Deoxyribonucleic acid flow cytometric analysis of cervical adenocarcinoma: prognostic significance of deoxyribonucleic acid ploidy and S-phase fraction

Adenocarcinoma of the Uterine Cervix with Massive Signet-Ring Cell Differentiation

Primary signetring cell adenocarcinoma of the cervix is very rare and less common than metastatic signet-ring cell adenocarcinoma. To the best of the authors' knowldge only one genuine case has been reported to date. Tvvo cases of primary signeting cell adenocarcinoma of the uterine cervix in patients aged 68 and 74 years are presented. The tumors were in stage IB. The light microscopic findings were conirmed by histochemical and immunohistochemical study. DNA nuclear analysis by flow cytometry of the neoplasms revealed an aneuploid (tetraploid) pattern. The paients had no evidence of recurrent or metastatic disease 35 and 25 months after a radical hysterectomy with bilateral salpingo-oophorectomy and lymph node dissecion respectively. Primary signet-ring cell adenocarcinoma of the cervix should be diferentiated from metastatic adenocarcinoma, endocervical involvement by signeting cell carcinoma of the endometrium, benign mucinfilled signet-ring cell aggregates that may accumulate in mucosal folds, microglandular hyperplasia, muciarminophilic histiocytosis, and other malignant neoplasms that may have signet ringlike cells and deserve consideration such as squamous cell carcinoma, maligant lymphoma, myeloma, and malignant melanoma. Although very rare, signeting cell adenocarcinoma of the cervix can exist as a primary tumor. Distinction beween a primary neoplasm and a metastasis to the cervix is decisive for treatment and prognosis.

Histologic subtype has minor importance for overall survival in patients with adenocarcinoma of the uterine cervix: a population-based study of prognostic factors in 505 patients with nonsquamous cell carcinomas of the cervix

BACKGROUND

The incidence of adenocarcinoma of the uterine cervix is increasing. For better prognostic information, the authors studied all nonsquamous cell carcinomas (non-SCCs) in the Norwegian population over a total of 15 years.

METHODS

All non-SCCs from three 5-year periods (1966-1970, 1976-1980, and 1986-1990) were reviewed and classified according to the World Health Organization classification system, and histopathologic and clinical parameters were registered. Tissue blocks were available from all patients.

RESULTS

Of 505 patients, 417 had tumors classified as adenocarcinoma, and 88 had tumors classified as other non-SCC. The mean ages were 53 years and 52 years for patients with adenocarcinoma and non-SCC, respectively. Sixty-two percent of the staged patients had clinical Stage I disease according to the classification system of the International Federation of Gynecology and Obstetrics (FIGO). In univariate analyses, histology, architectural and nuclear grade, extension to the vagina or corpus uteri, tumor length (> 20 mm) or tumor volume (> 3000 mm(3)), infiltration depth (in thirds of the cervical wall), thickness of the remaining wall (< 3 mm), vascular invasion, lymph node metastases, treatment, and patient age were significant variables in patients with FIGO Stage I disease. Variables with no significance in patients with Stage I disease were number of mitoses, state of resection margins, infiltration to ectocervix, tumor thickness, lymphoid reaction, earlier or concomitant cervical intraepithelial neoplasia, stump carcinoma, DNA ploidy or DNA index, or time period. Multivariate analyses of patients with FIGO Stage I disease identified small cell carcinoma, corpus infiltration, vascular invasion, and positive lymph nodes as independent prognostic factors.

CONCLUSIONS

Small cell carcinoma was the only histologic subgroup of independent importance for prognosis in patients with non-SCC of the uterine cervix. No significant difference between major subtypes of adenocarcinoma favored a simplified classification. Extension to the corpus in patients with early-stage disease was of independent significance and should be acknowledged in planning treatment.

DNA image cytometry in the differential diagnosis of endocervical adenocarcinoma

BACKGROUND

The value of DNA image cytometry in the differential diagnosis of endocervical adenocarcinoma was tested on a series of 65 cases of normal endocervical cells (n = 25), inflammatory changes (n = 18), and endocervical adenocarcinoma (n = 22).

METHODS

The investigation was performed on gynecologic routine smears by using a television image analysis system MIAMED-DNA (Leica, Wetzlar, Germany), combined with an automated Leica Medilux microscope. First, the Papanicolaou stained specimens were rescreened, and the x/y coordinates of at least 150 endocervical nuclei were stored per case by using a scanning program. After restaining according to Feulgen, the epithelial cells were relocalized and the DNA content, and the nuclear area were determined. The DNA content of 25-30 squamous epithelial cells of intermediate type served as an internal standard for the normal diploid value in each case. Various DNA cytometric parameters and the mean nuclear area were calculated. For statistical analysis, the cases of adenocarcinoma (n = 22) were defined as positive, and the cases with normal endocervical epithelium or inflammatory changes (n = 43) were defined as negative.

RESULTS

The presence of nuclei with a DNA content greater than 9c was observed exclusively in adenocarcinoma (sensitivity, 95.9%; specificity, 100%), indicating that this parameter is suited best for the differentiation between malignant and nonmalignant endocervical epithelium. High sensitivity rates at a specificity level of 100% also were calculated for the 2.5cER (95.5%), the mean ploidy (90.9%), 5cER (90.9%), and the diploid deviation quotient (90.9%). For the 2cDI (86.4%), the entropy (81.8%) and the ploidy imbalance (77.3%) lower values were obtained.

CONCLUSIONS

DNA single cell cytometry represents a highly relevant tool in the identification of malignant transformation in endocervical lesions that could be used as a complementary diagnostic method in cytologically difficult cases. Investigations on endocervical adenocarcinoma in situ should be performed in the near future.

Clear cell carcinoma of the uterine cervix: pathology and prognosis in surgically treated stage IB-IIB disease in women not exposed in utero to diethylstilbestrol

OBJECTIVE

The purpose of this research was to compare the clinical behavior, pathology findings, and prognosis of surgically treated FIGO stage IB-IIB clear cell carcinomas of the cervix with those of squamous cell carcinomas and non-clear cell adenocarcinomas.

METHODS

Fifteen patients with clear cell adenocarcinomas of the cervix (8 FIGO stage IB, 7 FIGO stage IIB) were reviewed. The control group consisted of 444 squamous cell carcinomas and 59 non-clear cell adenocarcinomas. None of the patients had a history of in utero exposure to diethylstilbestrol. All patients underwent radical abdominal hysterectomy with systematic pelvic lymphadenectomy. All specimens were processed as serial giant frontal sections. The mean follow-up in the clear cell group was 83 (13-182) months. Statistical analysis was done with contingency tables, chi(2) tests, and Fisher's exact test.

RESULTS

Twelve of the fifteen clear cell carcinomas (80%) were endophytic and tended toward deep cervical infiltration. Clear cell carcinomas extended to the uterine corpus significantly more often than squamous cell and non-clear cell adenocarcarcinomas (P < 0.001). The rates of parametrial involvement and pelvic lymph node involvement were 40 and 47%, respectively. Four patients (27%), all with positive pelvic nodes, developed recurrences an average of 14 (4-48) months after initial therapy. The extrapelvic sites of relapse were the lung, liver, and bone. Clear cell carcinomas had a worse 5-year survival rate (67%) than squamous cell carcinomas (80%) and non-clear cell adenocarcinomas (77%) but this was not statistically significant (P = 0.6). No significant differences were seen for age, growth pattern, parametrial and vaginal involvement, parametrial and pelvic lymph node metastases, frequency of recurrent disease, and time to first recurrence.

CONCLUSION

The clinicopathologic findings and prognosis of surgically treated patients with stage IB-IIB clear cell carcinomas without exposure to diethylstilbestrol in utero are similar to those of patients with squamous cell carcinomas and non-clear cell adenocarcinomas.

Flow cytometric DNA analysis of early stage adenocarcinoma of the cervix

OBJECTIVE

The aim of this study was to determine the utility of DNA flow cytometry as a prognostic indicator for risk of recurrence and overall survival in patients with early stage adenocarcinomas of the uterine cervix.

METHODS

DNA flow cytometry was performed to determine ploidy, DNA index, and proliferative index in 66 women with stage IB and IIA pure mucinous adenocarcinomas of the cervix treated by primary surgical therapy with radical hysterectomy and pelvic lymphadenectomy. Fifty-seven of 66 (86.3%) tissue samples were analyzable. Three sections were obtained from paraffin-embedded tissue blocks containing primary tumor. Flow cytometric results, along with other known prognostic variables for risk for recurrent disease and survival, were analyzed using the Cox regression proportional hazards model and survival curves generated by the Kaplan-Meier method.

RESULTS

Of 57 interpretable samples, DNA ploidy patterns were 18 (27%) diploid, 8 (12%) tetraploid, and 31 (47%) aneuploid. Thirteen of 66 patients (20%) experienced recurrence with a median time to recurrence of 1.6 years. No significant correlation was noted between DNA ploidy and risk of recurrence (P = 0.429). Multivariate analysis confirmed that positive metastatic lymph nodes were associated with risk of recurrence (P < 0.001). In node-negative patients, a high proliferative index (S% + G(2)M% > 20%), measured as a continuous variable, was the only significant factor for tumor recurrence (P = 0.002).

CONCLUSION

DNA ploidy does not predict a patient's risk for tumor recurrence; however, a high proliferative index value warrants further investigation as a potential prognostic indicator for risk of recurrent disease in patients with adenocarcinoma of the uterine cervix.

Flow-cytometric DNA analysis of early stage adenocarcinoma of the cervix

OBJECTIVE

The purpose of this study was to determine the utility of DNA flow cytometry as a prognostic indicator for risk of recurrence and overall survival in patients with early stage adenocarcinomas of the uterine cervix.

METHODS

DNA flow cytometry was performed to determine ploidy, DNA index, and proliferative index in 66 women with stages IB and IIA pure mucinous adenocarcinomas of the cervix treated by primary surgical therapy with radical hysterectomy and pelvic lymphadenectomy. Fifty-seven of 66 (86.3%) tissue samples were analyzable. Three sections were obtained from paraffin-embedded tissue blocks containing primary tumor. Flow-cytometric results, along with other known prognostic variables for risk for recurrent disease and survival, were analyzed using Cox regression proportional hazards model, and survival curves were generated by the Kaplan-Meier method.

RESULTS

Of 57 interpretable samples, DNA ploidy patterns were 18 (27%) diploid, 8 (12%) tetraploid, and 31 (47%) aneuploid. Thirteen of 66 patients (20%) experienced recurrence with a median time to recurrence of 1.6 years. No significant correlation was noted between DNA ploidy and risk of recurrence (P = 0.429). Multivariate analysis confirmed that positive metastatic lymph nodes were associated with risk of recurrence (P < 0.001). In node-negative patients, a high proliferative index (S% + G(2)M% > 20%), measured as a continuous variable, was the only significant factor for tumor recurrence (P = 0.002).

CONCLUSION

DNA ploidy does not predict a patient's risk for tumor recurrence; however, a high proliferative index value warrants further investigation as a potential prognostic indicator for risk of recurrent disease in patients with adenocarcinoma of the uterine cervix.

Changes in S-phase fraction and micronucleus frequency as prognostic factors in radiotherapy of cervical carcinoma

Twenty-five patients with cervical carcinoma were treated with combined external beam and high dose rate afterloading radiotherapy. Biopsies obtained at different time points in the course of therapy were analysed with respect to cell proliferation and cytogenetic damage. The fraction of cells with an S-phase DNA-content as well as the frequency of micronuclei were determined. These two parameters were then related to treatment outcome, in particular patient survival. Neither S-phase fraction nor the micronucleus frequency before radiotherapy were predictive of treatment outcome in this small group of patients. However, when changes in response to therapy were considered, patients whose S-phase fraction decreased and patients whose micronucleus frequency increased tended to have a better prognosis. Although statistical significance was not achieved with either criterion alone, when applied together the combination predicted patient survival quite reliably; the 5-year survival rate of those patients who showed a decrease in S-phase fraction as well as an increase in micronucleus frequency was about 90% in contrast to less than 30% for the non-responders (p < 0.03).

DNA cell-cycle analysis of cervical cancer by flow cytometry using simultaneous cytokeratin labelling for identification of tumour cells

DNA ploidy and cell-cycle distribution were determined by flow cytometry in fresh tumour tissue of 53 cervical carcinomas. Epithelial cells were labelled by a fluorescein-isothiocyanate-conjugated cytokeratin antibody (CK6, CK18) to study the influence of contaminating stromal and inflammatory cells on results of cell-cycle analysis of tumour cells. Without identification of cytokeratin-positive cells 30/53 (57%) tumours were found to be DNA-aneuploid compared to 43/53 (81%) after gating for cytokeratin. Only 7 of 15 DNA-multiploid tumours could be detected without cytokeratin staining. In addition, cytokeratin-negative cells, which are found in all tumours, can be used as an internal standard for the calculation of ploidy and for quality control (coefficient of variation, linearity) of each individual sample. Cell-cycle analysis revealed significantly higher S-phase and G2M-phase fractions in cytokeratin-gated compared to ungated samples (13.1% versus 10.0% and 8.0% versus 5.4%; P < 0.001). This difference was more pronounced in DNA-diploid than DNA-aneuploid tumours. In conclusion, about 30% of DNA-aneuploid tumours could only be detected after cytokeratin labelling of epithelial cells. Owing to the identification of cytokeratin-positive cells the influence of non-tumoural cell elements on cell-cycle analysis was reduced markedly. Therefore, in cervical cancer, cytokeratin labelling can optimize both the determination of DNA ploidy and cell-cycle analysis.

Nucleolar organizer regions in adenocarcinoma of the uterine cervix

BACKGROUND

Nucleolar organizer regions (AgNORs) are associated with proliferative activity and ploidy in many tumors. The endocervical growth pattern of cervical adenocarcinoma renders tumor volume assessment more difficult, necessitating additional prognostic indicators.

METHODS

Thirty-five cases of cervical adenocarcinoma were evaluated by reviewing charts and histologic sections. Nucleolar organizer regions were stained and counted manually; the mean number per cell and the percentage of cells with more than 5 AgNORs were recorded. Ploidy and S-phase fraction were determined by flow cytometry.

RESULTS

Mean AgNOR counts per cell were significantly higher in adenocarcinoma (3.0) and adenosquamous carcinoma (4.3) than in benign endocervical epithelium (1.4). Grade 3 tumors had higher values (4.0) than Grade 1 lesions (2.9), and tumors with lymphovascular space involvement had higher values (3.5) than tumors without such involvement (2.7). No significant correlation was seen with regard to tumor stage or size. Flow cytometric parameters did not correlate with any of the examined parameters, although the DNA index was higher in larger tumors. Correlation between AgNOR counts and flow cytometry was significant only in Grade I tumors.

CONCLUSIONS

Nucleolar organizer region counts correlated better with histologic parameters of cervical adenocarcinoma than did flow cytometry. Because it is easily performed and does not require sophisticated equipment, AgNOR counts should be investigated further in a larger group of patients to determine their prognostic value.

Deoxyribonucleic acid ploidy and S-phase fraction are not significant prognostic factors for patients with cervical cancer

OBJECTIVE

Our purpose was to determine the usefulness of deoxyribonucleic acid ploidy and S-phase fraction as prognostic factors in patients with cervical cancer.

STUDY DESIGN

Paraffin-embedded tumor specimens were obtained from 123 patients with cervical cancer (mean age 51 years, range 21 to 87 years). The mean follow-up period was 6.4 years. Deoxyribonucleic acid ploidy and S-phase fraction were determined by flow cytometry.

RESULTS

A total of 119 patients were evaluable for deoxyribonucleic acid ploidy and 92 were evaluable for S-phase fraction. The overall rate of deoxyribonucleic acid aneuploidy was 60%, and the median S-phase fraction was 12.5%. Neither factor was significantly related to stage of disease. In univariate survival analyses patients with deoxyribonucleic acid aneuploid tumors had slightly better early survival than did patients with deoxyribonucleic acid diploid tumors (median survivals 2.7 and 1.4 years, respectively, p = 0.08 [Wilcoxon]), but the overall survival was not significantly different, p = 0.37 (log-rank). In multivariate analyses deoxyribonucleic acid ploidy was not a significant predictor of survival. S-phase fraction was not statistically significant in either analysis.

CONCLUSION

Deoxyribonucleic acid ploidy and S-phase fraction are not useful prognostic factors for patients with cervical cancer.

Flow cytometric DNA content analysis of paraffin-embedded tissue derived from cervical carcinoma

PURPOSE

Flow cytometric deoxyribonucleic acid (DNA) content analysis has been shown to be of prognostic importance in some cancers. There have been recent reports of a prognostic importance for DNA content analysis in cervical carcinoma.

METHODS AND MATERIALS

We retrospectively reviewed the hospital and radiation oncology records of cervical carcinoma patients who presented between 1984-1990.

RESULTS

A total of 101 archival paraffin-embedded blocks were processed, of which 77 were of technical quality for analysis. Thirty-five percent were found to be DNA content aneuploid (DNA-A) and 65% DNA content diploid (DNA-D). No statistical difference was found between the two groups in age at diagnosis, % S-phase, coefficient of variation (CV), or proliferative index (PI). A statistical difference was noted in the G2M phase between the two groups (p = 0.004). The median % S-phase was 8.4% in the DNA-D group. A statistical difference (p = 0.017) in survival was noted between the low and high % S-phase DNA-D groups. In patients who received radiation alone, high-PI patients had improved survival compared to low-PI patients. No statistical difference in survival was noted in the high % S-phase DNA-D group and DNA-A group (p = 0.28). Proportional Hazard (Cox) Regression found clinical stage the only independent prognostic indicator for survival.

CONCLUSION

Flow cytometric DNA content analysis is being used more frequently in the management of different malignant tumors. Our study shows that DNA content analysis is useful in determining the prognosis and survival outcomes in cervical carcinomas and may aid in predicting outcome to certain types of treatment regimens.

The uses and limitations of DNA flow cytometry in stage IB or II cervical carcinoma

BACKGROUND

The role of flow cytometry in predicting prognosis for cervical carcinoma remains unclear.

METHODS

Flow cytometric analysis was performed on tissues, fixed in formaldehyde solution and embedded in paraffin, from 411 patients with Stage IB or II cervical carcinoma who had been treated with radical abdominal hysterectomy and bilateral pelvic lymphadenectomy.

RESULTS

DNA aneuploid-multiploid tumors were found in 37.5%, tetraploid in 4.6%, and diploid-peridiploid in 57.9%. Five-year recurrence-free survival rates of the three groups were 74.3%, 77.8%, and 76.4%, respectively (P > 0.05). DNA aneuploidy and DNA index (DI) of greater than 1.3 were highly correlated to parametria extension. In univariate analysis, pelvic lymph node metastases, stage, parametrial extension, depth of cervical stromal invasion, tumor size, and DI (1.3, 1.4, 1.5 as breakpoint) were significant prognostic factors. DNA ploidy, S-phase fraction, and S-G2M fraction were not significant. In multivariate analysis, DI of greater than 1.3, pelvic node metastases, clinical Stage II, and depth of stromal invasion greater than two-thirds of full cervical thickness were independent and significant variables. The prognostic index (PI), defined by the model, was able to categorize the patients into three distinct risk groups. The 5-year recurrence free survival rates of the low-, intermediate-, and high-risk groups were 89.5%, 73.0%, and 58.9%, respectively (P < 0.0001).

CONCLUSIONS

The prognostic value of the DI as a single variable is promising and warrants additional investigation to establish its appropriate use.

Flow cytometric DNA analysis in gynecological oncology

The relevance of flow cytometric DNA analysis in neoplasia of the female genital tract is reviewed. The virtues and limitations of the technique are discussed. There is good evidence, mainly from retrospective studies, that DNA ploidy and/or the tumor S-phase fraction are valuable prognostic indicators in patients with carcinoma of the ovary and endometrium. Further prospective studies are needed, however, to establish the precise value of flow cytometric DNA analysis before it can be used safely for stratification of therapeutic regimes.