pRb by immunohistochemistry. HPV status was assessed by a linear array HPV genotyping test. In 16 cases with available frozen tumor, quantitative real-time reverse transcriptase-polymerase chain reaction for CDKN2A(p16), CDKN1A, and Rb was performed. Protein expression was considered positive in 40 patients for p16, 35 for p21, 28 for p27, and 19 for pRb. HPV was positive in 43 of the 105 evaluable cases. Expression of CDKIs and pRb, with the exception of p16, seem to be linked to the early phases of vulvar carcinogenesis. Although p16 and p21 protein expression was associated with early stages of disease, no prognostic significance was found when analyzing CDKI proteins or detecting HPV status, limiting their clinical usage. No association was observed between expression of CDKI proteins and HPV status, suggesting that in spite of this association found in cervical cancer, this seems not to be valid for vulvar carcinoma.

Epithelial-mesenchymal transition-like events in vulvar cancer and its relation with HPV

Background:

Epithelial-to-mesenchymal transition (EMT) still remains an obscure event in vulvar squamous cell carcinoma (VSCC).

Methods:

Immunohistochemistry (IHC) expression of E-cadherin, β-catenin, Snail, Slug, Twist and Vimentin was analysed in 87 VSCC, controlled for human papillomavirus (HPV) positivity, considering tumour front and central tumour as different morphological categories from the same tumour.

Results:

Lower β-catenin and higher Vimentin expression was associated with invasive front when compared with the central tumour (P=0.013 and P⩽0.001, respectively). Higher expression of E-cadherin in central tumour was significantly related to absence of vascular and perineural invasion, lower invasion depth and ⩽2 lymph node involvement. Loss of β-catenin and high Slug, Snail and Twist expression was associated with HPV-negative tumours. Moreover, β-catenin lower expression associated with gain in Slug expression predicts a subgroup with worst outcome (P=0.001). Lower expression of β-catenin in both central tumour and invasive front correlated with lower overall survival (P=0.021 and P=0.011, respectively). Also, multivariate analysis showed that lower β-catenin expression was independently associated with poorer outcome (P=0.044).

Conclusion:

Human papillomavirus-related tumours show better prognosis and outcome; besides, they do not progress through EMT phenomenon. Immunohistochemical analysis of β-catenin in invasive tumour front is a key issue for establishing prognosis of vulva cancer.