Aberrant p53 expression does not correlate with the prognosis in anaplastic astrocytoma

Can quantifying the extent of 'high grade' features help explain prognostic variability in anaplastic astrocytoma?

PURPOSE

Both phenotypic and genotypic variations now underpin glioma classification, thus helping to more accurately guide their clinical management. However, WHO Grade III anaplastic astrocytoma (AA) remains an unpredictable, heterogeneous entity; displaying a variable prognosis, clinical course and treatment response. This study aims to examine whether additional tumour characteristics influence either overall survival (OS) or 3-year survival in AA.

MATERIALS AND METHODS

Data were collected on all newly diagnosed cases of AA between 2003 and 2014, followed up for a minimum of 3 years. Molecular information was obtained from case records and if missing, was re-analysed. Histological slides were independently examined for Ki-67 proliferation index, cellularity and number of mitotic figures. Kaplan-Meier and Cox regression analyses were used to assess OS.

RESULTS

In total, 50 cases were included with a median OS of 14.5 months (range: 1-150 months). Cumulative 3-year survival was 31.5%. Median age was 50 years (range: 24 - 77). Age, IDH1 mutation status, lobar location, oncological therapy and surgical resection were significant independent prognostic indicators for OS. In cases demonstrating an OS ≥ 3 years (n = 15), Ki-67 index, number of mitotic figures and percentage areas of 'high cellularity' were significantly reduced, i.e. more characteristic of lower-grade/WHO Grade II glioma.

CONCLUSIONS

IDH1 status, age, treatment and location remain the most significant prognostic indicators for patients with AA. However, Ki-67 index, mitotic figures and cellularity may help identify AA cases more likely to survive < 3 years, i.e. AA cases more similar to glioblastoma and those cases more likely to survive > 3 years, i.e. more similar to a low-grade glioma.

Expression of cyclin D2, P53, Rb and ATM cell cycle genes in brain tumors

Cyclin D2, P53, Rb and ATM as cell cycle genes regulate cell growth and proliferation. Considering their roles, we assumed that they have different level of mRNA expression in different grades of brain tumors. To determine this point, we investigated the mRNA expression in two types of brain tumors, including astrocytoma and meningioma. The mRNA of 52 brain tumor samples were extracted; cyclin D2, P53, Rb and ATM mRNA expression was quantified using the real-time quantitative reverse-transcription polymerase chain reaction. We compared mRNA expression of these genes between astrocytoma and meningioma tumors and also between different grades of them. Cyclin D2, P53, Rb and ATM had higher expression in astrocytoma than meningioma tumors. Higher grade (III and IV) of astrocytoma tumors had up-regulation for cyclin D2 and ATM genes, but higher grades of these tumors showed down-regulation of P53 and Rb genes. Analysis of relative expression between two grades of meningioma tumors showed a high down-regulation in grade II related to grade I. Also, cyclin D2, P53, Rb and ATM mRNA expression in each group of tumors (meningioma and astrocytoma) showed a highly positive correlation in lower grades. Considering this fact and also different templates of up- and down-regulation for these genes' interaction in different types of brain tumors, it seems that these genes do not have a unique model of interaction.

Prognostic significance of histological grading, p53 status, YKL-40 expression, and IDH1 mutations in pediatric high-grade gliomas

The objective of this study was to evaluate, in a series of 43 pediatric high-grade gliomas (21 anaplastic astrocytoma WHO grade III and 22 glioblastoma WHO grade IV), the prognostic value of histological grading and expression of p53 and YKL-40. Moreover, mutational screening for TP53 and IDH1 was performed in 27 of 43 cases. The prognostic stratification for histological grading showed no difference in overall (OS) and progression-free survival (PFS) between glioblastomas and anaplastic astrocytomas. Overexpression of YKL40 was detected in 25 of 43 (58%) cases, but YKL-40 expression was not prognostic in terms of OS and PFS. p53 protein expression was observed in 13 of 43 (31%) cases but was not prognostic. TP53 mutations were detected in five of 27 (18%) cases (four glioblastomas and one anaplastic astrocytoma). Patients with TP53 mutation had a shorter median OS (9 months) and PFS (8 months) than those without mutations (OS, 17 months; PFS, 16 months), although this trend did not reach statistical significance (p = 0.07). IDH1 mutations were not detected in any of the cases analyzed. Our results suggest that in pediatric high-grade gliomas: (i) histological grading does not have strong prognostic significance, (ii) YKL-40 overexpression is less frequent than adult high-grade gliomas and does not correlate with a more aggressive behavior, (iii) TP53 mutations but not p53 expression may correlate with a more aggressive behavior, and (iv) IDH1 mutations are absent. These observations support the concept that, despite identical histological features, the biology of high-grade gliomas in children differs from that in adults, and therefore different prognostic factors are needed.

Low-grade supratentorial astrocytomas in adults: Management, immunohistochemical analysis and long-term follow-up

A retrospective review of supratentorial, low-grade astrocytomas in adults over a 10-year period (1983-1993) was performed. All 62 patients had computed tomography and surgery with histological and immunohistochemical analysis of the tumour. Radiotherapy was administered to all patients, regardless of the extent of surgical resection. Multivariate analysis showed that age of the patient at the time of surgery (P=0.008) and female sex (P=0.031) were the most important indicators of improved survival. No significant survival advantage was found with any particular symptom or symptom duration. Neither presence of a tumour cyst nor site of the tumour affected survival. Histological grading (St Anne-Mayo system) found 61 grade II astrocytomas (98%) and one grade I tumour. Six tumours (10%) were protoplasmic astrocytomas and 56 cases (90%) were diffuse fibrillary astrocytomas. Proliferation index derived from Ki-67 antibody staining and the presence of p53 protein expression were not significantly correlated with survival. Most patients underwent biopsy (79%) with 8% undergoing subtotal and 13% total resection. Increased extent of surgical removal showed a trend towards an improved survival (P=0.05). No survival advantage was found with increasing radiotherapy dose. Median survival in the study population was 5.1 years, with survival rates of 70% at 2 years and 53% at 5 years. The follow-up period ranged from 1 to 10.5 years. Younger age, female sex and the extent of surgical resection are important prognostic factors in the management of low-grade astrocytomas, whereas the efficacy of postoperative radiotherapy needs further evaluation. The prognostic significance of Ki-67 and p53 expression in low-grade astrocytomas remains to be determined.

Prognostic value of Mdm2, p53 and p16 in patients with astrocytomas

Surgical cure of gliomas infiltrating into the brain is practically impossible and their clinical course is primarily determined by the biological behavior of the tumor cell. The purpose of this study was to analyze retrospectively prognostic input of p53, Mouse double minute-2 (Mdm2) and p16 in 103 uniformly treated patients with astrocytic tumors. The expression of these molecules was measured by immunohistochemical procedure. Prognostic evaluation was performed with the multivariate proportional hazards model. The follow-up period lasted 19 (5-122) months for the survivors. We observed that 66% of gliomas showed mutated p53, while only 17% overexpressed Mdm2, the p53-regulatory molecule. Besides, almost 50% of gliomas lost p16 immunopositivity. Only p53 labeling showed a positive correlation with the grade of malignancy, according with the WHO classification. The association between mutated p53 and histological grade remained when prognostic variables were considered in a multivariate analysis. No association between p53 status and overall survival was found. On the other hand, Mdm2 overexpression and, unexpectedly, p16 immunopositivity were associated with a shorter survival in an univariate analysis. However, Cox-regression analysis showed that only Mdm2 in female patients was an independent prognostic factor, associated with shorter survival. In conclusion, our results suggest that Mdm2 could be a relevant marker in determining the evolution of glioma patients and could provide a more objective way to classify astrocytomas.

The impact of p53 tumor suppressor gene on glioma biology

The tumor suppressor gene, p53, is important in glioma biology. The authors of this paper review its role in cell physiology, epidemiology, glioma progression, prognosis, and therapeutic advances.

Immunohistochemical markers for prognosis of anaplastic astrocytomas

Among the entire spectrum of astrocytic neoplasms, just anaplastic astrocytoma (or grade III astrocytoma) appears to be a more enigmatic tumor entity with vague criteria for pathological diagnosis, unclear biological behavior and diverse clinical outcome. Attempts have been made to identify biological markers that would be useful in prediction of prognosis of anaplastic astrocytomas but the results obtained are controversial. In the present study, survival data on 63 patients with anaplastic astrocytoma were studied to evaluate a possible association between clinical outcome and expression of some immunohistochemical variables. Both the progression-free (PFS) and overall (OS) survival times were significantly reduced for patients older than 45 years, for anaplastic astrocytomas containing multiple mitoses, for Ki-67 LI > 5%, for cyclin A LI > 4% and for PTEN-negative tumors. We found no differences in survival times in patients with or without p53 immunoreactivity and also in cases with different values of p16 and p27 immunostaining. Multivariate analysis revealed that risk of tumor progression and death is independently associated with tumors containing multiple mitoses and for PTEN-negative tumors. According to the data from the CART modeling, tumors were subdivided based on the three following subsets: (1) Anaplastic astrocytomas with solitary mitosis. (2) Anaplastic astrocytomas with multiple mitoses and PTEN positivity. (3) Anaplastic astrocytomas with multiple mitoses and PTEN negativity. Thus, the results obtained reveal the advantage of combined approach including evaluation of routine histological parameters and immunohistochemical variables for further clinical subdivision of anaplastic astrocytomas.

EGFR overexpression and radiation response in glioblastoma multiforme

PURPOSE

Recent studies have suggested relative radioresistance in glioblastoma multiforme (GM) tumors in older patients, consistent with their shorter survival. Two common molecular genetic abnormalities in GM are age related: epidermal growth factor receptor (EGFR) overexpression in older patients and p53 mutations in younger patients. We tested whether these abnormalities correlated with clinical heterogeneity in GM response to radiation treatment.

METHODS AND MATERIALS

Radiographically assessed radiation response (5-level scale) was correlated with EGFR immunoreactivity, p53 immunoreactivity, and p53 exon 5-8 mutation status in 170 GM patients treated using 2 prospective clinical protocols. Spearman rank correlation and proportional-odds ordinal regression were used for univariate and multivariate analysis.

RESULTS

Positive EGFR immunoreactivity predicted poor radiographically assessed radiation response (p = 0.046). Thirty-three percent of tumors with no EGFR immunoreactivity had good radiation responses (>50% reduction in tumor size by CT or MRI), compared to 18% of tumors with intermediate EGFR staining and 9% of tumors with strong staining. There was no significant relationship between p53 immunoreactivity or mutation status and radiation response. Significant relationships were noted between EGFR score and older age and between p53 score or mutation status and younger age.

CONCLUSION

The observed relative radioresistance of some GMs is associated with overexpression of EGFR.

The challenge of p53 as prognostic and predictive factor in gliomas

In recent years, increasing interest in genetic abnormalities and biologic factors such as the tumour suppressor gene p53 as possible predictive and prognostic factor in gliomas has emerged. Inactivation of p53 can result in resistance to apoptosis, one of the mechanisms thought to explain the failure to respond to DNA-damaging agents. Thus, inactivation of p53 might be associated with a worse prognosis. Considering the inconsistent results of several recent studies, it has remained controversial whether p53 actually can be related to response to treatment and patients' prognosis. Therefore, a systematic review of the literature was performed, which included 28 publications. Techniques for assessing the inactivation of p53 varied widely. Overall, approximately 50% or more of astrocytoma specimens evaluated by immunohistochemistry stained positively for p53, regardless of histologic grade. Eight studies were restricted to comparably treated patients within a single histologic group. In most instances, non-restrictive inclusion criteria and use of statistical methods, which were not sufficient to correct the possible bias, make it difficult to reach unequivocal conclusions. However, it appears that the prognostic information of p53 is at best marginal, especially when compared to established parameters such as grading, age, etc. Its predictive value, which most likely is rather limited too, can hardly be judged without prospective studies also evaluating other biological factors as well as end-points other than time to radiological progression.

Practical value of Ki-67 and p53 labeling indexes in stereotactic biopsies of diffuse and pilocytic astrocytomas

OBJECTIVE

Stereotactic biopsies are increasingly being used for the diagnosis and grading of astrocytomas, and there is a growing need to obtain maximum information from these tissue samples. In everyday practice, p53 protein and Ki-67 immunohistochemical analyses are the most frequently used ancillary studies to aid in diagnosis and grading, but their exact role is not clearly established. This study was undertaken to evaluate the practical value of these markers in stereotactic biopsy samples from diffuse astrocytomas as well as pilocytic astrocytomas. Methods/Results.-We analyzed the Ki-67 (MIB-1) and p53 labeling indexes in the stereotactic biopsy specimens from 11 pilocytic astrocytomas; 8 grade 2, 15 grade 3, and 16 grade 4 diffuse astrocytomas. Pilocytic astrocytomas and diffuse astrocytomas were evaluated as 2 separate groups. There was a strong correlation with poor outcome when both labeling indexes were higher than 15% in the same tumor for diffuse astrocytomas (P < 0.01). The indexes did not correlate with outcome in pilocytic astrocytomas.

CONCLUSION

Combined Ki-67 and p53 labeling indexes higher than 15% indicated a worse outcome than suggested by the histologic grading. The analysis aided or improved histologic evaluation of stereotactic biopsies in our patients. We believe that a realistic prognostic upgrading of diffuse astrocytomas should be made only when labeling indexes for both markers are greater than 15%.

Clinicopathologic study of 85 similarly treated patients with anaplastic astrocytic tumors. An analysis of DNA content (ploidy), cellular proliferation, and p53 expression

BACKGROUND

The biologic behavior of anaplastic (World Health Organization Grade III) astrocytomas and oligoastrocytomas is highly variable, ranging from rapid progression to prolonged survival. It is difficult to predict the outcome of an individual patient based on morphology alone.

METHODS

To determine the prognostic value of commonly used clinicopathologic markers, we reviewed our experience with 85 similarly treated patients enrolled in 3 North Central Cancer Treatment Group high grade glioma protocols. The pathology was comprised exclusively of primary anaplastic astrocytic tumors (66 astrocytomas and 19 oligoastrocytomas). Variables examined included patient age, morphologic type, preoperative performance score, extent of surgery, solitary versus multiple mitoses, DNA flow cytometric and image morphometric parameters, and expression of proliferating cell nuclear antigen, MIB-1, and p53 expression.

RESULTS

The study was comprised of 48 men and 37 women ranging in age from 14-79 years (median age, 47 years). Overall survival ranged from <1 month to >12 years (median, 21.6 months). Statistical analyses revealed that age accounted for the majority of this extensive variability in survival. The median survival times were 65. 5 months, 22.1 months, and 4.4 months, respectively, for the groups <40 years, 40-59 years, and >/=60 years, respectively (P < 0.0001). On univariate analyses, aneuploidy by flow cytometry and a low performance score also predicted a better survival (P values of 0.04 and 0.009, respectively). Statistical trends predicting a better survival were observed for patients with a solitary mitosis and p53 immunopositivity. However, only patient age remained significant in multivariate models.

CONCLUSIONS

In a small but relatively uniformly treated cohort of patients with anaplastic astrocytomas and oligoastrocytomas, patient age was associated strongly and inversely with overall survival. Once patient age was taken into account, the clinical and pathologic markers tested appeared to be of limited prognostic value.

p53 protein expression in grade II astrocytomas: immunohistochemical study of 100 cases with long-term follow-up

p53 protein expression was evaluated by immunohistochemistry in a homogeneous series of 100 supratentorial grade II astrocytomas with long-term follow-up. The staining was positive in 72 cases. The proportion of p53 positive tumors was slightly higher in younger patients. The tumor regrowths which derived from p53 positive tumors were themselves p53 positive, and this p53 immunopositivity was often stronger than in the initial tumors. All of the 10 gemistocytic astrocytomas included in our series were p53 positive, and age more than histological type appeared decisive in prognosis. p53 protein expression did not quite reach statistical significance as an independent predictive variable in multivariate analysis, whereas survival was related with age, mass effect, surgery and tumor location. Only a tendency to a longer survival was observed on the curves in younger patients with mildly positive tumors.

Accumulation of p53 and Ki-67 expression do not predict survival in patients with fibrillary astrocytomas or the response of these tumors to radiotherapy

OBJECTIVE

Although radiotherapy is often used in the treatment of patients with low-grade astrocytomas, its value is still uncertain. Radiotherapy carries a risk of morbidity for patients and has time and cost implications for health services. We have assessed the value of two histological variables, p53 accumulation and Ki-67 expression, in predicting the response of astrocytomas to radiotherapy. The former antigen was assessed because many astrocytic tumors show mutations in the p53 gene, the function of which is crucial for mediating cell death after radiotherapy, and the latter was assessed because it is expressed only in proliferating tumor cells, which may show greater radiosensitivity than nonproliferating cells.

METHODS

Immunohistochemistry was used to detect the accumulation of p53 and expression of Ki-67 in a retrospective series of 96 patients with supratentorial fibrillary astrocytomas, 58 of whom had received postoperative radiotherapy. The immunohistochemical data were correlated with survival after radiotherapy.

RESULTS

There was no significant difference in survival between the patients who did and those who did not receive radiotherapy. The p53 and Ki-67 labeling indices did not correlate with survival in either the irradiated or the nonirradiated cohort, nor with overall survival in the series as a whole.

CONCLUSION

Immunohistochemical assessment of p53 accumulation and Ki-67 expression does not help in predicting the survival of patients with supratentorial fibrillary astrocytomas or in predicting whether particular patients are likely to benefit from radiotherapy.

Vascular endothelial growth factor and neovascularization in astrocytic tumors

It has been widely recognized that the vascular structure is an important factor when making a histopathological diagnosis and assessing the malignancy potential, especially of astrocytic tumors. The vascular endothelial growth factor (VEGF), which is thought to be regulated by the p53 gene, is a regulation factor for tumor neovascularization. The relationship between VEGF distribution and neovasculature was studied in 42 cases of astrocytic tumors (grades 1-4), which were obtained from surgical material, and the St Anne-Mayo grading system was applied. The relationship between the labeling indices (LI) of VEGF and LI of p53 protein in tumor cells was also studied using immunohistochemistry. The VEGF LI in high-grade malignancy potential tumors, such as grade 3 and grade 4 tumors, was significantly higher than those that were low grade. In grade 4 tumors, a significant correlation between the VEGF LI and the proliferation indices of endothelial cells of neovasculatures was observed. No significant correlation was noted between p53 LI and VEGF LI, as well as p53 LI and histopathological grade. In astrocytic tumors, expression of VEGF may be correlated to tumor neovascularization, and can be considered as an indicator of malignancy potential in astrocytic tumors.