Simple hyperplasia of the endometrium: an evaluation of proliferative activity by Ki-67 immunostaining.

As endometrial hyperplasia has been characterized over the past 100 years, some investigators have questioned the hyperplastic nature of nonatrophic cystic glands associated with an increase in gland-to-stroma ratio, which is currently considered to represent simple endometrial hyperplasia. In the current study, the proliferative activity of simple endometrial hyperplasia was examined using an antibody to Ki-67 protein, a well-established marker of proliferative activity, and compared with the results of activity in inactive/atrophic endometrium, proliferative endometrium, and other forms of endometrial hyperplasia. In an evaluation of 68 endometrial biopsy specimens showing 110 histologic patterns, the mean Ki-67 index (percentage of Ki-67 positive nuclei) was 2.8% in inactive/atrophic endometrium, 23.2% in proliferative endometrium, 9.8% in simple hyperplasia, 12.7% in complex hyperplasia, and 10% in atypical complex hyperplasia. In simple hyperplasias, the mean Ki-67 index was 3.9% in dilated glands without infolding or outbranching, 14.6% in nondilated glands showing outbranching or slight crowding, and 6.9% in dilated glands with infolding or outbranching. Ki-67 indices for dilated glands were most similar, therefore, to atrophic/inactive endometrium with no statistical significant difference in the percentage of these cells staining between these two groups. In contrast, statistically significant differences were seen in staining between cystic patterns of simple hyperplasia and proliferative endometrium, simple hyperplasia showing outbranching and/or slight crowding but no dilation, complex hyperplasia, and atypical hyperplasia. The findings in the current study suggest that nonatrophic cystic glands with an increase in the gland-to-stroma ratio in the endometrium should not be considered a hyperplastic process and in the absence of other findings such as excessive bleeding or coexistent noncystic simple hyperplasia, treatment with progestin therapy, a widely used practice, is unnecessary. As discussed, the findings also suggest that these cystic forms of simple hyperplasia are precursors of cystic atrophies. Confirmation of these results on a larger population by a different research team appears desirable.

HER-2/neu oncogene amplification by fluorescence in situ hybridization in epithelial tumors of the ovary.

HER-2/neu gene amplification and protein overexpression have been associated with prognosis in breast, lung and prostate cancers but have not been extensively studied in ovarian carcinoma. For the study, we selected 5-micron-thick, formalin-fixed, paraffin-embedded tissue sections from 74 cases of ovarian epithelial tumors of low malignant potential and ovarian carcinoma. Tumors were graded and staged and evaluated for amplification of the HER-2/neu gene by fluorescence in situ hybridization. HER-2/neu amplifications was present in 3 of 13 serous, mucinous, and endometrioid epithelial tumors of low malignant potential and in 40 of 61 epithelial carcinomas. In the carcinoma group, amplification did not correlate with stage, grade, or tumor type. Mean follow-up was 31 months; 1 patient with a low malignant potential tumor and 32 patients with carcinomas died of disease. On univariate and multivariate analysis, survival correlated with stage of disease but not with HER-2/neu amplification. HER-2/neu amplification by fluorescence in situ hybridization can be performed on tissue sections of ovarian neoplasms; amplification is uncommon in ovarian tumors of low malignant potential, but is present in 66% of ovarian epithelial carcinomas. HER-2/neu amplification did not predict outcome in ovarian epithelial neoplasia but may have an important role in tumor development.

Needle biopsy DNA ploidy status predicts grade shifting in prostate cancer.

DNA ploidy analysis of prostate needle biopsy specimens was performed to determine whether ploidy status could predict tumor grade shifting at radical prostatectomy. The paired needle biopsy and radical prostatectomy specimens from 111 randomly selected men with prostate cancer were obtained from the surgical pathology files of the Albany Medical Center Hospital. The original tumor grades were assigned by a staff of 12 surgical pathologists according to the Gleason system. Tumors with original Gleason scores < or = 6 were classified as low grade, and tumors with scores of > or = 7 were considered high grade. DNA ploidy analysis was performed on the needle biopsy specimens using the CAS 200 image analyzer (Becton Dickinson Immunocytometry Systems, Mountain View, CA, USA) on Feulgen stained 5-microm tissue sections. There were 88 diploid and 23 nondiploid cases. Thirty-eight of 111 (34%) of cases had grade shifting from needle biopsy to radical prostatectomy specimens. Of 89 low-grade needle biopsy cases, 28 (31%) were upgraded at radical prostatectomy. Of 22 high-grade needle biopsy cases, 10 (45%) were downgraded to low grade at radical prostatectomy. Of the 28 low-grade needle biopsy specimens that were upgraded at radical prostatectomy, 19 (68%) featured an aneuploid histogram and 9 (32%) were diploid. Nineteen of 28 (68%) of aneuploid low-grade tumors on needle biopsy became high-grade at radical prostatectomy. Nine of 10 (90%) diploid high-grade tumors at needle biopsy became low-grade at radical prostatectomy. Of the 38 cases in which ploidy and grade were incongruous, 28 (74%) had grade shifting. In a multivariate regression analysis, a high-grade Gleason score on radical prostatectomy specimens correlated significantly with needle biopsy ploidy (p = 0.0001) but not with needle biopsy grade (p = 0.15). The sensitivity of the needle biopsy grade in the detection of high-grade tumors on radical prostatectomy was 30%, and the specificity was 86%. The sensitivity of ploidy status in the prediction of high grade at radical prostatectomy was 78%, and the specificity was 96%. With a prostate-specific antigen (PSA) level of >0.4 ng/ml as the indicator of post-radical prostatectomy disease recurrence on a subset of 106 patients, on univariate analysis, disease recurrence was predicted by needle biopsy ploidy (p = 0.001) and radical prostatectomy grade (p = 0.04) but not by needle biopsy grade (p = 0.39). On multivariate analysis, needle biopsy DNA ploidy status independently predicted disease recurrence (p = 0.002), whereas needle biopsy and prostatectomy grade did not. These results indicate that DNA ploidy analysis of needle biopsy specimens of prostate cancer predicts grade shifting, that it is a more sensitive and specific indicator of final tumor grade at radical prostatectomy than is the original needle biopsy grade, and that ploidy status independently predicts postoperative disease recurrence.

Clinicopathologic comparison of vulvar and extragenital lichen sclerosus: histologic variants, evolving lesions, and etiology of 141 cases.

Lichen sclerosus (LS) is a persistent inflammatory dermatosis of unknown etiology with a predilection for the vulva, where it is a risk factor for carcinoma. We performed a clinicopathologic study on 121 cases of vulvar LS and 20 of extragenital LS, and we reviewed 49 vulvectomy specimens with LS to define morphologic findings, identify the earliest lesions, and correlate outcomes with histologic findings. The vulvar LS lesions were pruritic/burning, white/red, ill-defined patches predominately affecting the labia, perineum, introitus, and perianal region. The extragenital LS lesions were asymptomatic, pink to ivory white, coalescing macules or patches with well-defined borders. All of the LS cases showed dermal sclerosis, vacuolar interface changes, and a lymphocytic infiltrate underlying the sclerosis, but vulvar LS showed changes of lichen simplex chronicus or spongiotic dermatitis, dermal eosinophils, and a frequent absence of atrophy. The presence of eosinophilic spongiosis, marked lymphocyte exocytosis, dermal eosinophils, and excoriations predicted poor symptomatic response to treatment. Patch testing is recommended for these individuals as these findings suggest an allergic contact dermatitis. Examination of vulvectomy specimens revealed either a lichenoid interface or a spongiotic dermatitis in continuity with pathognomonic LS. Additionally, in these contiguous regions, we identified histologic changes that might represent evolving lesions of LS, suggesting a multifactorial etiology. In conclusion, vulvar LS was significantly different clinicopathologically from extragenital LS, and if only classic features of LS were used for pathologic diagnosis, many cases of vulvar LS would be missed. Therefore, we proposed as the minimal histologic criterion for LS the presence of a vacuolar interface reaction pattern in conjunction with dermal sclerosis (homogenized and hyalinized eosinophilic collagen bundles) of any thickness intervening between the inflammatory infiltrate and epithelium and or vessel walls.

Cell proliferation-associated proteins in endometrial carcinomas, including papillary serous and endometrioid subtypes.

Cyclin dependent kinases (cdks) and cyclins regulate the progression of cells through the cell cycle and can be overexpressed in human cancers. The purpose of this study was to evaluate the immunohistochemical profile of these proliferation-associated proteins and correlate the results with clinicopathologic parameters of endometrial carcinomas. Archival tissue sections from 91 endometrial carcinomas were immunostained using monoclonal antibodies against p34CDC2 cdk, cyclins A and B1, p120, Ki-67, and PCNA. Immunoreactivity was semiquantitatively assessed and the results correlated with pathologic features and survival. Of the 91 endometrial carcinomas, 74 were endometrioid (17 villoglandular, 57 of usual type) and 17 were papillary serous carcinomas. The positivity rates for the different proteins in papillary serous and endometrioid tumors, respectively, were as follows: p34CDC2, 24% and 23%; cyclin A, 71% and 64%; cyclin B1, 24% and 26%; p120, 47% and 9%; Ki-67, 82% and 64%; and PCNA, 47% and 47%. Only p120 correlated with histologic tumor type with significantly higher expression in both papillary serous and villoglandular endometrioid carcinomas compared to nonvilloglandular endometrioid carcinomas (p = 0.0001). p120 positivity also correlated with advanced tumor stage (p = 0.0001). Ki-67, cyclin A, and PCNA correlated with patient survival in endometrioid carcinomas on univariate analysis (p = 0.01, 0.02, and 0.003, respectively), but, on multivariate analysis, only tumor grade (p = 0.02) and depth of invasion (p = 0.04) were independent predictors of outcome. In summary, although most of the cell proliferation-associated proteins studied did not appear to be associated with clinicopathologic features of endometrial carcinoma, there was significantly higher expression of p120 in papillary serous and villoglandular endometrioid carcinomas compared to nonvilloglandular endometrioid carcinomas, suggesting a possible role of p120 in tumor behavior. In addition, Ki-67, cyclin A, and PCNA expression correlated with survival in endometrioid carcinoma, but only in a univariate analysis.

Prognostic significance of tumor necrosis factors and their receptors in nonsmall cell lung carcinoma.

BACKGROUND: In vitro studies have shown an antiproliferative effect of tumor necrosis factor (TNF) against various nonsmall cell lung carcinoma (NSCLC) cell lines. However, clinical trials of combined interleukin-2 and TNF-alpha in patients with advanced NSCLC have demonstrated both conflicting and disappointing results. METHODS: Immunohistochemical (IHC) staining was performed on formalin fixed, paraffin embedded tissues from 39 bronchogenic adenocarcinomas and 32 squamous cell carcinomas using polyclonal antibodies against TNF-alpha, TNF-beta, TNF-R1, and TNF-R2 proteins. IHC positivity was correlated with tumor stage, grade, and patient survival. RESULTS: Significant coexpression of TNF-alpha, TNF-beta, TNF-R1, and TNF-R2 was observed in NSCLC (significance range, P < 0.001-0.02). Although immunoreactivity for TNFs remained high in all tumor stages, a loss of TNF-R expression was found in advanced NSCLC (P < 0.006 for TNF-R1 and P < 0.003 for TNF-R2), suggesting down-regulation of TNF-Rs in the process of tumor progression. When all stages were considered together, immunoreactivity for TNF-beta(P < 0.001), TNF-R1, and TNF-R2 (both P < 0.001) significantly correlated with favorable outcome in univariate analysis. However, when stages were studied separately, an association between immunopositivity for TNF-Rs and favorable prognosis was found only in NSCLC without distant metastasis (P < 0.04 and P < 0.005 for TNF-R1 and TNF-R2 in Stage I [according to the American Joint Committee on Cancer staging system] disease, and P < 0.03 and P < 0.02 for TNF-R1 and TNF-R2 in Stage III disease). On multivariate analysis, increased expression of TNF-R1 (P < 0.003) and TNF-R2 (P < 0.001) as well as tumor stage (P < 0.001) independently predicted favorable outcome in patients with NSCLC. CONCLUSIONS: Although NSCLC exhibits strong coexpression of TNF-alpha, TNF-beta, TNF-R1, and TNF-R2, there is a loss/down-regulation of TNF receptors in high stage tumors. TNF-R1 and TNF-R2 positivity independently predicts favorable outcome in NSCLC, particularly in tumors with no clinically distant metastasis. The current study supports a role for TNFs and their receptors in the evolution and progression of NSCLC.

Correlation of p34cdc2 cyclin-dependent kinase overexpression, CD44s downregulation, and HER-2/neu oncogene amplification with recurrence in prostatic adenocarcinomas.

PURPOSE: To test whether p34cdc2 overexpression, CD44s downregulation, and HER-2/neu amplification correlate with disease recurrence after radical prostatectomy, and to evaluate a possible biologic association between p34cdc2 and HER-2/neu expression. MATERIALS AND METHODS: Immunohistochemical (IHC) detection of both p34cdc2 cyclin-dependent kinase (CDK) and CD44s expression and fluorescence in situ hybridization (FISH)-based analysis of HER-2/neu gene status were performed on formalin-fixed, paraffin-embedded sections of 106 prostatic adenocarcinomas (PACs). Findings were correlated with Gleason grade, pathologic stage, DNA ploidy, and postsurgical biochemical disease recurrence. RESULTS: CDK overexpression correlated with tumor grade (P = .001), DNA ploidy (P = .001), pathologic stage (P = .04), and disease recurrence (P = .01). CD44s downregulation correlated with grade (P = .03), ploidy (P = .01), and recurrence (P = .02). HER-2/neu amplification correlated with grade (P = .001), ploidy (P = .001), and recurrence (P = .01). On multivariate analysis, CDK overexpression independently predicted recurrence (P = .001) after prostatectomy. CDK expression correlated with HER-2/neu status with 32 of 65 (49%) tumors that overexpressed CDK and showed concomitant HER-2/neu amplification (P = .04). CONCLUSION: This study showed that p34cdc2, CD44s, and HER-2/neu are variably expressed or amplified in prostatic carcinoma and that such alteration may affect tumor behavior. In addition, CDK overexpression and HER-2/neu amplification may be biologically related.

Identification of HER-2/neu oncogene amplification by fluorescence in situ hybridization in stage I endometrial carcinoma.

Prognostic factors capable of detecting potential for aggressive disease in early stage endometrial cancer might be useful in selecting patients for early adjuvant therapy. Sixty-three patients with surgical Stage I endometrial carcinoma treated by hysterectomy with a mean follow-up of 55 months were evaluated for tumor type, grade, depth of myometrial invasion, presence of vascular invasion, DNA ploidy, and HER-2/neu overexpression by immunohistochemical techniques. These results were compared with HER-2/neu gene amplifications evaluated by fluorescence in situ hybridization (FISH) and their ability to predict disease survival. For FISH, sections 5 microns thick of formalin-fixed, paraffin-embedded tissues were processed using the Oncor Chromosome In Situ Hybridization System. Automated hybridization using the Ventana Gen was performed with the Oncor unique sequence digoxigenin-labeled HER-2/neu DNA probe. Gene copy numbers were evaluated using the Zeiss Axioskop50 fluorescence microscope. HER-2/neu amplification was noted in 24 (38%) of 63 cases. By multivariate analysis, only aneuploidy (P = .04) and HER-2/neu amplification by FISH (P = .04) independently correlated with survival. Although we saw a relationship between HER-2/neu protein expression and gene amplification, this trend did not achieve statistical significance. HER-2/neu oncogene amplification can be assessed using automated FISH on formalin-fixed, paraffin-embedded tissue. HER-2/ neu amplification predicts poor outcome in Stage I endometrial cancer. HER-2/neu amplification status has potential use in the identification of patients with high risk of disease recurrence who might benefit from intensified therapy.

The prognostic significance of p34cdc2 and cyclin D1 protein expression in prostate adenocarcinoma.

BACKGROUND: Cyclin-dependent kinases (CDK) and cyclins constitute the subunits of the maturation-promoting factor that controls the process of cell division. High levels of these proteins have been reported in human malignancies of the stomach, colon, breast, and lung, and have been implicated in aberrant cell division and dysregulated tumor growth. METHODS: p34cdc2 CDK and cyclin D1 (D1) protein expression were evaluated in 140 radical prostatectomy specimens harboring adenocarcinoma (PAC), using the respective monoclonal antibodies on archival tissue sections. In each case, slides stained with hematoxylin and eosin were examined for evaluation of Gleason's grade and pathologic stage. The DNA content of the tumors was determined by the Feulgen method with the CAS200 Image Analyzer (Cell Analysis Systems, Lombard, IL). Nuclear immunoreactivity for the two proteins was semiquantitatively scored, and results were correlated with Gleason's grade, stage, ploidy, metastatic status, and disease recurrence after radical prostatectomy. RESULTS: p34cdc2 was expressed in 84 of 140 PACs (60%) and correlated with high Gleason's grade (P = 0.0001), advanced pathologic stage (P = 0.01), nondiploid DNA content (P = 0.0001), and metastases (P = 0.04). On multivariate analysis using the Cox proportional hazards model, p34cdc2 immunoreactivity (P = 0.0001) and high Gleason's grade (P = 0.01) each independently predicted disease recurrence. When tumors were of low Gleason's grade and lacked p34cdc2 expression, 4 of 39 PACs (10%) recurred, as compared with 18 of 47 (38%) that recurred when tumors were of high Gleason's grade and expressed p34cdc2 protein. D1 was positive in 31 of 140 PACs (22%) and showed a trend (P = 0.07) of high Gleason's grade, but it did not reach statistical significance with any of the prognostic variables. In the majority of PACs expressing both p34cdc2 and D1 proteins, the adjacent benign prostate acini showed focal, scattered nuclear positivity of the basal and secretory epithelial cells. CONCLUSIONS: p34cdc2 is expressed in a majority of PACs and correlates with high Gleason's grade, advanced pathologic stage, nondiploid DNA content, and metastases. On multivariate analyses high Gleason's grade and p34cdc2 immunoreactivity predict disease recurrence independently of the pathologic stage. Thus, p34cdc2 appears to play a critical role in the evolution, proliferation, and spread of PACs and may be of prognostic value when applied to initial prostate tissue samples taken by needle biopsy.

HER-2/neu gene amplification status in prostate cancer by fluorescence in situ hybridization.

HER-2/neu expression has been established as a prognostic factor in breast and other cancers. In prostate cancer (PC), a similar predictive role has been hindered by variable immunohistochemical (IHC) results. The authors studied DNA amplification of the HER-2/neu gene on 4-microm sections obtained from 62 formalin-fixed, paraffin-embedded PCs by fluorescence in situ hybridization (FISH). The results were compared with HER-2/neu protein expression as determined by IHC and correlated by logistic regression analysis with Gleason tumor grade, DNA ploidy, serum prostate specific antigen (PSA), and pathological stage. The HER-2/neu gene was localized using the Oncor (Gaithersburg, MD) digoxigenin-labeled unique sequence probe. Amplified PCs had at least 20 malignant cells, with 5 or more copies of the sequence. Amplification of HER-2/neu correlated with Gleason score (P = .0001). The mean Gleason score of unamplified tumors was 5.7 and that of amplified tumors was 7.5. Nondiploid tumors had a significantly greater rate of HER-2/neu amplification compared with diploid tumors (P = .0003). Of the 62 cases evaluated by IHC and FISH, 18 cases (29%) were overexpressed by IHC, and 27 cases (44%) were amplified by FISH. A trend for similar HER-2/neu status in each PC by the two methods did not reach statistical significance (P = .23). HER-2/neu amplification by FISH was associated with advanced pathological stage; however, this relationship reached only near-statistical significance (P = .06). There was no correlation of HER-2/neu amplification by FISH with patient age or preoperative serum PSA levels. The authors conclude that HER-2/neu gene amplification status can be determined by FISH on archival prostate cancer specimens, significantly correlates with high tumor grade and nondiploid DNA content, and is more frequently encountered in tumors with advanced pathological stage. Also, FISH is more sensitive than IHC for detection of abnormalities in the HER-2/neu gene, and further studies should be undertaken to determine whether a FISH-based HER-2/neu detection method may prove of importance in the prediction of prognosis and planning of therapy in prostate cancer patients.

Telomerase activity in benign endometrium and endometrial carcinoma.

Telomerase, a ribonucleoprotein associated with synthesis of telomeric DNA, is postulated to play a role in cellular senescence and immortalization. Telomerase adds a hexonucleotide telomeric sequence to the chromosomal ends during replication and is preferentially expressed in most malignant and germ-line tissues but is usually undetectable in normal somatic cells. In the current study, 34 human endometrial tissues (20 malignant and 14 benign) were analyzed for telomerase activity by a nonradioactive PCR-based method using the TRAP-eze telomeric repeat amplification detection kit (Oncor). Nineteen of 20 (95%) endometrial carcinomas and 8 of 8 (100%) benign endometrial tissues from premenopausal women exhibited strong telomerase activity, whereas 6 of 6 (100%) benign endometrial tissues from postmenopausal women showed only weak telomerase activity. There was no correlation of telomerase activity with tumor grade, depth of invasion, or DNA content. Benign cycling endometrium, a rapidly proliferating tissue, features positive telomerase activity, although expression in nonneoplastic tissues has only rarely been previously reported. Only weak activity is detected in endometrial tissues after menopause, but telomerase activity can be strongly reactivated in patients who develop endometrial cancer.

Prognostic significance of HER-2/neu gene amplification status by fluorescence in situ hybridization of prostate carcinoma.

BACKGROUND: HER-2/neu gene amplification, established as a prognostic factor in breast carcinoma and other cancers, has not been correlated with outcome in prostate carcinomas (PCs). METHODS: HER-2/neu gene amplification was determined by automated fluorescence in situ hybridization (FISH) using a unique sequence cosmid probe on 113 formalin fixed, paraffin embedded 4-microns tissue sections and the results compared with tumor grade, DNA ploidy, HER-2/neu protein expression by immunohistochemistry (IHC), serum prostate specific antigen, pathologic stage, and postoperative disease recurrence (mean follow-up of 44 months). RESULTS: HER-2/neu gene amplification by FISH (41% of PCs) correlated with tumor grade (P = 0.001) and DNA ploidy status (P = 0.0003). HER-2/neu protein overexpression by IHC (29% of PCs) correlated with grade (P = 0.03), but not with DNA ploidy. A trend for similar HER-2/neu status in each PC by IHC and FISH did not reach statistical significance (P = 0.25). On univariate analysis, HER-2/neu amplification by FISH (P = 0.029), tumor grade (P = 0.013), and DNA ploidy (P = 0.016) correlated with postoperative disease recurrence. HER-2/neu expression by IHC did not correlate with outcome. On multivariate analysis, grade (P = 0.0001) and ploidy (P = 0.001) were independent outcome predictors; HER-2/neu amplification by FISH reached near-independent significance (P = 0.125). CONCLUSIONS: HER-2/neu gene amplification by FISH on archival PCs significantly correlates with grade and DNA ploidy status, is more sensitive than IHC in detecting HER-2/neu gene abnormalities, predicts postoperative disease recurrence, and may prove important in planning therapy for patients with prostate carcinoma.

Non-neoplastic epithelial alterations of the vulva: recognition assessment and comparisons of terminologies used among the various specialties.

To assess the recognition of non-neoplastic epithelial alterations of the vulva and to compare terminologies used for these lesions by various specialties, we performed a clinical and dermatopathologic review of all of the cases diagnosed as non-neoplastic epithelial alterations of the vulva that were followed by one gynecologist. Forty-five initial clinical and pathologic diagnoses made by a group of 14 general surgical pathologists during a 15-year period were compared to the diagnoses made by two dermatopathologists at the time of review. Comparison of diagnoses between the three specialties revealed two types of disparities. The first represented differences in nomenclature. Although all parties frequently agreed on a diagnosis of lichen sclerosus, which represented the most frequent histologic diagnosis, the dermatopathologists did not use the term squamous hyperplasia for any case. Of greater significance was the second type of disparity identified, i.e., failure of the gynecologist and general surgical pathologist to identify uncommon dermatoses in eight cases. Concordance in diagnosis among the dermatopathologists was found in 43 of the 45 cases. These findings are consistent with the view that non-neoplastic epithelial alterations of the vulva are the same as elsewhere in the skin and that terms such as vulvar dystrophy or squamous hyperplasia are not meaningful or helpful in identifying or treating vulvar dermatoses. Unfamiliarity with specific dermatoses and the modified appearance of a dermatosis when occurring on the vulva might cause recognition failure by the gynecologist and general surgical pathologist. Entity recognition might be greatly improved if non-neoplastic vulvar lesions are approached as specific dermatoses rather than being labeled as squamous hyperplasias or vulvar dystrophies. Careful histories and physical examinations aid in identifying less common vulvar dermatoses. Referral to a dermatologist/dermatopathologist is indicated when the diagnosis is in doubt or if the response to treatment is poor.

MDM2 and p53 protein expression in the histologic subtypes of endometrial carcinoma.

The frequency of p53 protein overexpression differs among the histologic subtypes of endometrial carcinoma, from 21 to 48% in endometrioid carcinoma but from 80 to 86% in papillary serous carcinoma. Although p53 gene mutation can closely correlate with p53 protein overexpression in papillary serous carcinomas, high expression of p53 protein may also occur without detectable gene mutation in endometrioid carcinomas. Because MDM2 protein can bind mutant and wild-type p53 protein, we examined MDM2 and p53 protein expression in 27 endometrioid carcinomas and compared their expression patterns with those of 25 uterine papillary serous carcinomas. We detected p53 protein in 14 (52%) of the 27 endometrioid carcinomas but in 21 (84%) of the 25 papillary serous tumors (P = 0.02). MDM2 expression was more commonly detected in the endometrioid carcinomas. Nineteen (70%) of the 27 cases showed expression compared with 9 (36%) of the 25 papillary serous carcinomas (P = 0.03). p53 Expression correlated closely with MDM2 expression in endometrioid carcinomas but not in the papillary serous carcinomas. In endometrioid carcinomas, MDM2 was detected in 13 (93%) of 14 p53-positive carcinomas but in only 6 (46%) of 13 p53-negative tumors (P = 0.01). In papillary serous carcinomas, MDM2 was detected in 9 (43%) of 21 p53-positive carcinomas but in none of the 4 p53-negative tumors (P value not significant). These findings suggest that although high rates of p53 protein overexpression are most frequently associated with p53 gene mutation in uterine papillary serous carcinoma, p53 protein overexpression in endometrioid carcinoma is frequently associated with MDM2 overexpression. The selective correlation of MDM2 expression with p53 expression in endometrioid carcinomas but not in papillary serous carcinomas suggests an active role for MDM2 in binding and inactivating p53 in endometrioid carcinomas, leading to its overaccumulation and potentially impeding repair to damaged DNA. Additional study as to the cause of increased MDM2 expression in endometrial carcinoma, e.g., gene amplification, enhanced translation, or rearrangement, is indicated.

Cytokine, cell adhesion receptor, and tumor suppressor gene expression in vulvar squamous carcinoma: correlation with prominent fibromyxoid stromal response.

In a previous report, we observed by light microscopy the extracellular matrix in 51 vulvar squamous carcinomas and found that some tumors has a prominent stromal response in the form of a regional or diffuse zone of extracellular myxoid matrix containing immature collagen and fibroblasts at the tumor-stromal junction. These tumors were associated with clitoral involvement, ulcerative nonexophytic growth pattern, older age groups, poorer survival rate, and more extensive lymph node metastases than when prominent fibromyxoid stromal response (PFSR) was absent. This behavior was demonstrated despite the fact that these tumors were not larger, more deeply invasive, or of higher grade than when PFSR was absent. In the current immunohistochemical study, we examined cytokine, cell adhesion receptor, and tumor suppressor gene expression in 50 vulvar squamous carcinomas using a panel of antibodies to identify any potential role of these proteins in the development of a PFSR. Semiquantification of expression into none, focal (< 25% of cells showing expression), regional (25-50%), and diffuse (> 50%) patterns revealed PFSR to be statistically associated with high CD44, transforming growth factor (TGF) beta 3, and p53 protein expression, but not with fibroblast growth factor, epidermal growth factor, epidermal growth factor receptor, or E-cadherin expression. When expression of CD44 and either stromal or tumor TGF-beta 3 expression was high, i.e., regional or diffuse in distribution, 15 (50%) of 30 cases were associated with PFSR. In contrast, only 1 (7%) of 14 cases was associated with PFSR when expression was high for only one of these two proteins and none of 3 cases was associated with response when expression was low for both proteins (p = 0.005). Furthermore, in cases showing high expression for both TGF-beta 3 and CD44, PFSR was found in 13 (72%) of 18 cases when p53 expression was diffuse compared with 2 (17%) of 12 cases when expression was less (p = 0.01). Since TGF-beta acts mitogenically for fibroblasts and has been shown to be an inhibitor of epithelial cell growth, its high expression in a carcinoma with PFSR would suggest loss of effect on the epithelial component but an intact effect on the stroma. Since CD44 is known to act as a receptor for hyaluronic acid, which is a prominent stromal component and known to play an important role in cell mobility and tumor aggressiveness, its high expression in association with PFSR would suggest a role of CD44 overexpression in altered hyaluronate metabolism with accelerated tumor cell migration and subsequent distal spread. The current study demonstrates that alterations in cytokine and cell adhesion receptor status variably occur in vulvar squamous carcinoma and that such alterations may affect tumor morphology and behavior.

Clinicopathologic features of vulvar squamous cell carcinomas exhibiting prominent fibromyxoid stromal response.

The frequency, distribution, and significance of a prominent fibromyxoid stromal response to tumor was examined in 51 consecutive cases of invasive squamous carcinoma of the vulva in which the lesion was totally excised and follow-up information available. The stromal response consisted of an admixture of myxoid change and immature collagen with fibroblasts at the tumor-stromal junction and was focally (< 25% of tumor) in 11 of the 51 cases (21%), regionally (26-50% of tumor) in seven cases (14%), diffusely (> 50% of tumor) in eight cases (16%), and not at all in 25 cases (49%). Tumors showing a prominent fibromyxoid stromal response (> 25% of the tumor) were typically flat or elevated ulcerative lesions, whereas carcinomas without a prominent fibromyxoid stromal response were more commonly exophytic. Sixty percent of the tumors with a prominent fibromyxoid stromal response involved the clitoris, compared with clitoral involvement in only 14% of carcinomas without a prominent response. Case showing prominent fibromyxoid stromal response were associated with a significantly older age group, poorer survival rate, and more extensive lymph node metastases than when fibromyxoid stromal response was not prominent. This behavior was manifested despite the fact that these tumors were not larger, more deeply invading, of higher grade, or more likely to show infiltrating patterns of invasion than when fibromyxoid stromal response was not prominent. Because the ability of a tumor to invade is believed to be related in a large part to changes in the relationship of tumor to stroma, a correlation between fibromyxoid stromal response and aggressive tumor behavior would suggest that a specific pattern of alteration in the interaction of tumor cells with stroma occurs in a subset of vulvar squamous carcinomas. The current findings may reflect the diverse etiology of vulvar carcinoma. If the characteristic features of vulvar carcinomas showing a prominent fibromyxoid stromal reaction as shown in this study can be confirmed on larger study populations, "squamous cell carcinomas with prominent fibromyxoid stromal reaction" may be a useful designation for these tumors.

bcl-2 expression and the development of endometrial carcinoma.

The bcl-2 gene product inhibits programmed cell death (apoptosis). The expression of this protein has been examined in normal endometrium and found to be cycle dependent with consistent expression in the proliferative phase. In the current report, bcl-2 gene expression was examined in 88 endometrial biopsies that showed 99 histologic patterns ranging from proliferative endometrium to carcinoma. Whereas expression was always detected in 17 samples of proliferative endometrium, eight cases of simple hyperplasia, and five cases of complex hyperplasia, expression was detected in only five (42%) of 12 atypical hyperplasias and in only 27 (47%) of 57 carcinomas. In atypical hyperplasia and carcinoma showing expression, both staining intensity and distribution were less than that seen in their benign counterparts. Three of five biopsies showing both benign endometrium and carcinoma showed positivity in benign but not in malignant glands. In endometrial carcinoma, bcl-2 expression did not correlate with grade, stage, or survival. In addition, in cases of carcinoma, a negative correlation between bcl-2 and p53 expression, which has been reported in other tumors, was not observed in this study. The invariable expression of bcl-2 in proliferative endometrium suggests that this protein may be important for cell survival. Its role in preventing cell death, however, appears to be frequently bypassed in atypical hyperplasia and endometrial carcinoma possibly by other factors impeding programmed cell death. Thus, if an apoptotic pathway usually blocked by bcl-2 expression would not necessarily lead to cell death. Defects in an apoptotic pathway such as the transforming growth factor-beta pathway, which can be blocked by bcl-2, may possibly account for the phenomenon observed in this study.

Multivariate survival analysis of clinicopathologic features in surgical stage I endometrioid carcinoma including analysis of HER-2/neu expression.

OBJECTIVE: We previously described vascular invasion-associated changes, defined as the presence of vascular invasion or perivascular lymphocytic infiltrates, as key prognostic indicators in stage I endometrioid carcinoma. The current study was undertaken to examine the prognostic value of HER-2/neu expression in relation to other factors, including vascular invasion-associated changes, in surgical stage I endometrioid carcinoma. STUDY DESIGN: Seventy-one patients with surgical stage I endometrioid carcinoma treated by hysterectomy and followed up were randomly chosen for retrospective analysis of prognostic indicators including standard clincopathologic features, deoxyribonucleic acid ploidy, and HER-2/neu expression. The latter was examined by an objective computerized quantitative immunohistochemical system. RESULTS: By univariate analysis many factors were found to correlate with outcome, including age, tumor grade, depth of invasion, ploidy, HER-2/neu expression, and vascular invasion-associated changes. By multivariate analysis only vascular invasion-associated changes, aneuploidy, and HER-2/neu overexpression were found to independently correlate with survival. Stratification of patients on the basis of these three features revealed survival rates of 100%, 92%, and 60% when none, one, and two or three features were present, respectively. CONCLUSION: This study suggests that HER-2/neu expression correlated with outcome independent of other factors in endometrial carcinoma and may aid in estimating prognosis. The prognostic value of HER-2/neu overexpression independent of vascular invasion suggests that this factor may operate by increasing the ability of tumor cells to grow at a distal site once vascular invasion occurs.

Endometrial intraepithelial carcinoma: a distinctive lesion specifically associated with tumors displaying serous differentiation.

Endometrial intraepithelial carcinoma (EIC) is a recently described lesion characterized by replacement of endometrial surface epithelium or glands by malignant cells resembling high-grade invasive endometrial carcinoma. EIC has been identified in a high proportion of uteri containing serous carcinoma, but its association with other endometrial tumors is unknown. To determine the strength and specificity of the association of EIC with tumors displaying serous differentiation, the appearance of the endometrium in 38 uteri with serous carcinoma, 113 with endometrioid carcinoma, and 34 with malignant mixed mesodermal tumor (MMMT) were compared. EIC was present in 34 (98%) uteri with serous carcinoma compared with 7 (6%) uteri removed for endometrioid carcinoma (P = .0001). Hyperplasia without atypia was found in only 2 (5%) of 38 serous carcinomas compared with 38 (34%) of 113 endometrioid carcinomas. Similarly, atypical hyperplasia was not found in any uterus with serous carcinoma, but was present in 14 (12%) uteri with endometrioid carcinoma (P = .02). The endometrium was inactive or atrophic in 29 (76%) patients with serous carcinoma compared with 33 (29%) with endometrioid carcinoma (P = .0001). EIC was found in five (56%) of nine MMMTs with a serous epithelial component (serous-MMMT) compared with one (4%) of 25 MMMTs woth an endometrioid epithelial component (endometrioid-MMMT). As with endometrioid and serous carcinomas, hyperplasia with and without atypia was more common with endometrioid-MMMTs as compared with serous-MMMTs. Hyperplasia was found in 25 (100%) and atypical hyperplasia in 8 (32%) of 25 endometrioid-MMMTs, but in none of the nine serous-MMMTs. This study shows that EIC is frequently and specifically associated with uterine tumors displaying serous differentiation. The findings suggest that EIC represents a form of intraepithelial tumor growth characteristic of serous carcinoma and serous MMMT and that EIC is the likely precursor of these neoplasms. In addition, the findings provide further evidence supporting the view that MMMTs represent variants of carcinoma not sarcoma.