Luca Fuso

Angiopoietin-2 expression in breast cancer correlates with lymph node invasion and short survival

Angiogenic factors produced by tumor cells are essential for tumor growth and metastasis. In our study, the expression of Angiopoietin‐1 (ANG1) and Angiopoietin‐2 (ANG2) mRNA in archival human breast cancer tumor samples and in 6 breast cancer cell lines was investigated. Total RNA from biopsies of 38 breast cancer patients was extracted and ANG1 and ANG2 mRNA expression was measured by means of quantitative real‐time RT‐PCR (Taqman®). Matching data with available clinicopathologic and biochemical data revealed a significant association between ANG2 expression and axillary lymph node invasion. Univariate and multivariate survival analysis, by means of Kaplan‐Meier method and Coxs proportional hazards model, showed significant and independent association between ANG2 mRNA level and both disease‐free (p < 0.0001) and overall survival (p < 0.0003). An important fact is that, notwithstanding the small number of cases examined, this association was confirmed also in the group of lymph node‐negative patients (DFS, p < 0.003; OS, p < 0.020). Immunohistochemical analysis demonstrated that Ang2 is expressed by both tumor cells and endothelial elements. Expression in tumor cells was confirmed by studying a panel of human breast carcinoma cell lines in culture by RT‐PCR. In ZR75.1 and T47D cells, expression of ANG2 mRNA was increased up to 10‐fold by treatment with estrogen within 24 hr. Although preliminary, these data suggest a possible role of ANG2 as a prognostic factor for primary breast cancer.

Identification of new genes associated with breast cancer progression by gene expression analysis of predefined sets of neoplastic tissues

Gene expression profiles were studied by microarray analysis in 2 sets of archival breast cancer tissues from patients with distinct clinical outcome. Seventy‐seven differentially expressed genes were identified when comparing 30 cases with relapse and 30 cases without relapse within 72 months from surgery. These genes had a specific ontological distribution and some of them have been linked to breast cancer in previous studies: AIB1, the two keratin genes KRT5 and KRT15, RAF1, WIF1 and MSH6. Seven out of 77 differentially expressed genes were selected and analyzed by qRT‐PCR in 127 cases of breast cancer. The expression levels of 6 upregulated genes (CKMT1B, DDX21, PRKDC, PTPN1, SLPI, YWHAE) showed a significant association to both disease‐free and overall survival. Multivariate analysis using the significant factors (i.e., estrogen receptor and lymph node status) as covariates confirmed the association with survival. There was no correlation between the expression level of these genes and other clinical parameters. In contrast, SERPINA3, the only downregulated gene examined, was not associated with survival, but correlated with steroid receptor status. An indirect validation of our genes was provided by calculating their association with survival in 3 publicly available microarray datasets. CKMT1B expression was an independent prognostic marker in all 3 datasets, whereas other genes confirmed their association with disease‐free survival in at least 1 dataset. This work provides a novel set of genes that could be used as independent prognostic markers and potential drug targets for breast cancer.

Are surveillance procedures of clinical benefit for patients treated for ovarian cancer? A retrospective italian multicentric study

The aim of this retrospective investigation was to assess the pattern of failures of 412 patients with recurrent ovarian cancer followed up with different surveillance protocols. Time to recurrence was less than 6 months in 98 women (23.8%), 6 to 12 months in 102 women (24.7%), and more than 12 months in 212 women (51.5%). Symptoms at relapse were referred by 81 women (19.7%). Among the 331 asymptomatic patients, the surveillance procedure that raised the suspect of recurrent disease was clinical examination in 49 (14.8%), imaging technique in 90 (27.2%), serum CA 125 in 77 (23.3%), and both serum CA 125 and imaging technique in 115 (34.7%). At univariate analysis, survival from initial diagnosis was related to stage (P = 0.004), residual disease after initial surgery (P < 0.0001), time to recurrence (P < 0.0001), site of relapse (P = 0.04), and treatment at recurrence (P < 0.0001), and survival after recurrence was related to stage (P = 0.01), residual disease (P < 0.0001), time to recurrence (P < 0.0001), and treatment at recurrence (P < 0.0001). Conversely, symptoms at recurrence had no prognostic relevance. Cox proportional hazards model showed that residual disease and time to recurrence were the only independent prognostic variables for both survival from initial diagnosis (P < 0.0001) and survival after recurrence (P < 0.0001). In conclusion, there was no survival difference between asymptomatic and symptomatic patients at the time of relapse, and therefore, the diagnostic anticipation allowed by a scheduled follow-up protocol did not seem to improve the clinical outcome of patients who ultimately developed recurrent disease.

Quantitative real-time RT-PCR analysis of eight novel estrogen-regulated genes in breast cancer

BACKGROUND Biological markers capable of predicting the risk of recurrence and the response to treatment in breast cancer are eagerly awaited. Estrogen and progesterone receptors (ER, PgR) in tumor cells mark cancers that are more likely to respond to endocrine treatment, but up to 40% of such patients do not respond. Here, the expression of a group of estrogen-regulated genes, previously identified by microarray analysis of in vitro models, was measured in breast tumors and possible associations with other clinicopathological variables were investigated. METHODS The expression of CD24, CD44, HAT-1, BAK-1, G1P3, TIEG, NRP-1 and RXRalpha was measured by quantitative real-time RT-PCR on RNA from eighteen primary breast tumors. Statistical analyses were used to identify correlations among the eight genes and the available clinicopathological data. RESULTS Variable expression levels of all the genes were observed in all the samples examined. Significant associations of CD24 with tumor size, CD44 with lymph node invasion, and HAT-1 and BAK-1 with ER positivity were found. The possible combinatorial value of these genes was assessed. Unsupervised hierarchical clustering analysis demonstrated that the expression profile of these genes was able to predict ER status with an acceptable approximation. CONCLUSIONS Eight novel potential markers for breast cancer have been preliminarily characterized. As expected from in vitro data, their expression is able to discriminate ER- versus ER+ tumors.

Could different follow-up modalities play a role in the diagnosis of asymptomatic endometrial cancer relapses?: an Italian multicentric retrospective analysis

Objective To determine current practice and to assess the value of routine follow-up procedures for endometrial cancer surveillance. To discuss whether such procedures are feasible and effective to identify asymptomatic recurrences and describe the pattern of relapse detected by procedures. Methods The records of 282 consecutive women with recurrent endometrial cancer treated from 1986 to 2005 were retrospectively collected in 8 Italian institutions. Primary disease, clinical history, and recurrence features and data were analyzed. Results Thirty-five (12.4%) of 282 patients had recurrence in vaginal vault, 51 patients (18.0%) had recurrence in central pelvis, 14 patients (4.9%) had recurrence in pelvic wall, and 39 patients (13.8%) had recurrence in lymph nodes. One-hundred twenty-eight patients (45.3%) showed a distant relapse, whereas 15 patients (5.3%) developed both distant relapse and local relapse. The site of relapse influenced survival because the patients with vaginal vault recurrences lived significantly longer than the patients with recurrences in other sites. Eighty (28.4%) of the 282 patients became symptomatic and anticipated the scheduled visit, 37 (13.1 %) of the patients reported their symptoms during the follow-up meeting, and 165 (58.5 %) of the patients were asymptomatic and the diagnostic path was introduced by a planned visit or examination. Among the asymptomatic patients, the first procedure that led to further examinations was clinical visit alone for 60 (36.4%) of 165 patients, imaging for 103 patients (62.4%), and cytologic examination for 2 patients (1.2%). Symptoms at recurrence can predict survival: patients with an asymptomatic recurrence had a median survival time from relapse of 35 months versus 13 months if they had a symptomatic repetition (P = 0.0001). Conclusions Follow-up after endometrial cancer treatment varies in Italy. In this retrospective study, women with asymptomatic recurrence have shown a better clinical outcome compared with those with symptomatic relapse. The optimal approach is actually unknown, and guidelines comparing follow-up protocols have not been established. Prospective cost-effectiveness studies are needed.

Constitutional high expression of an APC mRNA isoform in a subset of attenuated familial adenomatous polyposis patients

Familial adenomatous polyposis is an inherited condition associated with hundreds to thousands of colorectal adenomas conferring a very high risk of cancer at a young age. In addition to “classical” form, there is also an attenuated polyposis, with fewer than 100 polyps and a delayed age of cancer onset. Both classical and attenuated polyposis are characterized by a relevant phenotypic heterogeneity. The disease has been linked to constitutive mutations of either APC tumor suppressor gene, or less frequently, MYH base-excision repair gene. However, the genetic cause remains undetected in up to 70–80% of patients with the attenuated form. This analysis was performed on 26 polyposis patients with the attenuated phenotype. All patients had formerly proven to be negative for APC truncating mutations that typically represent the majority of APC gene alterations. We evaluated the APC mRNA constitutional level by real-time quantitative reverse transcription polymerase chain reaction (PCR). Eleven patients (42%) showed an anomalous APC transcription level. One patient with reduced mRNA was a carrier of a whole APC gene deletion. In seven out of the ten remaining cases, we found the increased expression of an APC mRNA isoform resulting from exon 10/15 connection and giving rise to a stable truncated peptide. Mutations neither in the invariant splice sites nor in the known transcription regulatory signals were found. Our results support the notion that in attenuated polyposis patients, a detailed investigation of APC transcription can allow detection of rare alterations. Although functional data are required, the isoform we observed might have some pathogenic role, accounting for the heterogeneous phenotype that characterizes the polyposis syndrome.

Follow‐up strategies in gynecological oncology: searching appropriateness

Nowadays, the cost for oncology diseases is growing rapidly, in particular as a consequence of the introduction of new drugs and new diagnostic procedures, and becoming a considerable percentage of the global healthcare expense. On the other hand, a substantial amount of that cost is considered to be imputable to the follow-up procedures. The aim of our paper is to introduce the debate about follow-up policies adopted in gynecological oncology throughout a literature review just based on cost-effectiveness and cost-efficacy in order to explore if the data are consistent with evidences available in this field. Furthermore, it is discussed if common practice fits the needs of patients, gynecological oncologists, and health service. Despite the fact that in gynecological oncology we must consider different clinical situations concerning each specific neoplasm with their peculiar natural history, some general considerations could be drawn in order to set up future initiatives properly

Analysis of vitamin D receptor expression and clinical correlations in patients with ovarian cancer

OBJECTIVE Although the antiproliferative and differentiating properties of vitamin D have been demonstrated, its effects on cancer cells are variable. Little is known about vitamin D receptor (VDR) levels in patients with ovarian cancer. In this population we sought to determine correlations between VDR expression, clinical parameters and treatment outcome. METHODS We analyzed VDR content in platelets of healthy women and of a cohort of patients with ovarian tumors and we evaluated possible correlations with clinical parameters, tumor characterization (stage, histology, nuclear grading, ascites), response to therapy and survival. Moreover receptor expression was evaluated immunohistochemically on tissue samples. RESULTS VDR levels were markedly lower in healthy women when compared with the pathological group. In the latter a significant increase in receptor expression was observed in malignancies compared with benign cases. No correlation existed between VDR expression and clinicopathological parameters, although we observed an advantage on survival if patients had a higher level of VDR expression in platelets. A cytoplasmic localization of the protein was observed by immunohistochemistry in ovarian cancer cells. CONCLUSIONS Vitamin D receptor status measured in platelets differs significantly between healthy and pathological groups, increasing with malignancy, and there is a trend towards longer overall survival for tumors showing higher VDR levels. These data suggest that platelet VDR content could be used as a pathological marker. The meaning of this increased VDR expression in platelets needs further investigation and it is possibly linked to an inflammatory response.

Analysis of treatment failures and survival of patients with uterine papillary serous carcinoma: a Cooperation Task Force (CTF) Study.

Objective To assess the pattern of failures and the survival of patients with uterine papillary serous carcinoma (UPSC). Methods The hospital records of 119 women with UPSC were reviewed. Surgery was the initial therapy for all the cases. The median follow-up of survivors was 133 months (range, 3–216 months). Results Postoperative treatment was used in 98 patients (82.4%). Adjuvant treatment was radiotherapy in 25 women, chemotherapy in 61 women, and chemotherapy plus radiotherapy in 12 women. Tumor recurred in 44 (37.0%) of the 119 patients, after a median time of 15.1 months. Relapse was symptomatic in 15 patients (34.1%), and recurrent disease involved peritoneum or distant sites in 26 (66.7%) of the 39 patients for whom the site of failure was known. Five- and 10-year survival rates were 61.8% and 54.6%, respectively. Survival was related to disease stage (P < 0.0001). Among patients with advanced tumor, 5-year survival was lower in women who had macroscopic residual disease after surgery than in those who had not (15.4% vs 37.5%; P = 0.08). Distant failures were higher in women with histologically proven positive nodes than in those with negative nodes (28.6% vs 9.1%; P = 0.048). There was a trend to better survival for patients with stage I to stage II disease who underwent chemotherapy when compared with those who did not. Conclusions Uterine papillary serous carcinoma has an aggressive clinical behavior with a great tendency to recur especially in peritoneal and distant sites. Tumor stage is a strong prognostic factor, whereas the role of adjuvant treatment is still uncertain.

Prognostic factors and clinical outcome of patients with recurrent early-stage epithelial ovarian cancer: an Italian multicenter retrospective study.

Objective The objective of this study was to assess the clinical outcome of patients with recurrent early-stage ovarian cancer. Methods The hospital records of 87 patients were reviewed. The median follow-up of survivors from recurrence was 87.6 months. Results The 25%, 50%, and 75% quantiles of time to recurrence were 15, 25, and 44 months, respectively. The pelvis was the most common site of failure (39.1%), followed by abdomen (18.3%) and retroperitoneal nodes (18.3%). Treatment at recurrence consisted of chemotherapy in 46 patients, surgery plus chemotherapy in 29, surgery in 3, surgery plus radiotherapy in 2, and other therapies in 7. A macroscopically complete cytoreduction was obtained in 29 (85.2%) of the 34 patients who underwent secondary surgery. Five- and 7-year survival rates after recurrence were 34.3% and 29.6%. By log-rank test, survival after recurrence was related to patient age (≤60 vs >60 years; P = 0.001), time to recurrence (>15 vs ≤15 months; P = 0.049), site of recurrence (retroperitoneum vs pelvis vs other; P = 0.004), and surgery at recurrence (yes vs not; P = 0.001), but not to substage, histotype, grade, prior adjuvant chemotherapy, examination that detected recurrence, and chemotherapy at recurrence. On multivariate analysis, patient age (hazard ratio, 1.836; 95% confidence interval, 1.060-3.180) and surgical treatment at recurrence (hazard ratio, 1.972; 95% confidence interval, 1.084–3.587) were independent prognostic variables for survival after recurrence. Conclusions Patient age and surgery at recurrence were independent prognostic variables for patients with recurrent early-stage ovarian cancer. When feasible, salvage surgery appears to give a survival advantage in this clinical setting.