Cervical lymph node status and survival in laryngeal carcinoma: prognostic factors

The Role of Modified Killian's Method in the Evaluation of Hypopharyngeal and Supraglottic Cancers

Priyanka Schilling AmarObjectives  Hypopharyngeal cancer is one of the upper aerodigestive tract malignancies with the poorest prognosis. The aim of this study was to assess the role of modified Killian's (MK) method in routine, outpatient-based flexible laryngoscopy to improve visualization and assess the extent of supraglottic and hypopharyngeal cancers. Materials and Methods  An observational study was conducted in a tertiary hospital in India where fifty consecutive patients who presented to the outpatient clinic with suspected hypopharyngeal and supraglottic malignancy underwent a conventional laryngoscopy as well as MK method. The site and extent of the tumor on endoscopy were recorded and the videos were graded independently by two investigators on Murono's scale from 1 to 5. A subset of these patients who underwent direct laryngoscopy under general anesthesia was also scored with the above scale. The scores were compared to check the accuracy of flexible laryngoscopy with the MK method in staging cancer. Statistical Analysis  Descriptive statistics were given using mean (standard deviation [SD]) for continuous variables and frequency (percentage) for categorical variables. The difference between the mean scores was analyzed using the paired-t test. The agreement between the scales and the observer, that is, the inter- and intraobserver agreement, was presented with concordance rate and Kappa weighted analysis. Results  In this study, the mean scores of the Murono's scale grading of the conventional method, MK method, and direct laryngoscopy were 1.42 (SD: 0.64), 2.94 (SD: 0.95), and 4.30 (SD: 1.49), respectively, which showed significant improvement in scores with MK method. In addition, the subset analysis demonstrated a significant agreement between direct laryngoscopy and MK method. Conclusion  The MK method is a good diagnostic test and a valuable adjunct to diagnostic flexible laryngoscopy in the evaluation and staging of hypopharyngeal and supraglottic cancers.

Management of clinically node-negative glottic squamous cell carcinoma patients according to risk-scoring model for occult lymph node metastases

Background

Glottic squamous cell carcinoma (GSCC) is the most prevalent type of laryngeal carcinoma. The value of prophylactic lymph node dissection (LND) in resected GSCC remains controversial. This study aims to quantitatively assess the probability of occult lymph node metastasis (LNM) for GSCC patients and devise individualized postoperative radiotherapy strategies.

Methods

A total of 1319 patients with GSCC were retrospectively analyzed.

Results

GSCC patients with T1-T2 stages showed significantly lower LNM rate than those with T3-T4 stages. For patients with T3-T4 GSCC, multivariate logistic analyses indicated that three factors-maximum tumor diameter (MTD) of more than 2.0 cm, relatively low differentiation, and tumor invasive depth of no less than 1.0 cm-were independent risk factors for the existence of LNM. A predictive nomogram was established based on these factors. The accuracy and validity of our model were verified by 0.716 and remained at 0.717 after 1000 bootstrapping. The calibration curve was also plotted and showed a favorable agreement. The patients were stratified into two groups based on their individual LNM risk points. Possible LNM rates for low-risk and high-risk subgroups were 4.7% and 25.2%, respectively.

Conclusions

A new post-operative strategy selection flow chart was established based on our newly created nomogram which can effectively predict the individualized possibility of occult LNM for GSCC patients. For clinical T3-4N0 patients in the high-risk subgroup, prophylactic dose post-operative radiation therapy is recommended. However, for all those clinically diagnosed as T1-2N0 stage, regular follow-up is sufficient in view of the low occult LNM rate.Level of Evidence: 2a.

Differential Expression Levels of Urokinase-Type Plasminogen Activator and Cathepsin D in Locally Advanced Laryngeal Squamous Cell Carcinoma: Clinical Implications

The expression levels and the prognostic impact of urokinase-type plasminogen activator (uPA) and cathepsin D (CD) were evaluated in patients with locally advanced laryngeal squamous cell carcinoma (LSCC). uPA and CD protein levels were determined by immunoluminometric or immunoenzymatic assays in the cytosol of paired sets of tumor tissues and corresponding adjacent normal mucosa (NLM) from 57 patients with stage III/IV LSCC and were correlated with a number of clinicobiological parameters of this tumor including anatomical site, tumor grade, nodal status, clinical stage, DNA ploidy, proliferation rate, and patient outcome. Median uPA levels were significantly higher in LSCC than in NLM (1.8 ng/mg of protein vs 0.3 ng/mg; p<0.001) whereas median CD levels were not significantly increased in tumor tissue compared to NLM (24 pmol/mg vs 19 pmol/mg, p=0.063). No significant correlation was observed between uPA and CD concentrations in tumor tissues (r=-0.1; p=0.4). Furthermore, the distribution analysis of uPA and CD in tumors showed no correlation between expression levels of these proteinases and the parameters mentioned above including patient outcome. However, when data were matched according to each parameter examined it was observed that the differences in uPA content between LSCC and NLM, expressed as uPA tumor/normal tissue ratio (T/M), were more marked in clinically advanced and/or aggressive forms of LSCC (i.e., node positive, stage IV, poorly and moderately differentated, aneuploid multiclonal, low S-phase, subglottis tumors). These data suggest that in such tumors altered regulation of uPA may occur to a greater extent than in less aggressive and less advanced forms of LSCC. This phenomenon was not observed for CD. However, in tumors with a high proliferation rate, in stage IV tumors as well as in those located in the supraglottis, CD levels were significantly higher than those found in the corresponding NLM (p=0.008, p=0.02 and p=0.03, respectively). In conclusion, uPA is highly expressed in locally advanced LSCC and appears to be implicated in some key events of progression of this tumor such as local invasion and/or nodal involvement, whereas CD does not seem to have a role in promoting these processes. Nevetheless, neither of these proteinases seem to be prognostically useful in patients with stage III/IV tumors.

Adverse pathologic features in early oral squamous cell carcinoma and the role of postoperative radiotherapy-a review

The use of postoperative radiotherapy (PORT) in early stage oral cancer with adverse pathologic features (APFs) is controversial. Prognostically relevant APFs reviewed were perineural invasion, lymphovascular invasion, depth of invasion, worst pattern of invasion, and margin status. The current literature remains divided with regard to the benefit of treatment escalation in these patients; although these patients are at high risk for recurrence, the morbidity of PORT needs to be balanced against the likely benefit in disease control. A wide heterogeneity in the literature exists, likely as a result of differences in treatment protocols. We performed a literature review of the role of PORT in early-stage oral cancer with APFs. Based on the current evidence, the decision to administer adjuvant therapy needs to be made on an individual basis; patients with >1 APF are likely to benefit from PORT, and the use of risk-scoring systems may help in decision making.

Localization and Level of Expression of β-Catenin in Human Laryngeal Squamous Cell Carcinoma

OBJECTIVE: We studied the participation of β-catenin in the histologic differentiation of laryngeal squamous cell carcinomas.

STUDY DESIGN AND SETTING: At the National Institute of Respiratory Diseases, a tertiary referral center, localization and level of expression of β-catenin were compared between normal epithelium (15 cases) and primary tumors in different degrees of differentiation (38 cases), using an immunohistochemical procedure.

RESULTS: Cell membrane staining of β-catenin was observed in normal epithelium and in well and moderately differentiated carcinomas. Cytoplasmic redistribution was observed in poorly differentiated carcinomas. Loss of β-catenin correlated with tumor dedifferentiation.

CONCLUSION: Reduction of cell membrane β-catenin expression correlated with tumor dedifferentiation.

SIGNIFICANCE: Loss of β-catenin may lead to diminishing the strength of the intercellular adhesion system, thereby promoting the invasive phenotype of the squamous cell carcinoma of the larynx.

Cyclin D1, p53, MIB1, Intratumoral Microvessel Density, and Human Papillomavirus in Advanced Laryngeal Carcinoma: Association with Nodal Metastasis

OBJECTIVE: We sought to study various parameters in laryngeal squamous cell carcinoma (LSCC) that might predict nodal metastasis.

STUDY DESIGN AND SETTING: Sixty-four LSCCs were examined with respect to their histopathology and, using immunohistochemistry, their proliferative capacity (MIB1), p53 and cyclin D1 status, and intratumoral microvessel density. The presence of human papillomavirus was ascertained by the polymerase chain reaction.

RESULTS: Histopathologically, most tumors had an infiltrating/mixed growth pattern and a diminished inflammatory reaction at the growing margin. In addition, 56% of the tumors were positive for MIB1, with 64% showing p53 overexpression; 70% were positive for cyclin D1; and 59% showed increased tumor microvessel density. Of 42 cases analyzed, 9.5% were positive for human papillomavirus 16.

CONCLUSIONS: Of the parameters studied, a diminished lymphocytic inflammatory response at the periphery ( P < 0.05) and cyclin D1 overexpression ( P < 0.001) correlated significantly with cervical nodal metastasis at presentation.

SIGNIFICANCE: Cyclin D1 overexpression, easily assessed on biopsy samples, may thus help in optimizing therapy at the outset.

The Relationship between the Localization, Size, Stage and Histopathology of the Primary Laryngeal Tumor with Neck Metastasis

OBJECTIVE

In this study we aimed the investigate the laryngectomy (partial and total) and neck dissection (functional, radical) in patients undergoing larynx identified as a result of the operation of primary tumour localization, size, stage and histopathology of the relationship between neck metastasis.

MATERIALS AND METHODS

The files of 118 patients who has had operation of laryngectomy (partly, total) and neck dissection (functional, radical) because of larynx cancer in the Ear Nose and Throat (ENT) Clinic in the last ten years (1997-2007) have been evaluated retrospectively.

RESULTS

116 of them were male and 2 of them were female. Age average was 56+/-22. 189 neck dissections have been applied to 118 patients. While in supraglottic tumours, 55.2% cervical metastasis and 28.9% occult metastasis have been determined, in transglottic tumours 35.1% cervical metastasis and 18.9% occult metastasis have been determined. It has been seen that while the cervical metastasis ratio of tumours bigger than 4 cm is 55.8%, the tumours smaller than 4 cm is 27.27% (p=0.002). The cervical metastasis rate has been determined as 26.3% in T1 cases, 25.8% in T2 cases, 40.6% in T3 cases and 58.3% in T4 cases. In tumours with advanced T stage, the rate of cervical metastasis has been seen more than the ones with early T stage (p=0.027). Cervical metastasis has been determined as 27.3% in good differential (G1) tumours, 53.4% in medium differential (G2) tumours, and 74.1% in bad differential (G3) tumours (p=0.005).

CONCLUSION

Considered in the light of clinical parameters specified in the cervical lymph node metastasis, N0 patients with laryngeal cancer, tumour, according to the anatomical location as unilateral or bilateral elective neck dissection should be performed and histopathological specimens taken in the event of a positive detection of metastases concluded that postoperative radiotherapy should be performed.

Potential prognostic and therapeutic role for angiogenesis markers in laryngeal carcinoma

Angiogenesis is a hallmark of cancer, fundamental to its growth. The 'angiogenic switch' occurs when pro-angiogenic factors are not balanced by anti-angiogenic factors. A correlation between angiogenic properties and oncological prognosis (for laryngeal squamous cell carcinoma (LSCC) too) was first hypothesized in the 1990s. An exhaustive literature review was performed to investigate available data on angiogenesis markers and their biological role and therapeutic potential in LSCC. The prognostic significance of microvascular density in LSCC was investigated with endothelial targets, e.g. CD105, CD34, and CD31. Epidermal growth factor receptor (EGFR), vascular endothelial growth factor (VEGF), VEGF receptor 2, angiogenin, hypoxia-inducible factor 1, and other biological markers were also studied. Only anti-EGFR therapy has been approved by the USFood and Drug Administration (FDA) for head and neck carcinoma in recent years, while several agents interfering with VEGF and its receptors are being studied. Experimental findings indicate that anti-CD105 monoclonal antibodies efficiently inhibit tumor angiogenesis. There are two main ways to approach the vascular profile of solid malignancies: by inhibiting new vessel formation (anti-angiogenic therapy) or selectively damaging neoplastic vessels (vascular targeting therapy). In advanced LSCC, both these strategies seem promising and warrant further preclinical and clinical investigation.

p53, epidermal growth factor receptor and proliferating cell nuclear antigen in laryngeal squamous cell carcinoma are not predictive markers for the effect of adjuvant radiotherapy

CONCLUSION

These data indicate that the expression of p53, epidermal growth factor receptor (EGFR) or proliferating cell nuclear antigen (PCNA) is not a reliable predictor of the prognosis or the effect of adjuvant radiotherapy in patients with laryngeal squamous cell carcinoma (LSCC).

OBJECTIVE

The aim of this study was to investigate the prognostic significance of p53, EGFR, and PCNA in LSCC and to assess the relationships between the expression of these molecular markers and the effect of adjuvant radiotherapy.

PATIENTS AND METHODS

We retrospectively reviewed the expression of these molecular markers in 75 patients with LSCC.

RESULTS

None of the expressions of these molecular markers was associated with disease-free survival or overall survival and no significant correlations were found between them and the effect of adjuvant radiotherapy. Also, they were not associated with each other.

Histopathological grading of laryngectomy specimens

A material comprising 118 laryngectomy specimens, prepared by whole organ serial sectioning, was analyzed to determine the prognostic significance of histopathological tumor grading. No statistically significant association could be demonstrated between grading and a number of clinical and histopathological variables, including pathological staging, lymph node metastases or recurrence rate. The study supports the contention that the prognostic value of histopathological grading of laryngeal squamous cell carcinoma remains uncertain and unproven. Serial sections of the whole organ, processed by routine laboratory techniques, remain important for studying tumor extension but do not contribute to establishing histopathological grading as a significant prognostic parameter.

Prognostic relevance of cell proliferation in head and neck tumors

Cell proliferative activity has been extensively investigated in head and neck tumors. Ki67/MIB-1 immunostaining, tritiated thymidine or bromodeoxyuridine labeling indices, DNA S-phase fraction, proliferating cell nuclear antigen expression, potential doubling time and analysis of the nucleolar organizer region associated proteins (AgNORs) have shown significant correlation with prognosis in 4806 cases of tumors of the oral cavity, salivary glands, pharynx and larynx. However, this was not observed in 2968 other reported cases. Discrepancies may depend on various factors: the heterogeneity of the series, which include tumors from various anatomic sites and patients treated with different therapy, and the lack of standardization of methods for assessing cell proliferation. Furthermore, none of the methods currently applied can by themselves define the actual proliferative activity, as it depends both on the proportion of cells committed to the cycle (growth fraction) and the speed of the cell cycle. Indeed, the actual proliferative activity of a tumor could well be measured by the equation [PA = Ki67 or MIB-1 scores x AgNORs], as we did in pharyngeal carcinoma. Provided that large and homogeneous series are evaluated by standardized methods, cell proliferative activity can still be regarded as an inexpensive and reliable prognostic factor in head and neck tumors.

Immunogold labelling of PCNA and Ki-67 antigen at the ultrastructural level in laryngeal squamous cell carcinoma and its correlation with lymph node metastasis and histological grade

Streptavidin-gold was used for the immunolocalization of PCNA and Ki-67 antigen at the ultrastructural level with a postembedding technique in biopsies of 15 patients with laryngeal squamous cell carcinoma. Positive immunoelectron staining was obtained in 9 cases for PCNA (60%) and in 8 cases for Ki-67 (53%). PCNA was predominantly found in heterochromatin of the nucleus of laryngeal carcinoma cells in a granular pattern. Positivity for PCNA was not found in nucleoli. In 4 cases, positive staining was observed both in nucleus and cytoplasm. In the cytoplasm, it was found to be present on the endoplasmic reticulum and on ribosomes throughout the cytoplasm. Ki-67 antigen was localized in the nucleus where it was associated with heterochromatin and euchromatin. It was also observed in nucleoli in all cases. Cytoplasmic localization of Ki-67 antigen was similar to that of PCNA. All 8 cases that were positive for Ki-67 were also positive for PCNA. Control incubations did not result in labelling with steptavidin-gold particles for both antigens. A significant correlation between PCNA and Ki-67 expression in association with pathological characteristics such as nodal status and histological grade was not found. Our data indicate that Ki-67 antigen staining correlates with PCNA labelling, whereas a relationship between proliferation markers and tumour progression was not found.

Prognostic importance of lymphatic reaction pattern in laryngeal carcinoma

PURPOSE

Cervical lymph node status is a widely accepted important prognostic parameter in laryngeal carcinoma.

PATIENTS AND METHODS

In this study, we retrospectively reviewed neck specimens of 46 laryngeal carcinoma patients operated in our clinic. Presence of neck metastasis and pattern of reactivity in nonmetastatic nodes was correlated with recurrence and survival during a follow-up period of at least 2 years.

RESULTS

Fourteen of the patients had at least one metastatic node and survival was 64%; 32 of the patients had reactional nodes only and the survival was 81%. Pattern of lymph node reactivity was evaluated as stimulated in type I (lymphocyte predominance) and type II (germinal center predominance); as unstimulated in type III (histiocytosis and/or normal) and type IV (lymphocyte depletion). Thirty two neck [-] patients had reactional nodes--16 of them were classified as stimulated and 16 of them as unstimulated; the 2-year survivals were 94% and 68%, respectively. In the 14 patients with cervical metastasis (classified according to nonmetastatic reactional nodes) 9 were stimulated and 5 were unstimulated with 2-year survivals of 100% and 0%, respectively.

CONCLUSION

Stimulated lymphatic pattern reflects a better prognosis, especially in N+ neck laryngeal cancer patients.

Prognostic factors in carcinoma of the larynx: relevance of DNA ploidy, S-fractions and localization of the tumour

The influence of the cell cycle profile and the site of the primary tumour on the overall survival were examined in 36 patients with squamous cell carcinoma of the larynx. DNA ploidy (p = 0.0091), the overall proliferative activity (p = 0.0001), the overall proliferative activity of diploid tumour cells (p = 0.0017) and primary tumour site (p = 0.0008) were found to be significant single prognostic factors of the overall survival. Multivariate analysis showed that only the overall proliferative activity was prognostically significant (p = 0.013). The results of the study show that the supraglottic site of the tumours correlates significantly with DNA ploidy (p = 0.0334) and the overall proliferative activity of tumour cells (p = 0.0159), whereas the correlation with proliferative activity of diploid tumour cells (p = 0.1416) has not been confirmed by this study. Glottic tumours showed a prognostically significant correlation with the overall proliferative activity (p = 0.0037) and proliferative activity of diploid tumour (p = 0.0054). Such a prognostic correlation was not found for DNA ploidy (p = 0.6542).

Histologic evaluation of neck dissection specimens

Histologic evaluations of neck dissection specimens from carcinomas of the head and neck provide information required for disease staging, planning further treatment, and prognosis. Histologic evaluation performed adequately and accurately can and continues to provide a more accurate, meaningful, and promising means of formulating and predicting prognosis including risk of metastases. A multi-institutional study using comprehensive standardized histologic evaluation of histopathologic variables of primary tumor and cervical lymph nodes among homogenous patient groups receiving similar therapy is important. Histopathologic parameters remain an important adjunct parameter to clinical evaluation in guiding, planning treatment, and predicting prognosis for patients with head and neck cancers.

Cathepsin D in tissue and serum of patients with squamous cell carcinoma of the head and neck

Aspartic proteinase cathepsin D (CD) is believed to be associated with proteolytic processes leading to local invasion and seeding of tumour cells. To estimate a potential prognostic value of cathepsin D in squamous cell carcinoma of the head and neck, its total concentration was measured immunoradiometrically (ELSA-CATH-D kit, CIS bio international) in cytosols of tumour and adjacent normal tissue samples from 111 patients; in 42/111 patients, the CD concentration was determined in serum samples obtained at diagnosis (serum no. 1) and after the therapy (serum no. 2) from each of these patients. Sera of 15 healthy volunteers served as controls. A significantly elevated concentration of CD was measured in tumour cytosols as compared to normal tissue cytosols (31.1 versus 12.6 pmol/mgp, P < 0.0001) and in cytosols of normal laryngeal tissue than of the oral cavity or pharynx (13.3 versus 11.2 pmol/mgp, P = 0.03). The higher CD tumour concentration correlated with the age of the patients (< or =60 versus >60 years, 28.8 versus 32.8 pmol/mgp, P = 0.045) and histopathological tumour grade (G1+2 versus G3, 32.6 versus 24.4 pmol/mgp, P = 0.02). In serum samples, a lower concentration of CD was measured in the control group than in the patients (3.6 versus 4.1 pmol/mls, P = 0.045) and in serum no. 1 than in serum no. 2 (4.1 versus 5.1 pmol/ mls. P = 0.05). The CD concentration in sera obtained at diagnosis was stage-dependent (S(I-III) versus S(IV), 3.9 versus 4.7 pmol/ mls. P = 0.09); there was a trend towards lower CD concentrations with an increasing time delay in serum no. 2 sampling (Rs = -0.20, P = 0.21). No correlation was observed between cytosolic and serum concentrations of CD. We conclude that our results confirm a specific role of CD in the process of invasion and metastasis of squamous cell carcinoma of the head and neck, which might also be of prognostic value in this particular cancer type.

Prognostic significance of vascular and perineural invasion in cancer of the larynx

PURPOSE

Perineural and vascular invasion are generally recognized as poor prognostic factors in cancer. The authors report the prognostic significance of perineural and vascular invasion in cancer of the larynx.

MATERIALS AND METHODS

The laryngectomy specimens of 94 patients with squamous cell carcinoma of the larynx were analyzed histopathologically for vascular and perineural invasion. Prognostic significance of vascular and perineural invasion was evaluated related to the cervical lymph node metastasis, recurrence, and disease-free survival.

RESULTS

Vascular invasion significantly influences cervical lymph node metastasis for supraglottic tumors, yet not for glottic and transglottic tumors. Perineural invasion has marginal significance in cases of cervical lymph node metastasis of supraglottic tumors; it has no significance in cases of cervical lymph node metastasis of glottic and transglottic tumors. Vascular invasion significantly increases local and regional recurrence rate, but not distant metastasis rate. Perineural invasion significantly increases local recurrence rate, but not regional recurrence and distant metastasis rate. The disease-free survival is significantly shortened by the presence of vascular and perineural invasion. According to multivariant analysis, neither vascular nor perineural invasion significantly effects the disease-free survival independently (P> .15). The presence of vascular invasion significantly affects the recurrence independently (P=.045). The presence of vascular invasion significantly reduces the interval between surgery and the development of recurrence (P=.013).

CONCLUSION

The presence of vascular and perineural invasion should be checked in every laryngectomy specimen because both have a significant prognostic value; both influence the disease-free survival and recurrence significantly. Vascular invasion significantly increase cervical lymph node metastasis of supraglottic tumors; perineural invasion has only marginally significant effect on cervical lymph node metastasis of supraglottic cancers. Vascular invasion plays an independent role in determining the recurrence.

Role of DNA measurements of head and neck tumors

The measurement of DNA ploidy has been used as a tool to try to determine the prognosis of many neoplasms. DNA ploidy can be determined by flow cytometry or image analysis of a tumor. In squamous carcinomas of the head and neck, a poorer prognosis has been associated with nondiploid tumors. Similar results have been obtained from studies of salivary gland neoplasms. The role of DNA ploidy as a provider of independent information has yet to be determined. With rarer head and neck tumors, measurement of tumor ploidy has yet to be established as a valuable adjunct to routine light microscopic study.

Immunohistochemical localization of lysosomal cathepsin D in schwannomas

The immunohistochemical localization of cathepsin D (CD) was demonstrated for the first time in 54 schwannomas (32 intra- and 22 extracranial; 47 benign and 7 malignant) and 5 normal nerve fibers. Granular or vesicular CD-reactive structures were observed in all normal Schwann cells. All tumors contained CD-reactive tumor cells, although the population of CD-reactive tumor cells, the density, intracellular localization, and morphology of CD-reactive structures, and the intensity of CD immunoreactivity varied from case to case, portion to portion, and cell to cell, differing variously from those in normal Schwann cells. The variations were greater in malignant than in benign schwannomas. In mildly degenerate tumor cells, CD immunoreactivity was increased, possibly in response to the increased intracellular degenerate proteins, suggesting that the mechanism of induction of lysosomal proteases preserved in normal cells is not affected by the process of neoplastic transformation. In lesions of severe degeneration or necrosis, CD immunoreactivity was lost in most tumor cells but was strong in macrophages invading the lesions and perivascular regions. CD immunoreactivity was observed at various intensities in tumor cells in the Antoni type A area but not in most tumor cells in the Antoni type B area, suggesting that Antoni type B lesions show degenerative changes. The presence of CD-reactive tumor cells in all tumors examined and strong CD immunoreactivity observed at the invasion front of tumors in some cases of benign or malignant schwannoma suggests the possible role of CD in tumor invasion in some cases.

Immunohistochemical and clinical evaluation of cathepsin expression in soft tissue sarcomas

Lysosomal proteases are known to enhance the spread of epithelial tumour cells, but little is known of the possible role of proteases in the growth of soft tissue sarcomas (STS). We investigated the expression of cathepsins D, B, S, H, L and procathepsin L in frozen sections of 34 STS from 34 patients by immunohistochemistry (IHC). Cathepsins D, B and H were relatively highly expressed in STS (77-91%). The expression rate of cathepsins S and L and of procathepsin L was lower (40-66%). Cathepsin S and L expression showed a moderate (P = 0.078 and P = 0.019) and procathepsin L a strong (P = 0.00001) correlation with the survival rate of STS patients. Cathepsin S expression is also correlated with the local recurrence rate (P < 0.01). Lysosomal proteases may play a role in STS progression, and cathepsin expression may also have significance as a prognostic factor in STS.