Cornelia Leo

Lack of Correlation between Expression of HIF-1α Protein and Oxygenation Status in Identical Tissue Areas of Squamous Cell Carcinomas of the Uterine Cervix

Hypoxia inducible factor-1α (HIF-1α) has been proposed as a candidate endogenous marker of tumor hypoxia and as a molecular mediator of hypoxia-driven malignant progression and acquired treatment resistance. In this study, HIF-1α expression in 68 biopsies of oxygenation measurement tracks from squamous cell carcinomas of the uterine cervix of 38 patients was assessed. Expression of HIF-1α was commonly found to increase as a function of distance from microvessels, at the center of tumor cell aggregations, and in the vicinity of necrotic areas. However, there was no correlation of HIF-1α expression with median oxygen tension (oxygen partial pressure; pO2) and hypoxic fractions (hypoxic fraction < 2.5 mm Hg, hypoxic fraction < 5 mm Hg). The results indicate that HIF-1α should not be used as an endogenous marker of tumor hypoxia in locally advanced squamous cell carcinomas of the uterine cervix. Additionally, no significant prognostic impact of HIF-1α expression was found in this group of patients.

Lack of Hypoxic Response in Uterine Leiomyomas despite Severe Tissue Hypoxia

Hypoxia is now established as a key factor influencing the pathophysiology of malignant growth. Among other effects, hypoxia modulates the expression of a multitude of genes through the induction of hypoxia-inducible transcription factors. This differential gene expression favors angiogenesis, cell survival, an invasive/metastatic phenotype, and resistance to anticancer therapies. Because benign tumors do not exhibit these traits, one might expect these entities to be neither hypoxic nor to induce the genetic hypoxia response program. To test this hypothesis, an investigation of the oxygenation status of 17 leiomyomas and 1 leiomyosarcoma of the uterus using polarographic needle electrodes (Eppendorf pO(2) sensor) and the expression of hypoxia-related markers in biopsy specimens of the same tumors was carried out. Marker expression in eight additional archival leiomyosarcomas was also assessed. Leiomyoma tissue was generally found to be severely hypoxic, with median oxygen (O(2)) partial pressure values ranging from 1 to 5 mm Hg. In contrast, none of the hypoxia-related markers hypoxia-inducible factor (HIF)-1alpha, HIF-2alpha, glucose transporter-1, or carbonic anhydrase IX were expressed in any leiomyoma. Larger intercapillary distances were correlated with a poorer oxygenation status. Conversely, the expression of hypoxia-related markers was abundant in the leiomyosarcomas and they also exhibited a high-turnover phenotype (significantly increased proliferation and apoptosis). Uterine leiomyoma might therefore represent a state of oxygen-limited proliferation. Malignancy in the same organ system is associated with growth and metabolism beyond tissue-inherent limitations leading to the induction of hypoxia-related markers, thereby contributing to a self-perpetuating aggressive phenotype.

p16, p14, p53, and cyclin D1 expression and HPV analysis in small cell carcinomas of the uterine cervix

Summary: Small cell carcinomas (SmCCs) of the uterine cervix are rare tumors. The knowledge regarding protein expression of several checkpoint candidates of cell cycle regulation is limited. Surgically treated SmCCs were selected from our files for immunohistochemical staining (neuroendocrine markers, p53, p16, p14, and cyclin D1). Polymerase chain reaction analysis, using general primers, was performed for human papillomavirus analysis. Nine of 677 tumors (1.3%) were classified as SmCCs after Grimelius staining (8/9 tumors positive) and immunohistochemical reaction against neurone-specific enolase, chromogranin A, synaptophysin (7/9 positive tumors), and CD 56 (8/9 positive tumors). All specimens were positive for at least two of the above. Two SmCCs were p53 positive and one case was p14 positive. Cyclin D1 staining was completely negative. All cases showed strong nuclear and/or cytoplasmic p16-immunostaining. Seven tumors represented human papillomavirus positivity for high-risk types. Four patients died of the tumor after a median time of 36.7 months (range, 15-56 months), representing a 5-year survival rate of 56%. The results suggest that p16 is up-regulated or accumulated in the SmCCs of the uterine cervix, probably caused by infection with human papillomavirus. p14 inactivation is of high prevalence in SmCCs and detection rate of p53 is similar to other histologic types of cervical carcinomas.

Expression of Erythropoietin and Erythropoietin Receptor in Cervical Cancer and Relationship to Survival, Hypoxia, and Apoptosis

Purpose: Physiologically, hypoxia induces the expression of erythropoietin (Epo) in adult kidney cells. Epo, in turn, acts on the Epo receptor (EpoR) in RBC precursors to stimulate growth and prevent apoptosis. Because hypoxia plays a major role in the malignant progression of tumors and Epo and its receptors have also been detected in malignant tumors, we investigated the expression of Epo and EpoR and their relationship with hypoxia, proliferation, apoptosis, and clinicopathologic variables in cervical cancer. Experimental Design: Intratumoral oxygen measurement and needle biopsies of the tumors were done in 48 patients with cervical cancer. The obtained tissue was analyzed by immunohistochemistry with antibodies against Epo, EpoR, and Ki-67 as well as by terminal deoxynucleotidyl transferase–mediated deoxyuracil triphosphate nick-end labeling assays. Results: Epo and EpoR were expressed in 88% and 92% of samples, respectively. Cervical cancers with higher Epo expression showed a significantly reduced overall survival (3 years, 50.0% versus 80.6%; P = 0.0084). Epo and EpoR expression correlated significantly with apoptosis (r = 0.49, P = 0.001 and r = 0.36, P = 0.021). Furthermore, EpoR expression correlated significantly with tumor size (r = 0.32, P = 0.032) and was significantly associated with the presence of lymphovascular space involvement (P = 0.037). However, we observed no correlation between Epo or EpoR expression and intratumoral hypoxia, although in well-oxygenated tumors, EpoR localized significantly more often to the invasion front (P = 0.047). Conclusions: This study analyzes Epo/EpoR expression and their relationship with intratumoral pO2 levels as well as with survival in patients with cervical cancer. The data suggest a critical role of the endogenous Epo/EpoR system in cervical cancer.

Local spread of cervical cancer revisited: A clinical and pathological pattern analysis

BACKGROUND Local tumor spread of cervical cancer is currently considered as radial progressive intra- and extracervical permeation. For radical tumor resection or radiation the inclusion of a wide envelope of tumor-free tissue is demanded. However, this concept may lead to considerable treatment-related morbidity and does not prevent local relapse. We propose an alternative model of local tumor propagation involving permissive compartments related to embryonic development. METHODS We analyzed local tumor spread macroscopically and microscopically in consecutive patients with advanced cervical cancer and post-irradiation recurrences. RESULTS Macroscopically, all 33 stage I B (>2cm) tumors, 40 of 42 stage II tumors and 32 of 44 stage III B tumors were confined to the embryologically defined uterovaginal (Müllerian) compartment. Local tumor permeation deformed the uterovaginal compartment mirroring the mesenchyme distribution of the Müllerian anlage at the corresponding pelvic level in cases of symmetrical tumor growth. Tumor transgression into adjacent compartments mainly involved the embryologically related lower urinary tract. Compartmental transgression was associated with larger tumor size, paradox improvement in oxygenation and an increase in microvessel density. Post-irradiation pelvic relapse landscapes were congruent with the inflated Müllerian compartment. Microscopically, all locally advanced primary cancers and post-irradiation recurrences were confined to the uterovaginal and lower urinary tract compartments. CONCLUSION Cervical cancer spreads locally within the uterovaginal compartment derived from the Müllerian anlage. Compartment transgression is a relatively late event in the natural disease course associated with distinct phenotypic changes of the tumor. Compartmental tumor permeation suggests a new definition of local treatment radicality.

Cyclooxygenase-2 expression, Ki-67 labeling index, and perifocal neovascularization in endometriotic lesions.

There is a suggested pathogenetic role of cyclooxygenase-2 (COX-2) in endometriosis via angiogenesis and proproliferative mechanisms. The aim of the study was to investigate the immunohistochemical COX-2 expression in different anatomical sites of endometriosis and its correlation to proliferative activity and periendometriotic vascularization. Sixty endometrioses from different sites (ovarian, uterine, and peritoneal) were evaluated immunohistochemically for COX-2 expression. Cyclooxygenase-2 staining of 75% or more of the cells was defined as COX-2 overexpression and used as cutoff. Proliferative activity was determined by performing Ki-67-labeling index. Periendometriotic vascularization was evaluated by determining microvessel density surrounding the endometriotic focus using CD-34-immunostaining. Cyclooxygenase-2 overexpression was significant more frequent in ovarian endometriosis, when compared with uterine and peritoneal localization (70.8% versus 41.7%; P = .027). There was no significant correlation between COX-2 overexpression and perifocal neovascularization (P = .49). Endometriotic lesions with COX-2 overexpression represented reduced proliferative activity (P = .055). Cyclooxygenase-2 is expressed in the majority of endometriosis, but differences exist within the frequency of overexpression at different anatomical sites of the endometriosis. Cyclooxygenase-2 inhibitors are of clinical interest as treatment options.

Lack of Apoptotic Protease Activating Factor-1 Expression and Resistance to Hypoxia-Induced Apoptosis in Cervical Cancer

Purpose: Clinical observations suggest that intratumoral hypoxia increases the aggressiveness of tumors through clonal selection of cancer cells that have lost their apoptotic potential. The aim of this study, therefore, was to investigate the expression of the proapoptotic protein apoptotic protease activating factor-1 (Apaf-1) in cervical cancers and to analyze its relation to intratumoral hypoxia and apoptosis. Furthermore, the effect of hypoxia and apoptosis on survival was examined. Experimental Design: In 56 patients, intratumoral oxygenation measurements and subsequent needle biopsies were done. The obtained tissue was analyzed by terminal deoxynucleotidyl transferase–mediated dUTP nick end labeling assays and by immunohistochemistry with an Apaf-1 antibody. Results: Apaf-1 was expressed in 86% of cancers. The median apoptosis rate was 1.0%. There was no correlation between Apaf-1 expression and intratumoral hypoxia. However, Apaf-1 expression was negative in 37.5% of hypoxic cervical cancers (pO2 ≤ 10 mmHg) with low apoptosis rates (≤1.0%) compared with only 5.0% in nonhypoxic cancers and hypoxic cancers with high apoptosis (P = 0.005; Fishers exact test). With a median follow-up period of 44 months, there was a nonsignificant trend toward worse prognosis in the hypoxic low-apoptotic group (P = 0.08). Conclusions: Although Apaf-1 is expressed in the vast majority of cervical cancers, a significant proportion of tumors with low apoptosis rates despite intratumoral hypoxia showed a lack of Apaf-1 expression. This finding suggests that loss of Apaf-1 expression is a mechanism by which hypoxic cervical cancers acquire resistance to apoptosis. Thus, low Apaf-1 expression in hypoxic tumors may be an unfavorable prognostic factor.

The value of endocervical curettage after conization for cervical intraepithelial neoplasia

The objective of this study is to assess the value of postcone endocervical curettage, after conization of cervical intraepithelial neoplasia or carcinoma as a predictive tool for residual lesions. This is a retrospective observational study. All data were obtained by the University Hospital of Zurich, Department of Gynaecology. One hundred fifty patients underwent hysterectomy within 12 months after conization and endocervical curettage from 1993 to 2006. To analyze the sensitivity, specificity, and the positive predictive value (PPV) and negative predictive value (NPV) of the endocervical curettage after conization, we used the Fisher exact test and χ(2) test. The main outcome measures are the sensitivity and specificity as well as the PPV and NPV of the postconization endocervical curettage. The endocervical curettage exhibited a sensitivity of 0.38, a specificity of 0.85, a PPV of 0.56, and an NPV of 0.73. Comparing patients younger than 50 years to women 50 years or older, endocervical curettage had a sensitivity of 0.35 and 0.44, a specificity of 0.83 and 0.94, a PPV of 0.46 and 0.88, and an NPV of 0.76 and 0.63, respectively. The endocervical curettage after conization of cervical intraepithelial neoplasia does not generally improve the prediction of residual lesions. However, in women 50 years or older, a higher specificity and PPV, 0.94 and 0.88, respectively, was observed. Therefore, this subgroup of patients may benefit from an endocervical curettage.

Expression of COX-2 and HER-2/neu and estrogen and progesterone receptor in primary squamous cell carcinomas of the endometrium

Purpose Primary endometrial squamous cell carcinoma (ESCC) are rare but aggressive malignancies. To evaluate therapeutically relevant molecules, ESCC were investigated immunohistochemically.Material and methods Eight ESCC were stained with antibodies against estrogen and progesterone receptors, HER-2/neu, and COX-2 followed by semiquantitative evaluation of the staining results.Results Seven out of eight ESCC were negative for estrogen receptor as well as for HER-2/neu. Four tumors showed positivity for progesterone receptor. All ESCC displayed COX-2 overexpression.Conclusions Primary ESCC are probably not under hormonal control of estrogens and lack HER-2/neu expression. Thus, anti-hormonal or antibody therapy with herceptine is not indicated. The use of COX-2 inhibitores might be a therapeutic alternative in ESCC that requires further investigation.

Overexpression of Lox in triple-negative breast cancer

BACKGROUND Triple negative breast cancer (TNBC) accounts for approximately 15% of breast cancers. It is associated with a poor prognosis and typically earlier onset of metastasis in comparison with other breast cancer subtypes. Since TNBC lacks the expression of estrogen and progesterone receptors and Her2 status is also negative, there is currently no target that can be used for systemic therapy. Epithelial-mesenchymal transition (EMT) plays an important role in tumor progression and metastasis. In this study, we examined a subset of EMT markers consisting of Snail, Twist-1 and Lox in TNBC and non-TNBC breast cancer subtypes and analyzed their expression pattern in regard to subtype, clinico-pathological parameters and prognosis. EXPERIMENTAL DESIGN We analyzed 659 breast cancer samples from two tissue microarrays. Breast cancer samples were categorized into two groups according to hormone receptor expression and Her2 status (n = 146 were triple negative, n = 513 were non triple-negative). Immunohistochemical expression of Snail, Twist-1 and Lox was semi-quantitatively analyzed using a three-tiered (weak-moderate-strong) scoring system. Results were statistically analyzed and correlated to clinico-pathological parameters and overall survival. RESULTS Strong overexpression of Lox was significantly higher in triple negative breast cancers when compared to non triple-negative breast cancers (p < 0.001). No difference was seen between the groups regarding Snail and Twist expression (p > 0.05). In addition, Lox expression was significantly stronger in poorly differentiated (G3) breast cancers (p < 0.001 for Lox). CONCLUSIONS The EMT marker Lox has a differential expression pattern in breast cancer, being significantly overexpressed in triple negative breast cancers. We could not link this expression to prognosis, however, this marker might be explored in future studies as possible target for systemic therapy of TNBC.