Prognostic significance of vascular endothelial growth factor and its receptors in endometrial carcinoma

Expression analysis of TRAF2‑ and NCK‑interacting protein kinase (TNIK) and phosphorylated TNIK in papillary thyroid carcinoma

The aim of the present study was to evaluate the expression of TRAF2- and NCK-interacting kinase (TNIK) and the levels of the active form of TNIK, phosphorylated (p)-TNIK, in papillary thyroid carcinoma (PTC), and to identify and compare the levels of TNIK and p-TNIK among PTC, benign thyroid tumors and normal tissues. The levels of TNIK and p-TNIK were examined by reverse transcription-quantitative (RT-q)PCR and immunohistochemical analysis (IHC) in PTC, benign thyroid tumors and normal tissues, and their association with clinicopathological features was evaluated. First, analysis of the Gene Expression Profiling Interactive Analysis and The Cancer Genome Atlas datasets suggested that the mRNA expression of TNIK was markedly increased in PTC tissues compared with that in normal tissues. RT-qPCR analyses then indicated that the relative mRNA expression of TNIK in PTC tissues was 4.47±6.16, which was significantly higher than that in adjacent tissues 2.57±5.83. The IHC results suggested that the levels of TNIK and p-TNIK in PTC tissues were markedly elevated compared with those in benign thyroid tumors and normal tissues. The levels of p-TNIK in patients with PTC were significantly associated with extrathyroidal extension (χ²=4.199, P=0.040). Positive staining for TNIK was observed in 187 out of 202 (92.6%) cases in the cytoplasm, nucleus or cytomembrane of PTC cells. Among the 187 positive cases, cytoplasm expression was identified in 162 cases (86.6%), nuclear expression in 17 cases (9.1%) and cytomembrane expression in 8 cases (4.3%). Positive staining for p-TNIK was observed in 179 out of 202 (88.6%) cases in the nuclei, cytoplasm or cytomembrane of PTC cells. In the 179 p-TNIK-positive cases, localization in the nuclei plus cytoplasm was identified in 142 cases (79.3%), nuclear localization in 9 cases (5.0%), presence in the cytoplasm in 21 cases (11.7%) and cytomembrane localization in 7 cases (3.9%). Both TNIK and p-TNIK were upregulated in PTC tissues and p-TNIK was significantly associated with extrathyroidal extension. It may act as a crucial oncogene to participate in PTC carcinogenesis and progression.

Angiogenesis in gynecological cancers and the options for anti-angiogenesis therapy

Angiogenesis is required in cancer, including gynecological cancers, for the growth of primary tumors and secondary metastases. Development of anti-angiogenesis therapy in gynecological cancers and improvement of its efficacy have been a major focus of fundamental and clinical research. However, survival benefits of current anti-angiogenic agents, such as bevacizumab, in patients with gynecological cancer, are modest. Therefore, a better understanding of angiogenesis and the tumor microenvironment in gynecological cancers is urgently needed to develop more effective anti-angiogenic therapies, either or not in combination with other therapeutic approaches. We describe the molecular aspects of (tumor) blood vessel formation and the tumor microenvironment and provide an extensive clinical overview of current anti-angiogenic therapies for gynecological cancers. We discuss the different phenotypes of angiogenic endothelial cells as potential therapeutic targets, strategies aimed at intervention in their metabolism, and approaches targeting their (inflammatory) tumor microenvironment.

Prognostic significance of VEGF and components of the plasminogen activator system in endometrial cancer

Objective

The plasminogen activator system (PAS) and vascular endothelial growth factor (VEGF) are important in the carcinogenesis and play a key role in cancer invasion and mediating metastasis of carcinomas. The aim of the study was to evaluate the correlation of serum levels of VEGF and components of the PAS with clinicopathological risk factors and outcome in patients with endometrial cancer (EC).

Methods

Preoperative blood was collected from 173 patients treated for EC between 1999 and 2009. Serum concentrations of VEGF, urokinase plasminogen activator (uPA) tissue plasminogen activator (tPA), plasminogen activator inhibitor type-1 (PAI-1) and -2 (PAI-2) were assessed by enzyme-linked immunosorbent assays (ELISA).

Results

Serum levels of VEGF and components of the PAS were significantly associated with stage of the disease, tumor histology, tumor grade, myometrial invasion (MI), presence of lymphovascular space invasion (LVSI) and lymph node metastases (LNM). Preoperative serum levels of PAI-1 and -2 and tPA were higher in patients who experienced a recurrence than in patients who remained disease free (p < 0.01). PAI-1 and -2 and tPA were significantly independent prognostic factors for DFS with a HR of 3.85 (95% CI 1.84–8.07), 3.90 (95% CI 1.75–8.66) and 2.53 (95% CI 1.16–5.55), respectively. PAI-1 and tPA turned out to be independent prognostic factors for OS, with a HR of 2.09 (95% CI 1.08–4.05) and 2.16 (95% CI 1.06–4.44), respectively.

Conclusion

Serum levels of VEGF and components of the PAS at primary diagnosis were associated with well-known clinicopathological risk factors such as; FIGO stage, tumor histology, tumor grade, MI, LVSI and LNM. High concentrations of PAI-1 and-2 and tPA are independent factors for poor prognosis in patients with endometrial cancer.

CT textural analysis of gastric cancer: correlations with immunohistochemical biomarkers

To investigate the ability of CT texture analysis to assess and predict the expression statuses of E-cadherin, Ki67, VEGFR2 and EGFR in gastric cancers, the enhanced CT images of 139 patients with gastric cancer were retrospectively reviewed. The region of interest was manually drawn along the margin of the lesion on the largest slice in the arterial and venous phases, which yielded a series of texture parameters. Our results showed that the standard deviation, width, entropy, entropy (H), correlation and contrast from the arterial and venous phases were significantly correlated with the E-cadherin expression level in gastric cancers (all P < 0.05). The skewness from the arterial phase and the mean and autocorrelation from the venous phase were negatively correlated with the Ki67 expression level in gastric cancers (all P < 0.05). The width, entropy and contrast from the venous phase were positively correlated with the VEGFR2 expression level in gastric cancers (all P < 0.05). No significant correlation was found between the texture features and EGFR expression level. CT texture analysis, which had areas under the receiver operating characteristic curve (AUCs) ranging from 0.612 to 0.715, holds promise in predicting E-cadherin, Ki67 and VEGFR2 expression levels in gastric cancers.

Biomarker potential of IL-6 and VEGF-A in ascitic fluid of epithelial ovarian cancer patients

BACKGROUND

Ovarian cancer is represented with significantly higher mortality rate predominately due to asymptomatic behaviour during initial disease course and at diagnosis majority patients already progressed to advanced stage. Acellular fraction of ascites in epithelial ovarian cancer (EOC) has been suggested to promote growth of tumor cells by providing ambient micro-environment for their proliferation. This acellular fraction contains multiple growth factors including IL-6 and VEGF-A, which were exploited to establish their bio-marker significance in EOC patients.

METHODS

IL-6 and VEGF-A levels in ascitic fluid of 30 EOC patients and 15 controls were measured using high sensitivity sandwich enzyme linked immune sorbent (ELISA) assay. Their levels were correlated with clinico-pathological characteristics and bio-marker potential was assessed.

RESULTS AND CONCLUSION

EOC patients showed significantly higher levels for IL-6 (median-5636 pg/ml) and VEGF-A (median-4556 pg/ml) in ascitic fluid compared to controls. Levels of IL-6 and VEGF-A significantly correlated with clinico-pathological parameters. ROC curves of IL-6 and VEGF-A showed absolute combination of sensitivity and specificity. Kaplan Meier analysis demonstrated that higher levels of IL-6 and VEGF-A were significantly associated with shorter progression free survival. Thus, this study revealed that IL-6 and VEGF-A have great potential to be used as superior bio-markers for progression free survival in future after validation in larger patients' cohort.

Clinical significance of pretreatment serum levels of VEGF and its receptors, IL- 8, and their prognostic value in type I and II endometrial cancer patients

Objectives

The study aimed to assess the usefulness of the determination of cytokines: IL-8, VEGF and its soluble receptors: VEGF-R1, VEGF-R2 in patients with endometrial cancer (EC).

Material/Methods

The study group consisted of 118 patients with EC subjected to surgical treatment. Before the treatment we determined the serum levels of cytokines IL-8, and VEGF as well as VEGFR1 and VEGFR2 receptors. For comparison, the concentration of CA 125 was also measured. VEGFR1 and CA 125 were determined in the COBAS e601 system using Roche Diagnostics kits, while IL-8, VEGF and VEGFR2 were measured by ELISA assay using R&D Systems kits.

Results

The concentrations of IL-8, VEGF, VEGFR1 and CA 125 allowed to distinguish patients for the control group. The highest diagnostic sensitivity has been shown for the concentrations of VEGF (AUC = 0.904) and IL-8 (AUC = 0.818). Among all studied parameters only CA125 concentrations increased with the clinical stage; being significantly higher in patients in FIGO III-IV, than FIGO I-IB. In patients at the FIGO stage I-IB, complementary determinations of CA 125 and VEGF resulted in the largest increase of diagnostic sensitivity. Patients with metastases to the para-aortic lymph nodes had significantly higher levels of VEGF compared to subjects without such lesions. The concentrations of IL-8 were an independent prognostic factor in the assessment of overall survival in patients with type I endometrial cancer, while the concentrations of VEGFR2 in those with type II.

Conclusions

In patients with endometrial cancer, the clinical usefulness of IL-8 and VEGFR2 measurements as the potential prognostic factors has been demonstrated. In type I, the concentrations of IL-8 determined before treatment can be helpful in predicting overall survival. In patients qualified to type II EC, the concentrations of VEGFR2 have the value of an independent prognostic factor for overall survival, this requires research on larger groups of patients. The increased levels of VEGF may be useful in the preoperative assessment of the status of para-aortic lymph nodes.

Targeting angiogenesis in endometrial cancer - new agents for tailored treatments

INTRODUCTION

Endometrial carcinoma represents the most frequent gynecologic tumor in developed countries. The majority of women presents with low-grade tumors but a significant subset of women experience recurrence and do not survive their disease. Patients with stage III/ IV or recurrent endometrial cancer have a poor prognosis. Identification of active and tolerable new targeted agents versus specific molecular targets is a priority objective. Angiogenesis is a complex process that plays a crucial role in the development of many types of cancer and in particular endometrial cancer.

AREAS COVERED

In this review, the authors highlight the main angiogenetic molecular pathways and the anti-angiogenic agents in Phase II clinical trials for endometrial cancer treatment. The authors focus on reports from recent years on angiogenesis inhibitors used in endometrial cancer, including anti- vascular endothelial growth factor (VEGF) monoclonal antibodies (bevacizumab and aflibercept), mammalian target of rapamycin inhibitors (mTORi) (everolimus, temsirolimus and ridaforolimus), PI3 K inhibitors (BKM120), tyrosine kinase inhibitors (brivanib, sunitinib, dovitinib and nintedanib) and thalidomide.

EXPERT OPINION

These anti-angiogenic drugs, while used either alone or in combination with chemotherapy, have presented mixed results in treating endometrial cancer patients. Challenges for the future include the identification of new pathways, early identification and overcoming resistance and the use of these molecules in combination with old and new chemotherapeutic and targeted agents.

Oncostatin M activates STAT3 to promote endometrial cancer invasion and angiogenesis

Oncostatin M (OSM), a pleiotropic cytokine, can either promote or inhibit the growth of tumors derived from specific tissues. However, little is known about the activity and expression pattern of OSM in endometrial cancers (ECs). Herein we show that expression of OSM in human ECs was significantly higher than that in hyperplastic or normal tissues. In EC tissues, high OSM levels were positively correlated with tumor stage, histological grade, myometrial invasion, and lymph node metastasis. Additionally, we demonstrated that recombinant human OSM (rhOSM) promoted tumor angiogenesis in EC cell lines by activating STAT3 (signal transducer and activator of transcription 3) and enhanced both cell migration and cell invasion. rhOSM did not, however, influence the proliferation of EC cells in vitro. In contrast, in our in vivo xenograft model, overexpression of rhOSM promoted cell proliferation, tumor growth, and angiogenesis in nude mice. Collectively, these experiments suggest that OSM may be a tumor promoter that encourages EC progression. OSM may thus serve as a potential target of antiangiogenic therapy for endometrial cancer.

SHARP1 suppresses angiogenesis of endometrial cancer by decreasing hypoxia-inducible factor-1α level

Recent data support a role for SHARP1, a basic helix-loop-helix transcription repressor, in the regulation of malignant cell behavior in several human cancers. However, the expression and role of SHARP1 during the development of endometrial cancer (EC) remain unclear. Here we show that upregulation of SHARP1 suppressed tumor angiogenesis by decreasing hypoxia-inducible factor-1α (HIF-1α), inhibited cell viability and tumor growth in EC. Immunohistochemical staining showed that the expression of SHARP1 was negatively correlated with tumor stage, histological grade, myometrial invasion, lymph node metastasis, blood vessel permeation in the myometrium and HIF-1α expression. Mechanistic studies showed that SHARP1 interacted with HIF-1α physically, and the protein level of HIF-1α and the mRNA level of its target genes (VEGFA, ANGPTL4 and CA9) were decreased by SHARP1 under hypoxia. Upregulation of SHARP1 in EC impeded hypoxia-induced angiogenesis by reducing VEGF secretion. Immunohistochemical analysis verified a correlation between decreased SHARP1 expression and increased microvessel density in EC tissues. Additionally, SHARP1 inhibited cell viability in EC cell lines. Overexpression of SHARP1 in vivo inhibited tumor growth and angiogenesis, and decreased HIF-1α expression. In this study, we established SHARP1 as a novel tumor suppressor of EC and shed light on the mechanisms by how SHARP1 inhibited EC progression. Therefore, SHARP1 may be a valuable prognostic biomarker for EC progression and shows promise as a new potential target for antiangiogenic therapeutics in human EC.

A phase II evaluation of pazopanib in the treatment of recurrent or persistent carcinosarcoma of the uterus: a gynecologic oncology group study

OBJECTIVE

Carcinosarcomas of the female genital tract, also called malignant mixed müllerian tumors, are aggressive biphasic tumors. Second-line treatment options in the recurrent/persistent setting have yielded marginal responses. Given the potential role of angiogenesis in the gynecological carcinomas, pazopanib, a VEGFR inhibitor, was investigated in the management of patients with recurrent carcinosarcoma of the uterus.

METHODS

Eligible patients had histologically confirmed carcinosarcoma of the uterus, a maximum of two prior lines of therapy, adequate renal, hepatic and hematologic function and a performance status of 0-2. Pazopanib was administered orally at 800mg. Two dose reductions were allowed. The primary objective was to ascertain the activity of pazopanib as measured by the proportion of patients who survive progression-free for at least six months and the proportion of patients that have objective tumor responses. Secondary objectives included the frequency and severity of adverse events as assessed by CTCAE v4.0.

RESULTS

Of the 22 enrolled patients, 19 were eligible and evaluable for toxicity and survival. No patients had a partial or complete response (90% confidence interval [CI]: 0%, 14.6%). Three patients (15.8%) had PFS ≥6months (90% CI: 4.4%, 35.9%). The median PFS was 2.0months (first and third quartiles were 1.6 and 4.0months, respectively). The median overall survival was 8.7months (first and third quartiles were 2.6 and 14.0months, respectively).

CONCLUSION

Pazopanib demonstrated minimal activity as a second or third line treatment for advanced uterine carcinosarcoma. Potential clinical trial participation should be discussed with the patients.

Endoglin, VEGF, and its receptors in predicting metastases in endometrial carcinoma

Preoperative evaluation of the risk for metastases in endometrial carcinoma is challenging. The growth of new vessels, angiogenesis, is important for tumor growth and purported to be involved in the metastatic process. The aim of this study was to evaluate the significance of preoperative serum levels and immunohistochemical expression of angiogenic markers in predicting a metastasized disease. Preoperative sera from 98 consecutive women presenting with endometrial carcinoma were collected. Serum concentrations of VEGF, sFLT1, and CD105 were assessed by enzyme-linked immunosorbent assay (ELISA). Immunohistochemistry was used to assess the expression of CD105, VEGF, FLT1, and KDR. The results were correlated to the presence of metastases, presence of deep (≥50%) myometrial invasion, and the histological grade of the tumor. Tumors with other than endometrioid histology were excluded. Of the 80 evaluable patients, 11 had a metastasized disease. The serum concentration of VEGF was higher in the group with metastases than in the group without metastases (median [range], 743 pg/mL [546-1,183 pg/mL] vs. 383 pg/mL [31-1,524 pg/mL], p < 0.001, respectively). In the multivariable analysis, the concentration of VEGF was the sole independent, albeit weak predictive factor for the presence of metastases (odds ratio, 1.004, 95% confidence interval, 1.002-1.007; p = 0.001). The immunohistochemical expression of the markers was not associated with any of the clinicopathological features of the tumors. The results of the present study suggest that preoperative serum VEGF concentration correlates with the presence of metastases in endometrioid endometrial carcinoma.

Prognostic value of tgfb1 protein in endometrioid adenocarcinoma

BACKGROUND

Angiogenesis is a prerequisite for tumour development, progression and metastasis; however, its underlying molecular mechanisms in endometrial carcinoma are poorly understood.

DESIGN

In this study, the mRNA and protein expression profiles of two key regulators of angiogenesis, vascular endothelial growth factor (VEGF) and transforming growth factor beta-1 (TGFB1), were evaluated by real-time PCR and western blot analysis in 23 endometrial cancer tissue-paired specimens (malignant vs. adjacent normal tissues). We aimed to investigate whether VEGF and TGFB1 serve as markers of the malignant transformation of the endometrium and whether VEGF or TGFB1 expression can constitute a useful prognostic marker of survival in patients with endometrial carcinoma.

RESULTS

Tissue-pair analysis revealed VEGF transcriptional up-regulation and TGFB1 mRNA down-regulation as the most frequent transcriptional features. VEGF and TGFB1 mRNA were positively correlated (P < 0·001). VEGF protein levels were higher in endometrioid-type tissue pairs (P = 0·047). TGFB1 protein and mRNA levels were negatively correlated (P = 0·042). TGFB1 protein expression was related to survival only in patients with endometrioid adenocarcinoma (P = 0·045).

CONCLUSIONS

Tissue-pair mRNA and protein analysis reveals VEGF transcriptional up-regulation and TGFB1 down-regulation that are correlated with the malignant transformation of the endometrium, while post-transcriptional mechanisms control VEGF and TGFB1 protein. TGFB1 protein demonstrated a prognostic value only in endometrioid adenocarcinoma.

Relationship between expression and prognostic ability of PTEN, STAT3 and VEGF-C in colorectal cancer

Expression of phosphatase and tensin homolog deleted on chromosome 10 (PTEN), signal transducer and activator of transcription-3 (STAT3) and vascular endothelial growth factor-C (VEGF-C) and their relationship with clinico-pathological features and prognostic ability was determined using immunohistochemistry in 68 cases of colorectal cancer with follow-up data. Kaplan-Meier survival analysis was performed and the prognostic value was determined using univariate analysis. PTEN, STAT3 and VEGF-C expression was detected in 32.4, 60.3 and 63.2% of colorectal carcinoma cases and 90.0, 0 and 0% of normal colon samples, respectively. PTEN and STAT3 were correlated with pathological grade (p=0.011, p=0.001, respectively), but not with tumor size, lymph node metastasis or clinical stage. VEGF-C was correlated with lymph node metastasis (p=0.002), but not with tumor size, pathological grade or clinical stage. Expression of STAT3 and VEGF-C was negatively correlated with PTEN (r=−0.402, r=−0.320, respectively), whereas STAT3 and VEGF-C expression was positively correlated with PTEN (r=0.254). The 3- and 5-year survival rates of PTEN protein-positive patients (68.1 and 50.0%, respectively) were significantly higher than those of PTEN protein-negative patients (32.6 and 19.6%, respectively; p=0.008). The 3- and 5-year survival rates of STAT3-positive (29.3 and 17.1%, respectively) were significantly lower than those of STAT3-negative patients (66.7 and 48.1%, respectively; p=0.005). The 3- and 5-year survival rates of VEGF-C-positive patients (29.3 and 17.1%, respectively) were significantly lower than the rates of VEGF-C-negative patients (66.7 and 48.1%, respectively; p=0.003, p=0.004, respectively). Multivariate analysis revealed that VEGF-C expression was an independent prognostic factor. In conclusion, this study indicates that PTEN, STAT3 and VEGF-C expression are beneficial prognostic factors, which may aid in the accurate assessment of prognosis and guide clinical treatment of colorectal cancer patients.

Medical therapy of endometrial cancer: current status and promising novel treatments

While early-stage endometrial cancer is often successfully treated with surgical intervention, treatment of advanced endometrial carcinoma can be difficult and prognosis poor, particularly in the context of metastatic or recurrent disease. Standard chemotherapy agents for both adjuvant first-line treatment (for selected patients deemed at high risk of relapse) and recurrent endometrial cancer include doxorubicin, platinum agents and paclitaxel. Investigational options currently being studied in phase II trials include both combined regimens of standard chemotherapeutic agents versus radiation as well as targeted treatments such as epothilones, mammalian target of rapamycin (mTOR) inhibitors and anti-angiogenic agents. Recent interest in the molecular pathways of carcinogenesis have lead to increased investigation of these novel agents and the hope that they will impact positively on the overall survival of women with endometrial cancer.

Promising novel therapies for the treatment of endometrial cancer

OBJECTIVES

To discuss the novel agents which are being developed for the treatment of advanced and recurrent endometrial carcinoma and to review other molecular targets that may be interesting in the treatment of this disease. While the majority of women with endometrial cancer enjoy a relatively good prognosis, the options for those women who suffer from a disease recurrence are limited and there is a need to identify novel agents.

METHODS

A review of clinical trials of novel therapeutic agents and their molecular targets is provided. In addition, a review of the current literature on other potential molecular targets for endometrial cancer was performed.

RESULTS

Several phase II trials of novel agents, both alone and in combination with traditional cytotoxic chemotherapy, have been completed or are nearing completion. It appears that the targeted agents may have the most efficacy in combination with cytotoxic chemotherapy or in a multi-targeted agent approach.

CONCLUSIONS

Chemotherapy offers the opportunity for a meaningful response rate in women with endometrial cancer, but the responses are often short lived and cure is uncommon in the setting of recurrent disease. The recent increase in molecular targets has led to the availability of many novel therapies. Determining how these agents are to be used, alone or in combination with "standard" therapies, needs to be defined and translational studies are needed to develop rational combinations of these novel agents before we can move into clinical trials.

Current challenges in clinical management of endometrial cancer

Endometrial cancer remains a management challenge. Improved understanding of the mechanisms of carcinogenesis may enable better understanding of biologic behavior and guide therapy. Improvements in diagnostic imaging, radiation delivery systems, and systemic therapies potentially can improve outcomes while minimizing morbidity. Novel strategies for screening and prevention also hold promise for reducing incidence and mortality of this disease.

Immunohistochemical markers in endometrial hyperplasia: is there a panel with promise? A review

OBJECTIVE

Despite advances in defining the biology of endometrial carcinomas, there has been little progress in determining markers that distinguish preinvasive endometrial proliferations. The goal of this literature review was to identify studies on endometrial hyperplasia (EH) that describe markers with potential to predict response to progestin therapy or potential for progression to invasive disease.

METHODS

Articles published between January 2000 and October 2006 were identified using the key words endometrial hyperplasia and progesterone receptor or estrogen receptor or biologic marker or immunohistochemistry/immunohistochemical. Articles that reported immunohistochemical studies on specimens of human EH +/-endometrioid endometrial carcinoma with a normal comparison group were included. Only those who reported hyperplasia with atypia separately from nonatypical hyperplasia and with a sample size greater than 10 specimens for the sum of complex and atypical samples were included.

RESULTS

A total of 289 abstracts were reviewed and 150 articles potentially met inclusion criteria. Of these, 123 described immunohistochemical studies on human EH specimens. Only 46 met all criteria for analysis of 61 different markers.

CONCLUSIONS

PTEN seems to have the greatest potential for diagnostic utility in EH, perhaps in combination with Bcl-2 and Bax. However, more uniform and rigorous studies are required to confirm these and additional markers' utility diagnostically in a diagnostic panel. As a major clinical priority is to determine which lesions can be treated medically and which require surgical intervention, focusing future studies on markers that distinguish response to hormone therapy or are involved in hormone regulation, will be important future considerations.

The determination of VEGF and MVD, among patients with primary breast cancer

The purpose of the study was to ascertain the value of assessment of vascular endothelial growth factor (VEGF) levels and microvessel density, and to search for correlations between them, in women with breast cancer. The assessment considered factors such as the stage of clinical disease advancement--according to International Union Against Cancer, the grade of histological malignancy, status of axillary lymph nodes and the size of the primary tumour. The concentration of VEGF was assessed in the plasma of 103 women with breast cancer, using an immunoenzymatic method (Quantikine test of R&D Systems). Assessment of microvessel density was performed using histopathological immunoperoxidase methods, using an anti-von Willebrand factor antibody (DAKO A/S). A statistically significant relationship was found between rising VEGF levels and microvessel density in women with breast cancer, when compared to values from a control group. A correlation was found between VEGF concentration and microvessel density (MVD) values. Statistically significant differences were found between VEGF levels of patients in stages I, II and III of clinical disease advancement. For MVD, differences were found only between stages I and III. A statistical relationship was also found between VEGF and MVD and tumour size. Similar results were found between VEGF concentrations in women with metastases to the axillary lymph nodes and cytokine levels in women with no metastases. The results of the study suggest that the degree of tumour vascularization and the concentration of VEGF may represent valuable indicators for the assessment of the angiogenic process in women with breast cancer.

Expression of vascular endothelial growth factor and assessment of microvascular density with CD 34 and endoglin in proliferative endometrium, endometrial hyperplasia, and endometrial carcinoma

The aim of this study was to compare vascular endothelial growth factor (VEGF), CD 34, and endoglin expressions as markers of angiogenesis in proliferative endometrium (PE), endometrial hyperplasia (EH), and endometrial carcinoma (EC) and to find the possible impact of angiogenesis on malign transformation. Formalin-fixed, paraffin-embedded tissues from 12 patients with PE, 23 patients with simple EH and complex EH with atypia, and 31 patients with EC were included. A semiquantitative scoring system was used to assess the intensity and degree of staining of VEGF. Microvessel density (MVD) was assessed with endoglin and anti-CD 34 in most vascular areas. VEGF expression was significantly higher in EC and EH than PE, but there was no difference between EC and EH. According to CD 34 staining, there were no differences in MVD between groups. However, mean MVD counts assessed by endoglin were significantly higher in EC than PE and EH. Although VEGF expression in EC was significantly higher, it did not correlate with other measures of angiogenesis. MVD using endoglin seemed to reflect neoplastic angiogenesis better than CD 34

Hormone therapy in advanced and recurrent endometrial cancer: a systematic review

Endometrial cancer is a hormone-dependent malignancy, and the majority has a precursor phase of endometrial hyperplasia. Histologic subtypes have been recognized with differing natural history. The relationship between hormone response, histology, and molecular profile is not established, but the relevant biology is summarized. This study was a systematic review of the literature to identify which populations should be considered for hormone interventions. Systematic searches were carried out in the English literature for randomized controlled trials and phase II studies of hormone interventions in endometrial cancer. Five randomized trials and 29 phase II studies were identified comprising a total of 2471 patients. In previously untreated patients with grade 1 (G1) or G2 tumors, the response rate for progestogens and the progression-free survival is in the range of 11–56% and 2.5–14 months, respectively. Higher response rates are seen in progesterone receptor–positive cases. Phase II studies comprise the majority of the data and many are of poor quality. There was considerable heterogeneity in patient selection, prior treatment, and type of regimen, and meta-analysis was not possible. G3 or G4 toxicity was less than 5%. We conclude that hormone receptor assessments should be carried out in all patients entered on clinical trials and may aid clinical management in selected cases. Receptor-negative status should not be an absolute contraindication to hormone intervention. Integration of hormone treatment with conventional chemotherapy and growth factor–targeted therapy needs to be explored.

A phase II trial of thalidomide in patients with refractory leiomyosarcoma of the uterus and correlation with biomarkers of angiogenesis: A gynecologic oncology group study

OBJECTIVES

To evaluate the efficacy and adverse events (AEs) of thalidomide in previously treated, measurable, persistent or recurrent leiomyosarcoma (LMS) of the uterus, and to explore associations between angiogenic markers and treatment or clinical outcome.

METHODS

Eligible, consenting patients were treated until disease progression or toxicity intervened with daily starting dose of 200 mg thalidomide/day that was increased by 200 mg every 2 weeks to a target dose of 1000 mg/day. End-points included progression-free survival (PFS)>or=6 months, toxicity, response, PFS and survival. Vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF) and soluble endothelial protein C receptor (sEPCR) were evaluated in pre- and post-treatment serum and plasma.

RESULTS

Of 30 enrolled patients, one was ineligible (wrong histology). Median age was 56 years. Among 29 eligible patients, seven reached the target dose and only two received more than 4 cycles. Two patients (7%) experienced PFS>or=6 months. There were no objective responses, seven (24%) had stable disease, 19 (66%) progressed and 3 (10%) were not evaluable for response. Median PFS was 1.9 months and median overall survival was 8.3 months. Grade 4 AEs were not observed. The most common grade 3 AEs were neurologic (6), pulmonary (4) and constitutional (3). Treatment with thalidomide was associated with a significant decrease in plasma bFGF (p=0.008) and serum sEPCR (p=0.006), but not in plasma VEGF. Plasma VEGF was associated with increased risk of progression (hazard ratio [HR]=3.5; 95% confidence interval (CI)=1.5-7.8; p=0.003) and death (HR=4.7; 95% CI=1.6-13.8; p=0.005) after adjusting for GOG performance status.

CONCLUSIONS

Thalidomide was not active in patients with uterine LMS and did not alter VEGF concentration. The association between pretreatment VEGF and prognosis in this population supports further evaluation of anti-angiogenic therapies in uterine LMS.

The potential role of intrinsic hypoxia markers as prognostic variables in cancer

Tumor hypoxia is related to tumor progression and therapy resistance, which leads to poor patient outcome. It has been suggested that measuring the hypoxic status of a tumor helps to predict patient outcome and to select more targeted treatment. However, current methods using needle electrodes or exogenous markers have limitations due to their invasiveness or necessity for preinjection. Recent studies showed that hypoxia-regulated genes could be alternatively used as endogenous hypoxia markers. This is a review of 15 hypoxia-regulated genes, including hypoxia-inducible factor-1 and its targets, and their correlation with tumor hypoxia and patient outcome from 213 studies. Though most of the studies showed significance of these genes in predicting prognosis, there was no definitive prognostic and hypoxia marker. In conclusion, this review suggests the need for further studies with standardized methods to examine gene expression, as well as the use of multiple gene expressions.

A phase II trial of thalidomide in patients with refractory endometrial cancer and correlation with angiogenesis biomarkers: a Gynecologic Oncology Group study

OBJECTIVES

A phase II trial was conducted to evaluate the anti-tumor activity and adverse effects of thalidomide in persistent or recurrent endometrial cancer refractory to cytotoxic chemotherapy and to correlate angiogenesis biomarker expression with clinical outcome.

METHODS

Consenting patients were treated until progression or intolerable toxicity with an oral starting dose of 200 mg thalidomide/day that was to increase by 200 mg every 2 weeks to a target dose of 1000 mg/day. Vascular endothelial growth factor (VEGF), basic fibroblastic growth factor (bFGF), and soluble endothelial protein C receptor (sEPCR) were analyzed by ELISA in pre and post-treatment specimens.

RESULTS

Twenty-four of twenty-seven patients enrolled in the study were eligible, of whom 2 reached the target dose, 8 progressed before achieving the target dose, and 14 refused or had toxicity that prohibited escalation. Two patients (8.3%) remained progression-free>or=6 months. There were 3 (12.5%) with partial responses, 2 (8.3%) with stable disease, 15 (62.5%) with increasing disease, and 4 (16.7%) who were inevaluable for response. Median progression-free survival and overall survival were 1.7 months and 6.3 months, respectively. No grade 4 toxicities were observed. Common grade 3 toxicities included hematologic (n=3), cardiovascular (n=3), constitutional (n=3), and neurologic (n=4). Thalidomide did not decrease VEGF or bFGF levels but reduced sEPCR levels in serum. Elevated plasma vascular endothelial growth factor levels were associated with increased risk of progression and death.

CONCLUSIONS

Thalidomide demonstrated limited ability to delay progression (as measured by PFS at 6 months), produce objective responses, or reduce angiogenic marker levels in chemotherapy refractory endometrial cancer. VEGF level appears to be prognostically significant in such patients, independent of thalidomide treatment.

The ratio of membrane-bound form Flt-1 mRNA to VEGF mRNA correlates with tumor angiogenesis and prognosis in non-small cell lung cancer

Fms-like tyrosine kinase 1 (Flt-1), a receptor for vascular endothelial growth factor (VEGF), have two isoforms: membrane-bound form (mFlt-1) and soluble form. In the present study, we quantitatively evaluated expression level of mFlt-1 mRNA and VEGF mRNA in non-small cell lung cancer, and demonstrated the clinical significance of the ratio of mFlt-1 mRNA to VEGF mRNA (mFlt-1/VEGF). High mFlt-1/VEGF tumor showed a significantly lower microvessel density (P=0.004), and patients with high mFlt-1/VEGF tumor had a significantly favorable survival (P=0.037). Thus, the ratio of mFlt-1 mRNA to VEGF mRNA was inversely correlated with tumor angiogenesis, and was a significant prognostic factor.

CD105 expression is an independent predictor of survival in patients with endometrial cancer

OBJECTIVE

The purpose of this study was to detect the prognostic value of CD105 (endoglin) and also to compare with CD34 and vascular endothelial growth factor (VEGF) in patients with endometrial adenocancer.

METHODS

Ninety patients with endometrial carcinoma, who were treated at Gazi University Hospital, were included. Staging was performed according to the FIGO recommendations. Angiogenesis was estimated by using CD105 and CD34 and tested for possible significant relation with age, stage, histologic type, grade, depth of myometrial invasion, lymphovascular space invasion, lymph node metastasis, and overall survival (OS). In addition, VEGF staining intensity and distribution were analyzed with respect to all these variables.

RESULTS

The mean age at the time of diagnosis was 57.7 years (range, 28-81 years). The mean microvessel density (MVD) for CD105 was 32.87+/-19.99, and it was 55.46+/-31.25 for CD34 (P<0.001). A significant correlation was noted between these two markers (r=0.257, P=0.02). The mean VEGF score was 4.13+/-1.73, and it was significantly correlated with MV counts determined by CD105 (r=0.291, P=0.006). It was not significantly related with CD34 (r=0.031, P=0.78). With respect to clinicopathological variables, none of the comparisons was found to be significant. The mean follow-up period was 60.5 months. To analyze the prognostic value of MVD, the patients were divided into three groups with respect to quartiles (<or=25%, 26-74%, and >or=75%). With CD105 staining, the 5-year OS rates for patients with the highest MVD count (>or=75%) were significantly poorer than the remaining two groups (P=0.01 for both). None of the comparisons for CD34 was significant. Survival analysis for VEGF was performed by grouping patients using staining characteristics. No significant difference was noted for OS. Multivariate analysis showed that MVD determined by CD105 correlated significantly and independently with OS (P=0.02). None of the remaining variables was significant in multivariate analysis.

CONCLUSION

The current study showed that CD105 is an independent predictor of survival in patients with endometrial cancer. We recommend the use of this highly specific and prognosis-related antigen in further investigations.

Lymphangiogenesis in human gynaecological cancers

The metastatic spread of tumor cells is responsible for the majority of cancer deaths, and with few exceptions, all cancers can metastasize. Clinical findings have for a long time suggested that by providing a pathway for tumor cell dissemination, tumor-associated lymphatics act as key components of metastatic spread. This is believed to occur principally via pre-existing and possibly also newly formed lymphatics (lymphangiogenesis). Increased expression of vascular endothelial growth factor-C (VEGF-C) and VEGF-D in primary tumors correlates with increased dissemination of tumor cells to regional lymph nodes (LNs) in a variety of human carcinomas. Here we will review the mechanisms of lymphangiogenesis, particularly in the context of metastatic tumor spread, and will critically examine the role of VEGF-C and VEGF-D in this process in gynaecological cancers. Potential anti-lymphangiogenic strategies are also discussed.

Morphology of angiogenesis in human cancer: a conceptual overview, histoprognostic perspective and significance of neoangiogenesis

This paper reviews the histomorphological aspects of angiogenesis and neoangiogenesis, quantitative and qualitative, and their applications in prognostic evaluation of neoplastic diseases. The merits and weak points of intratumoral microvessel density (MVD), a widely regarded bona fide predictor of tumour growth, metastases and patient survival, are discussed. Total microvascular area (TVA) has been found useful in recent prognostic studies utilizing newer immunohistochemical vascular markers. Of particular significance is the fact that MVD and TVA are most predictive of patient outcome in those tumours that induce significant neoangiogenesis, namely carcinomas of breast and prostate, and haematological malignancies. In contrast, carcinomas of lung and urinary bladder do not show significant associations of MVD and TVA with poor prognosis, reflecting differences in angiogenic mechanisms. In gliomas, MVD appears to correlate with outcome in high-grade, but not low-grade tumours, and does not correlate with tumour cellularity in the infiltrating portions of the tumour, reflecting a paucity of neoangiogenesis and directional vascular growth. Recent studies have found CD105, Tie-2/Tek and vascular endothelial growth factor receptors to be the best markers of neoangiogenesis. The vascular parameters so measured correlate better with overall and disease-free survival in breast, colon and lung carcinoma than panendothelial markers such as CD31. A correlation of vascular patterns with prognosis has been established in ocular melanomas, glioblastomas and squamous carcinomas of head and neck region. Vascular networks with closed loops are closely associated with mortality due to metastases in uveal melanomas. Fewer bizarre glomeruloid vessels and prominent classical capillary pattern was an independent predictor of longer survival in glioblastoma. Therefore a judicious combination of quantitative and qualitative microscopic angiogenic parameters, with emphasis on neoangiogenesis and vascular patterns wherever applicable, should be an integral component of a more consistent tumour staging system for accurate prognostic evaluation of tumours, selection of optimal anti-angiogenic therapy and pertinent research.

VEGF and its receptors (flt-1 and KDR/flk-1) as prognostic indicators in endometrial carcinoma

Vascular endothelial growth factor (VEGF) is associated with increased angiogenesis and aggressive tumour growth. We investigated the expression and clinical significance of VEGF and its receptors, flt-1 and KDR/flk-1, in patients with uterine endometrial carcinoma. The series consisted of 115 endometrioid endometrial adenocarcinoma patients with FIGO stage I-IV. Additionally, samples from 3 patients with adenoacanthoma and 12 patients with poor prognostic variants of endometrial carcinoma were examined. Immunohistochemical assessment was classified as negative or positive based on staining intensity. The median follow-up time of patients with endometrioid endometrial adenocarcinoma was 87 months. In endometrioid endometrial carcinomas, the positive immunostaining rate was 39% for VEGF, 65% for flt-1 and 68% for KDR/flk-1. There was a significant correlation between VEGF and both its receptors. Furthermore, this receptor expression was correlated between the two types of receptors. VEGF-, flt-1- and KDR/flk-1-positive immunostainings were not related to poor prognosis. We conclude that VEGF, flt-1 and KDR/flk-1 expressions are not useful prognostic markers for overall survival in patients with endometrioid endometrial carcinoma.

Endometrial Angiogenesis: From Physiology to Pathology

Numerous factors have been implicated in angiogenesis. This article concentrates on the expression of the major angiogenic factors, namely, vascular endothelial growth factor (VEGF) and the angiopoietins in the human endometrium. Particular emphasis is placed on the expression of the angiopoietins and their physiological and pathological expression.

Prediction of metastasis risk (11 year follow-up) using VEGF-R1, VEGF-R2, Tie-2/Tek and CD105 expression in breast cancer (n=905)

Neoangiogenesis in tumours contributes to the development of blood-borne metastases, and can be evaluated by markers of activated endothelial cells in preference to panendothelial markers. Our purpose was to document the prognostic significance of VEGF-R1, VEGF-R2, Tie-2/Tek and CD105 immunoexpression in breast carcinoma frozen samples (n=905, follow-up=11.7 years). We observed that: (i) CD105 (P=0.001) and Tie-2/Tek (P=0.025) (but not VEGF-R1 and VEGF-R2) overexpression correlated with a shorter survival, and were (Cox's model) independent histoprognostic indicators; (ii) only CD105 marked expression correlated (P=0.035) with a shorter survival of node-negative patients; (iii) three markers – CD105 (P=0.001), Tie-2/Tek (P=0.01), VEGF-R1 (P=0.001), but not VEGF-R2 – correlated with metastatic risk in node-negative patients in univariate analysis; and (iv) VEGF-R1 (P=0.01) expression correlated with high local recurrence risk. It is concluded that CD105 and to a lesser extent Tie-2/Tek and VEGF-R1, but not VEGF-R2 are endowed with prognostic significance that may be useful for patient monitoring, particularly CD105 expression for selecting node-negative patients for more aggressive postsurgery therapy.

Endoglin (CD105) expression in endometrial carcinoma

Tumor angiogenesis plays an important role in tumor growth and metastasis. We evaluated endoglin (CD105) as an endothelial marker of angiogenesis in endometrial carcinoma (EC) and its prognostic significance. Fifty-five cases of EC, 10 cases of complex endometrial hyperplasia with atypia (CHA), and 10 cases of simple hyperplasia (SH) were immunohistochemically stained for endoglin, CD31, and vascular endothelial growth factor (VEGF). Positively stained microvessels (MV) were counted in densely vascular foci (hot spots) in a 400x field in each specimen. For VEGF, intensity of staining was scored on three-tiered scale. Results were correlated with other prognostic parameters using appropriate statistics. Endoglin staining demonstrated significantly more MV than did CD31 (mean 30.8 +/- 10.95 vs. 13.38 +/- 7.53, p < 0.001). There was a positive correlation of both endoglin and CD31 MV counts with tumor differentiation (p < 0.05) and the depth of invasion (p < 0.01). However, only endoglin counts correlated significantly with the presence of angiolymphatic invasion (p < 0.01), lymph nodes metastases (p < 0.01), and tumor stage (p < 0.001). VEGF expression in EC had a significant correlation with angiolymphatic invasion (p < 0.01) and lymph node status (p < 0.05) but not with other prognostic parameters. Endoglin and VEGF showed significant differences between CHA and SH (p < 0.001). Our study showed that endoglin, by staining the proliferating MV in EC, is a more specific and sensitive marker for tumor angiogenesis than is the commonly used pan-endothelial marker, CD31. Endoglin staining also had prognostic significance, with positive correlation with angiolymphatic invasion, lymph node metastases, and tumor stage.

Vascular endothelial growth factor-D is an independent prognostic factor in epithelial ovarian carcinoma

We assessed the presence of vascular endothelial growth factor (VEGF)-C, VEGF-D and their receptor VEGFR-3 by immunohistochemistry in 59 epithelial ovarian carcinomas, 11 borderline tumours and 20 benign cystadenomas. VEGF-C and VEGF-D were generally expressed in tumour cells and also in endothelia adjacent to tumour nests which showed a strong staining for them. VEGFR-3 was expressed in lymphatic and vascular endothelial cells adjacent to tumour nests. Immunoreactivity was significantly more frequent as lesions progressed from a benign tumour to advanced carcinoma. A strong correlation was found between VEGF-C and VEGF-D detected in carcinoma and VEGFR-3 detected in neighbouring endothelial cells. Increased expression of VEGF-C, VEGF-D and VEGFR-3 was significantly associated with lymph node metastasis and peritoneal metastasis outside the pelvis. There was a significant correlation between the high levels of VEGF-C and VEGF-D proteins, and poor survival. The presence of VEGF-D was an independent prognostic indicator by multivariate analysis. We conclude that VEGF-C, VEGF-D and VEGFR-3 play an important role in lymphatic spread and intraperitoneal tumour development in ovarian carcinoma. Since VEGF-D was found to be an independent predictor of poor outcome, its measurement, together with other prognostic markers may improve prospective identification of patients with a poor prognosis.

Current status and future innovations of hormonal agents, chemotherapy and investigational agents in endometrial cancer

The median survival of women with advanced or recurrent endometrial cancer is less than one year. Only half the women with early stage endometrial cancer and poor prognostic factors such as high grade or deep myometrial invasion will survive for 5 years. Over the past decade, incredible strides have been taken in evaluating systemic therapy for this disease. However, survival rates remain poor. A literature search was conducted using CANCERLIT, EMBASE, Medline, Investigational Drug database (Current Drug Ltd.) and R&D Focus (IMSworld Publications). The references of the articles were also explored. Search terms included: endometrial cancer, chemotherapy, endocrine/hormonal therapies, molecular biologics, and specific drug names. Progestin therapy offers a 10-20% response rate and survival of less than 1 year. Progestins are most effective in women with well-differentiated tumours and a long disease-free interval. There is no role for adjuvant progestin therapy in early stage disease. Single-agent chemotherapy with the most activity includes ifosfamide, cisplatin/carboplatin, doxorubicin and paclitaxel. Combination chemotherapy provides a response rate of 40-60%; however, median survival is still less than a year. New areas of research include the identification and evaluation of new active endocrine therapies (i.e. LY353381.HCl and letrozole), chemotherapeutics (i.e. herceptin), evaluating chemotherapeutic agents in combination (i.e. paclitaxel, doxorubicin and platinum), in addition to radiation or instead of radiation. New avenues under development involve the specific molecules and pathways responsible for the initiation and growth of endometrial carcinoma, including: tumour suppressor genes, DNA mismatch repair genes, oncogenes, molecules involved in adhesion and invasion and angiogenesis. Further significant advances in radiotherapy, hormonal therapy and chemotherapy are unlikely. Exciting developments in understanding the molecules involved in tumour development and metastasis will allow the development of specific and selective inhibitors.

Carbonyl reductase as a significant predictor of survival and lymph node metastasis in epithelial ovarian cancer

We have recently reported a novel function for carbonyl reductase (CR), namely, its ability to modulate the metastatic potential of malignant mouse cells. Because there are currently no data addressing a similar function for CR in human cancers, the aim of this study was to assess a correlation between survival and metastasis, and CR level in epithelial ovarian cancer. Using anti-CR antibody, immunohistochemical staining was performed on 73 epithelial ovarian cancers, 13 borderline malignant tumours, and 25 benign ovarian tumours for a total of 111 specimens. The combined rate for strongly and weakly positive reactions for CR was 32.0% for benign tumours, 38.5% for borderline malignant tumours, and 61.6% for ovarian cancers. The CR-positive rate was 35.7% (weakly positive alone) for ovarian cancers with retroperitoneal lymph node (RLN) metastasis and 67.8% for those without RLN metastasis (P< 0.05). The 5-year survival rate was 62.7% for the patients with CR-negative cancer and 86.1% for those with CR-positive cancer (P< 0.05). The present results indicate that decreased CR expression in epithelial ovarian cancer is associated with RLN metastasis and poor survival.

High sensitivity of PCR in situ hybridization for the detection of human papillomavirus infection in uterine cervical neoplasias

OBJECTIVE

This study was designed in order to examine whether the sensitivity of PCR in situ hybridization (PISH) is superior to that of fluorescence in situ hybridization (FISH) and immunocytochemical staining (ICS) in detecting the presence of human papillomavirus (HPV) infection in uterine cervical neoplasias.

METHODS

Three cell specimens were obtained from every 54 patients who had been histologically and cytologically diagnosed as severe dysplasia of the uterine cervix (SD), carcinoma in situ of the uterine cervix (CIS), or microinvasive carcinoma of the uterine cervix (MIC). All of them were first stained by the Papanicolaou (pap) method before the experiments. After specimens were classified into SD (n = 17) and CIS/MIC groups (n = 37), the sensitivities of detection for HPV infection were compared among PISH, FISH, and ICS methods which had been carried out after decolorization of the pap stain.

RESULTS

In the SD group, PISH demonstrated a 58.8% positive incidence of HPV, which was significantly higher than that (23.5%) shown by FISH (P < 0.05). There was no significant difference in the positivities of HPV between the PISH and ICS (47.1%) methods. In the CIS/MIC group, PISH, FISH, and ICS showed 73.0, 43.2, and 54.1% positive incidences of HPV, respectively. There was significant difference in HPV positivities between PISH and FISH as well as ICS (P < 0.01, P < 0.05). The total frequency of the detection of HPV infection by PISH was significantly higher than that by FISH (P < 0.01) and high with a marginal significance compared to that by ICS (P = 0.051). Moreover, the morphologic change of a single cell and the HPV-positive signals could be observed simultaneously by the PISH technique.

CONCLUSION

Because PISH possesses high sensitivity for the detection of HPV infection in morphologically intact cells from uterine cervical neoplasia, the PISH technique might have promising potential for application to the detection of HPV presence in situ in screening.

Immunohistochemical analysis of gynecologic tumors

Ancillary techniques such as immunohistochemistry (IHC) enable the surgical pathologist to extract additional information from fixed, deparaffinized tissue specimens and to provide data critical to optimal clinical management of the patient. In this review of applications of IHC to the analysis of gynecologic malignancies, the usefulness of immunohistochemical analysis of neoplasms of the cervix, endometrium, and ovary is summarized. In the uterine cervix, dysplasia is associated with qualitative and quantitative alterations in the expression of the Ki-67 antigen expression, as well as an ability to detect human papillomavirus. Endometrial endometrioid adenocarcinomas display a highly characteristic immunophenotype, with coexpression of cytokeratin and vimentin and demonstration of foci of high molecular weight cytokeratin expression; in addition, IHC analysis of estrogen and progesterone receptor and p53 expression can provide important prognostic information about this tumor. Stromal tumors of the endometrium may display a partial smooth muscle immunophenotype, but novel markers such as CD10 provide new tools for the identification of these tumors. The immunophenotypes of the normal ovarian surface epithelium (OSE) and corresponding tumors display significant overlap with, but important distinctions from, mesothelium, and important new markers such as the Wilms tumor gene product can prove useful in the identification of carcinomas of the OSE. Important prognostic markers for carcinomas of the OSE include the HER-2/neu gene product and p53, alterations of which can both be assessed by IHC techniques. Finally, the recent availability of markers of ovarian stroma, including Melan-A and inhibin-alpha, has provided a means for the positive identification of ovarian stromal tumors, which can manifest protean histological appearances.

Novel strategies for systemic treatment of endometrial cancer

The median survival of women with advanced or recurrent endometrial cancer is less than one year. Of the women with early stage endometrial cancer and poor prognostic factors like high grade or deep myometrial invasion, 40% will recur. Over the last decade, incredible strides have been taken in evaluating systemic therapy for this disease, however, survival rates remain poor. Progestin therapy offers a 10 - 20% response rate and survival of less than one year. Progestins are most effective in women with well-differentiated tumours and long disease-free interval. There is no role for adjuvant progestin therapy in early stage disease. Single-agent chemotherapy with most activity include ifosfamide, cisplatin/carboplatin, doxorubicin and paclitaxel. Combination chemotherapy provides a response rate of 40 - 60%, however, median survival is still less than a year. New areas of research include the identification and evaluation of new active endocrine therapies (i.e., LY-353381.HCl and letrozole), chemotherapeutics (i.e., paclitaxel), evaluating chemotherapeutic agents in combination (i.e., paclitaxel, doxorubicin and platinum), in addition to radiation or instead of radiation. New avenues under development involve the specific molecules and pathways responsible for the initiation and growth of endometrial carcinoma (i.e., Herceptintrade mark). Exciting developments in the understanding of the molecules involved in tumour development and metastasis will allow the development of specific and selective inhibitors.