DNA ploidy, grade, and stage in prognosis of uterine cervical cancer

DNA Ploidy is Stronger Than Lymph Node Metastasis as Prognostic Factor in Cervical Carcinoma: 10-Year Results of a Prospective Study

Introduction:

To improve the outcome of patients with cervical cancer, a more accurate prognostic assessment is essential. The aim of this study was to evaluate the role of tumor DNA ploidy as an independent prognostic factor in cervical carcinoma. Furthermore, we investigated whether the presence of lymph node metastasis may have a different clinical impact according to ploidy status.

Methods:

In a long-term prospective study, DNA ploidy was evaluated by flow cytometry from fresh tumor samples from 136 patients with cervical cancer who underwent surgery. Ploidy, lymph node metastasis, and other classical parameters were analyzed in relation to the length of disease-specific survival. Treatment modalities did not differ between patients with diploid tumors and patients with aneuploid tumors.

Results:

DNA aneuploidy was found in 52 patients (38.2%). Patients with DNA-aneuploid tumors had a significantly reduced disease-specific survival (P= 0.003). Overall, the 10-year survival probability was 54% for patients with DNA-aneuploid tumors and 80% for patients with DNA-diploid tumors. Among 64 patients with International Federation of Gynecologists and Obstetricians stage I disease, the 10-year survival rates were 38.7% for the patients with DNA-aneuploid tumors and 86.3% for those with DNA-diploid tumors (P= 0.003). Overall, diploid tumors with lymph node metastasis did significantly better than aneuploid tumors with lymph node metastasis (P= 0.05). Among the patients with International Federation of Gynecologists and Obstetricians stage I disease, there was a highly significant difference between patients with diploid node-positive tumors and patients with aneuploid node-positive tumors, with no deaths from the disease in the former group in contrast with the worst outcome in the latter group (P= 0.005). By multivariate analysis, pathologic tumor stage, lymph vascular invasion, and tumor ploidy were significant and independent parameters, whereas lymph node metastasis yielded no independent information.

Conclusions:

DNA ploidy was an independent prognostic factor in cervical carcinoma. Presence of lymph node metastasis may not always have the same impact on survival but may vary according to DNA ploidy of the primary tumor.

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.

Ploidy in human papillomavirus positive and negative vulvar squamous cell carcinomas and adjacent skin lesions

To better characterize the two clinicopathologic types of squamous cell carcinoma, human papillomavirus (HPV) positive and negative, and their adjacent skin changes, we performed cytomorphometric analysis on 12 HPV-positive squamous cell carcinomas and adjacent vulvar intraepithelial neoplasia and 22 HPV-negative squamous cell carcinomas and adjacent squamous cell hyperplasia and lichen sclerosis. Our results were that 83% (10 of 12) HPV-positive carcinomas and 78% (7 of 9) adjacent vulvar intraepithelial neoplasia were aneuploid, compared with 59% (13 of 22) HPV-negative carcinomas, 6% (1 of 16) squamous cell hyperplasias and 0% (0 of 20) lichen scleroses. Seventy-five percent (9 of 12) HPV carcinomas and 78% (7 of 9) vulvar intraepithelial neoplasias showed two aneuploid peaks, but no HPV-negative carcinoma or non-neoplastic epithelial lesion showed multiple aneuploid peaks. Fifty percent of squamous cell hyperplasias (8 of 16) and lichen scleroses (10 of 20) adjacent to HPV-negative carcinomas were hypodiploid. The mean DNA indices were: 1.70 for the dominant tumor cell population of HPV-positive carcinoma, 1.64 for the dominant population of vulvar intraepithelial intraepithelial neoplasia, 1.41 for HPV-negative carcinoma, 0.85 for squamous cell hyperplasia and 0.83 for lichen sclerosis. In conclusion, the higher rate of aneuploidy, higher mean DNA index, and presence of multiploid peaks in HPV-positive carcinomas and adjacent vulvar intraepithelial neoplasias compared with the lower rate of aneuploidy, lower mean DNA index, absence of multiploid peaks of HPV-negative carcinomas and tendency to hypodiploidy in squamous cell hyperplasia and lichen sclerosis support the hypothesis that there are two clinicopathologic types of vulvar carcinoma, with different pathogenetic mechanisms. The similarities in ploidy findings between vulvar HPV-positive carcinomas and vulvar intraepithelial neoplasia and those previously published for cervical carcinoma and cervical intraepithelial neoplasia support the view that these two cancers are analogous and have similar pathogenetic mechanisms. The frequent finding of hypodiploidy in squamous cell hyperplasia and lichen sclerosis next to HPV-negative carcinomas requires further investigation of the molecular pathogenesis of this cancer type.

Biology of cervical carcinoma

Cervical cancer is generally a locoregional disease. The endopelvic fascia envelops the cervix in anterior-posterior fashion and serves as a natural barrier. Thus, cervical cancer preferentially grows to the parametria and involves the ureters before it infiltrates the bladder or rectum. Disease stage, grade, cell type, tumor volume, depth of stromal invasion, vascular space invasion, and lymph node status are common prognostic indicators. Irregular vaginal bleeding and discharge are the two most frequent complaints. Although cervical cancer is still staged clinically, data continue to accumulate favoring a conversion to surgical staging to improve accuracy and treatment outcome.

Tumour cell kinetics as a prognostic factor in squamous cell carcinoma of the cervix treated with radiotherapy

PURPOSE

Proliferative rate and DNA ploidy status were evaluated by flow cytometry in cervical cancer patients, prior to radiotherapy, to assess their importance as prognostic factors to predict survival rates.

MATERIAL AND METHODS

Between 1987 and 1995, a total of 260 patients with squamous cell carcinoma (SCC) of the cervix, FIGO stages IB-IIIB were analysed. Tumour samples were incubated with bromodeoxyuridine (BrdUrd) in vitro to measure their total labelling index (totLI) and LI (totLI for diploid and anLI for aneuploid tumours). Proliferation was also assessed by S-phase fraction (SPF) analysis of the DNA profile. Patients had intracavitary therapy (three applications, each of 16 Gy to point A) and XRT of 40-50 Gy given over 4-5 weeks.

RESULTS

The cervical tumours were characterized by a high proliferation rate which varied within each clinical stage of disease. The totLI ranged from 1.1 to 33.1% with median value of 9.6% whilst the LI ranged from 1.1 to 37.1% with a median value of 10.9%. Univariate analysis identified patient's age (cut-offpoint < or = 50&greater; years) and to a lesser extent proliferation (cut-off point, median totLI=9.6%) as significant prognostic factors for 5-year survival. The median survival time for younger patients ( < or = 50 years) with tumours of low proliferation (totLI < or = 9.6%) tumours was 17.5 months compared with 56 months in the faster proliferating tumours (P=0.0354). In the older patient sub-group, proliferation rate had no influence on survival. The median LI value was not a useful parameter in survival. Cox multivariate analysis showed that patient age ( < or = 50 years) and low proliferation of the tumour cells (totLI < or = 9.6) were unfavourable prognostic factors for cervical cancers treated with radiotherapy. DNA ploidy was not significant in this series.

CONCLUSIONS

These data suggest that further improvements in therapy might be gained by selection of alternative treatments strategies such as neoadjuvant chemotherapy or radiation sensitizers in younger patients with more slowly proliferating tumours.

Prognostic significance of DNA cytometry of postirradiation cervicovaginal smears

BACKGROUND

Cytologic sampling is performed routinely after radiotherapy for cervical carcinoma. The prognostic significance of postirradiation dysplastic and atypical cells is uncertain because of difficulties in distinguishing preneoplastic and cancerous changes from benign radiation changes. DNA cytometry studies may provide a more objective method of identifying significant lesions.

METHODS

Postirradiation cervical carcinoma patients with cervical/vaginal smears containing atypical or dysplastic cells were identified prospectively. Papanicolaou smears were destained, restained with a Feulgen stain, and evaluated for DNA content using image cytometry. Pathologic and clinical records were monitored on each patient for evidence of recurrence or biopsy-proven dysplasia.

RESULTS

Of 46 patients, 14 had been diagnosed on cytology as having atypical squamous cells, 4 as having atypical/suspicious cells, 12 with low grade squamous intraepithelial lesions (SIL), 3 with high grade SIL, and 13 with ungraded SIL. DNA histograms were classified as follows: 14 diploid, 19 polyploid, and 13 aneuploid. Cytologic diagnosis and histogram type were correlated significantly and both correlated with clinical outcome. The probability of either postirradiation dysplasia or recurrence was as follows: SIL, 82%; suspicious, 100%; polyploid, 79%; and aneuploid, 92%. Patients with atypical squamous cells of undetermined significance or diploidy most frequently had negative follow-up (57% each). All patients with both SIL and aneuploidy developed either dysplasia or recurrence. The stage of disease did not correlate with outcome or histogram pattern.

CONCLUSIONS

DNA analysis of postirradiation cytologic smears demonstrating atypia or dysplasia may provide useful ancillary information. The presence of aneuploidy usually signifies either recurrence or dysplasia. Polyploidy most frequently occurs in dysplastic processes, whereas diploid histograms usually denote a benign disease course.

Proliferation measurements with flow cytometry Tpot in cancer of the uterine cervix: correlation between two laboratories and preliminary clinical results

PURPOSE

To assess the prognostic value of the pretreatment potential doubling time (Tpot) in carcinoma of the uterine cervix, relative to other established clinical factors.

METHODS AND MATERIALS

Fifty-two patients with cervical cancer were studied prospectively from March 1991 to October 1993. Pretreatment evaluation included examination under anesthesia and tumor biopsy 6 h following the intravenous administration of bromodeoxyuridine (200 mg). Tpot was determined by deriving the labeling index (LI) and S-phase synthesis time (Ts) using flow cytometry. Six patients were not evaluable and excluded. The remaining 46 patients (average age 55 years) were treated uniformly with radical radiation therapy. There were 39 squamous carcinomas and 7 adenocarcinomas. Fédération Internationale de Gynécologie et d'Obstétrique (FIGO) stages were: Ib and IIa, 12 patients; IIb, 18 patients; III and IV, 16 patients. The median external beam dose was 50 Gy (range, 45-52.8 Gy) delivered in 25 fractions. The median intracavitary dose was 40 Gy (range. 25.5-40 Gy) delivered with a single line source to a point 2 cm lateral of the midline, with a mean dose rate of 0.71 Gy/h. The median overall treatment time was 45 days (range, 34-73 days). As of July 31, 1994, 12 patients had died of disease, and the average follow-up for alive patients was 1.4 years (range, 0.5-3.3 years).

RESULTS

There were 27 tumors with diploid deoxyribonucleic acid (DNA) content and 19 tumors were aneuploid. The median and mean Tpot for the 46 patients were 5.5 and 6.6 days, respectively [range, 2.0-25.6 days; coefficient of variation (CV), 74%]. For 25 patients where Tpot measurements were performed at two separate laboratories, there was a fair correlation (r = 0.74), but systematic differences were detected suggesting that the lack of agreement was not simply due to intratumoral variation. To date, 30 patients remained disease free, while 8 patients had pelvic failure and 9 patients developed distant metastases as the first failure site (1 patient developed both at the same time). In univariate analysis, the only significant prognostic factor for disease-free survival was tumor size (p = 0.004). A short Tpot (or high LI) and long overall treatment time (OTT) were weakly associated with poorer disease-free survival, although not statistically significant (1/Tpot, p = 0.14; LI, p = 0.23; OTT, p = 0.04). Age, FIGO stage, hemoglobin level, S-phase fraction, DNA ploidy, and Ts were not associated with disease-free survival. Multiple regression analysis was not performed because of the relatively small number of patients and short follow-up.

CONCLUSIONS

Tpot values determined with current techniques by different laboratories cannot be used interchangeably for the purpose of therapy decisions. Vigorous quality assurance and standardization of the laboratory procedures and analysis methods are important to reduce interlaboratory variation. In this uniformly treated group of patients with cancer of the uterine cervix, traditional clinical prognostic factors remain the most important. Preliminary data suggest that the flow cytometry-determined Tpot and labeling index predict for disease-free survival, although a larger number of patients with longer follow-up is required to assess the true prognostic significance of these assays and to determine if their effect is independent of other clinical factors.

The histologic grading of cancer

BACKGROUND

The histologic grade of a tumor provides prognostic information in addition to that provided by stage of disease. Poorly differentiated tumors are known to pursue a more aggressive course than their well differentiated counterparts.

METHODS

The frequency of grading and the relationship of grade to outcome was investigated for 793,649 cases of cancer from 15 anatomic sites as recorded in the Surveillance, Epidemiology, and End Results Program.

RESULTS

For all cancers, the frequency of grading increased from 1973 to 1987 and varied by anatomic site and histologic type. Survival decreased with advancing grade, and within each stage, grading separated cases into at least three distinct prognostic subgroups. For some cancers, regional stage cases assigned Grade 1 or 2 had higher survival rates than did localized stage cases assigned Grade 3 or 4. Therefore, grading allowed the identification of high and low risk subgroups within each stage grouping.

CONCLUSIONS

The tumor grade was a strong prognostic indicator for cancers of the urinary bladder, endometrium, and prostate--sites most often graded by pathologists. The histologic grade was also an important determinant of outcome for cancers of the brain, soft tissue, and breast; however, only a small percentage of these tumors were graded. The results are important because no common criteria for grading were established among the many contributing pathologists. Therefore, observer variation did not alter the known relationship of histologic grade to outcome. This review demonstrates that the histologic grade is a strong predictor of outcome that refines the prognostic information provided by the stage of disease.

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.

Measurement of cell kinetics in cervical tumours using bromodeoxyuridine

The pre-treatment cell kinetics of 120 cervical tumours were assessed following the in vivo labelling with the thymidine analogue Bromodeoxyuridine (BrdUrd). In 89% both static and temporal kinetic parameters could be measured. Through the analysis of multiple biopsies from each tumour marked intra tumour heterogeneity was demonstrated. The median values for the most highly labelled sample analysed for each tumour were; S-phase duration (Ts) 12.1 h, BrdUrd labelling index (CLI) 9.5% and potential tumour doubling time 4.4 days. There was a significant elevation in CLI, but no difference in Ts, between tumour and non-neoplastic cervical tissue. There was a significant elevation in CLI, advanced stage and large size tumours. Although a significant elevation in CLI was found in aneuploid tumours this is likely to represent the systemic bias of the calculation methods, with no difference being seen between aneuploid and diploid tumours when BrdUrd labelling was measured with-out reference to the nuclei DNA content. The majority of these patients were treated with radiotherapy and cell kinetic data will be correlated with treatment response when adequate follow up has been achieved.

Flow cytometric evaluation of ovarian cancer

BACKGROUND

Despite recent advances in the treatment of ovarian cancer, the long-term prognosis for patients with this malignancy appears to depend more on tumor prognostic factors than on treatment regimens. The traditionally used prognostic factors are often subjective and, currently, have not been sufficient to determine individual patient prognosis.

METHODS

Newer techniques of quantitative cytologic testing, including flow cytometry, facilitate the objective evaluation of tumor cell heterogeneity and the identification of additional prognostic factors.

RESULTS

There is good evidence, mainly from retrospective studies, that DNA ploidy is a valuable prognostic indicator in patients with both early-stage and late-stage ovarian cancer. Most of the recent flow cytometric studies have identified ploidy as an independent prognostic factor, with aneuploidy predicting a significantly shorter survival time, even in patients with borderline malignant tumors. Flow cytometric determination of cell cycle information (e.g., S-phase fraction or proliferative index) may represent additional prognostic information and may be used to predict the early tumor response to treatment.

CONCLUSIONS

Although additional prospective studies are needed to establish the exact value of flow cytometric evaluation for ovarian cancer and other gynecologic malignancies, there is little doubt that the prognostic value of this information will influence clinical management of patients with these malignancies in the near future.

Study of the relationship between abnormalities in nuclear DNA and drug sensitivity of human gynecological cancer transplanted into nude mice

The relationship between abnormalities in nuclear DNA and anticancer-drug sensitivity of human gynecological cancer transplanted into nude mice is reported. Nuclear DNA content was expressed in terms of the DNA index (DI) and heterogeneity index score (HIS) using flow cytometry (FCM). Southern blot analysis was used to examine changes in DNA and in observed abnormal-size DNA fragments. Drug sensitivity was carried out according to a procedure described by Battelle Columbus Laboratories. The results were as follows: (1) Tumors with a high degree of DNA content were more sensitive to anticancer drugs than tumors with less DNA damage. (2) Severe heterogeneity of nuclear DNA caused drug resistance.

Prognostic factors in invasive cervical carcinomas associated with human papillomavirus (HPV). Quantitative data and cytokeratin expression

As a part of a larger programme to search for the prognostic factors in cervical cancer, quantitative morphometry, demonstration of AgNORs and expression of different cytokeratin polypeptides (SK2-27, SK1, A 53-B/A2) were used to study a series of 85 cervical squamous cell carcinomas, previously analysed for the presence of human papillomavirus (HPV) DNA by in situ hybridization and polymerase chain reaction (PCR). The following nuclear profile parameters were calculated: nuclear area, perimeter, maximum diameter, ellipsoidity (form Ell), regularity (form Ar) and roundness (form Pe). In each case, the number of small (< 3 microns), large (> 3 microns), the total number and the ratio large/small AgNORs were registered. The cancer cell density and the lymphoid cell density were assessed. In the survival analysis, neither the expression of different cytokeratin polypeptides or the pattern of cytokeratin staining proved to be an independent variable. Similarly, none of the nuclear profile parameters analysed possessed an independent prognostic value in the survival analysis. The ratio of large/small AgNORs proved to be a significant independent prognostic predictor (p = 0.0104), second only to the lymphoid cell density. Also the total number of AgNORs was a prognostic indicator. This suggests that AgNOR size and ratio reflect tumor proliferation also in cervical squamous cell carcinoma, as shown in other human malignancies. Similarly, the density of cancer cell nuclei proved to be an independent prognostic predictor (p = 0.0601) in that the tumours in patients with longer survival showed lower density of the nuclei.(ABSTRACT TRUNCATED AT 250 WORDS)

DNA cytometry in postirradiation cervical-vaginal smears

Benign radiation change (BRC) in cervical-vaginal smears may be difficult to distinguish from postirradiation dysplasia (PRD) or recurrent cervical carcinoma. The utility of DNA analysis in postirradiation smears was evaluated retrospectively in 71 patients. Representative Papanicolaou smears were restained with a Feulgen method and 100 to 250 cells were analyzed for DNA content using the CAS 200 image analysis system. Thirty-three control irradiated patients had negative smears with a minimum 3-year follow-up. Thirty controls (91%) had diploid histograms with a mean coefficient of variation of 8.2% and an average of 6.8% of cells in S and G2/M phase. Three control patients had atypical nondiagnostic histograms. Twenty-three patients had abnormal smears and subsequent local recurrence; 21 (91%) had abnormal histograms, with seven showing polyploidy and 14 showing aneuploidy. The remaining 15 patients had abnormal smears diagnosed as PRD but no evidence of recurrent carcinoma. Five were polyploid, six were aneuploid, one was diploid, and three were atypical but nondiagnostic. Interactive DNA cytometry is useful in differentiating BRC from PRD and recurrent cancer. Aneuploidy is rarely, if ever, seen in negative smears with BRC. However, BRC may be associated with broad diploid peaks and increased proliferating cells. An abnormal histogram can be seen with PRD and does not always correlate with recurrent disease.

Flow-cytometric DNA analysis of stages IB and IIA cervical carcinoma

The prognostic significance of flow-cytometric DNA analysis was assessed in 375 stages IB and IIA squamous cell carcinoma patients treated with radical hysterectomy and lymphadenectomy at the Mayo Clinic between 1956 and 1985. Paraffin-embedded samples containing at least 20% tumor were dewaxed, rehydrated, stained with propidium iodide, and analyzed. Among 344 assessable samples, 136 (40%) were diploid and 208 (60%) were nondiploid (26 tetraploid, 158 aneuploid, and 24 polyploid). Diploid cases were further subclassified: 25 high proliferative phase (HPP) (S+G2M greater than 20%) and 111 low proliferative phase. No significant correlation was noted between DNA diploid patterns and stage, tumor size, grade, or histotype, but HPP diploid tumors had a significantly higher risk of nodal metastasis. With a mean follow-up period of 150 months, 62 patients died of disease. No significant difference was observed in survival rates (SR) between diploid and nondiploid tumors, but the subset of HPP diploid tumors had a prognosis significantly worse than that of any other group (P less than 0.01). Other significant variables included nodal metastases, parametrial extension, age, and clinical stage. While ploidy patterns did not assign additional risk to node-positive lesions, HPP diploid tumors in node-negative patients were associated with a significantly lower SR. Multivariate analyses in node-negative patients demonstrated that stage, histologic subtype, and HPP diploid patterns retained prognostic independence.

Immunohistochemical assessment of the growth fraction in cervical cancers using the monoclonal antibody Ki-67; relationship to the clinical stage, histologic type and DNA content

To assess the growth potential of cervical cancer, cell populations in proliferating cycle (%PC) were examined by an immunohistochemical technique using the monoclonal antibody Ki-67. The %PC was 31.63 +/- 16.61% in 36 cervical cancers and was significantly higher when compared to the 7.8 +/- 3.81% found in 24 samples of normal ectocervical tissues. In cervical cancer tissues, the %PC increased in accordance with progression of the clinical stage of the disease, however, the %PC was not different among the various histologic types of invasive cervical cancers. The DNA index also increased in accordance with progression of the clinical stage of cervical cancer, however, there was no correlation between the %PC and the DNA index. These results suggest that the value of %PC obtained using the monoclonal antibody Ki-67 can be used as a parameter for evaluating the growth activity of cervical cancer and for predicting biological heterogeneity in a tumor.

Prognostic value of flow cytophotometric DNA content analysis in single treatment stage IB-IIA squamous cell carcinoma of the cervix

DNA content was measured flow cytometrically in archival tissue from 65 single-treatment stage IB and IIA squamous cell carcinomas of the cervix with at least 5 years of clinical follow-up. Thirty-five cases were treated exclusively by hysterectomy and thirty exclusively by radiation therapy. Tumors were categorized into four groups on the basis of DNA content and cell cycle distribution. DNA content was measured relative to the position of the first resolvable cell peak. G2/M and S-phase fractions were estimated as percentage of cells with DNA contents greater than or equal to relative position 1.70 and percentage of cells with relative positions between 1.20 and 1.70, respectively. The 40 tumors characterized as either aneuploid or nondemonstrably aneuploid with high S-phase fraction estimate had a 5-year recurrence rate significantly higher than that of the 25 tumors categorized as tetraploid or nondemonstrably aneuploid with low S-phase fraction estimate (52 and 4%, respectively; chi 2 = 15.8, P less than 0.001). Similar results were found when radiation and surgically treated tumors were considered independently (chi 2 = 7.95, P less than 0.005 and chi 2 = 5.7, P less than 0.025, respectively). These data suggest that an increased 5-year recurrence rate is associated with both abnormal DNA content and elevated S-phase fraction in stage IB-IIA squamous cell carcinoma of the cervix, and that this relationship is largely independent of treatment method.

Small cell carcinoma of the cervix: a clinical and flow-cytometric study

The clinical course of 14 patients diagnosed with small cell carcinoma of the cervix (SCC) was reviewed and compared to that of 37 cases of undifferentiated large cell nonkeratonizing carcinoma (LCNK). We observed the following differences between the two: SCC patients had a higher incidence of pelvic wall involvement and distant metastasis; the development of progressive disease was more frequent in SCC than in LCNK patients; median survival time was 9 months in SCC and 40 months in LCNK patients; flow cytometry revealed aneuploidy in all SCC and in 30% of the LCNK patients; the mean DNA index was 2.24 in SCC, significantly higher than in LCNK (1.15). DNA index in cases of SCC was related to survival time. SCC of the cervix is an extremely aggressive tumor, even when compared to other undifferentiated cervical cancers. Aneuploidy is a consistent feature and thus helpful for diagnosis. Due to the wide range of values, the DNA index cannot be used for diagnostic purposes, but it is of prognostic importance in SCC cases.

Prognostic significance of human papillomavirus (HPV) type and nuclear DNA content in invasive cervical cancer

Eighty-one women treated for an invasive squamous cell carcinoma of the uterine cervix during the period from 1964 to 1987 were studied to assess the prognostic value of human papillomavirus (HPV) types 6,11, 16 and 18, as well as the nuclear DNA ploidy pattern, analyzed using HPV amplification by polymerase chain reaction (PCR) and flow cytometry, respectively. The mean age of the women was 57.7 ± 13.4 years, and the mean follow-up until the patients death or January 1990 was 99 ± 87 months. Altogether, 46 women died; 38 (82.6%) of these deaths were due to cervical cancer. The 5-year survival was significantly correlated with age (P= 0.01), and the FIGO stage of the tumors (P= 0.015), but not with tumor differentiation. Diploid tumor was found in 40 (63.5%) cases, and aneuploid in 23 (36.5%) cases. A DNA index 3= 1.5 was found in 47.8% (11/23) of the cases of aneuploid tumors. The 5-year survival rate in diploid tumors was 60.0% (21/35), as compared to 54.5% (12/22) in aneuploid ones, and in patients with a DNA index of < 1.5, the 5-year survival rate was 58.7% (27/46), as compared to 54.5% (6/11) in those with a DNA index ≥ 1.5. Amplified HPV DNA was found in 30 cases (37.0%) with the pairs of HPV DNA primers for HPV types of 6, 11, 16 and 18. When repeated with the anticontamination primers, only 19 (23.5%) cases remained HPV DNA positive. HPV 16 was the most frequent type present in 57.9% (11/19) of the cases, followed by HPV 18 in 36.8% (7/19). Neither the HPV DNA-positivity nor HPV type proved to be of prognostic significance. The results suggest that despite an intimate association of HPV 16 and 18 in cervical carcinogenesis, the presence of their DNA in cancer biopsies does not seem to have any prognostic value. The most significant prognostic factors are still the age and the FIGO stage at diagnosis. Aneuploid tumors or those with DNA index ≥ 1.5 seem to have a slightly (not statistically significantly) impaired prognosis as compared with the diploid tumors and those with DNA index < 1.5.

DNA ploidy level as prognostic factor in low stage carcinoma of the uterine cervix

Flow cytometry was used to measure DNA content of tumor cells in paraffin-embedded archival material from 89 patients with squamous cell carcinoma of the cervix uteri stages IB and IIA. Patients were all treated with radical hysterectomy and transperitoneal lymphadenectomy. Twenty-four percent received radiotherapy postoperatively because of tumor spread into parametria or positive lymph nodes. Ploidy grade was compared to other prognostic factors. DNA-aneuploidy was seen in 44 (49%), DNA-diploidy in 16 (18%) and 29 (33%) of the tumors were DNA-periploid. Sixty-nine (78%) patients were in FIGO stage IB, 20 (22%) in IIA. In 19 (21%) lymph node metastases were found, vasoinvasion in 25 (28%). Overall disease-specific 5-year survival was 80%. There was a significant effect of positive lymph nodes (90% vs 47%) and vasoinvasion (87% vs 64%) on the 5-year survival (resp. P less than 0.01 and P = 0.02). No correlation was found between stage (81% for IB vs 80% for IIA) or DNA-ploidy grade (81% for aneuploidy, 82% for periploidy, 79% for diploidy) and survival (resp. P = 0.9 and P = 0.8). Ploidy grade was equally divided over other prognostic factors. In stepwise Cox regression analysis DNA-ploidy grade showed no independent effect on survival. We conclude that DNA flow cytometry in this material was of no additional prognostic value.

Flow cytometric evaluation of epithelial ovarian cancer

We investigated the prognostic significance of deoxyribonucleic acid content and proliferative activity of tumor cell populations as measured by flow cytometry of the tumor specimens from 115 women with epithelial ovarian cancer. Deoxyribonucleic acid aneuploidy was found in 87 of 115 (76%) of these cancers with a mean deoxyribonucleic acid index of 1.6 and S-phase fraction of 14.7%. The S-phase fraction of the 28 (24%) diploid tumors was 7.0%. Deoxyribonucleic acid ploidy was significantly correlated with survival. S-phase fraction was significantly correlated with ploidy, residual tumor, histology, grade, ascites, time to recurrence, and survival. Diploidy versus aneuploidy were the best discriminating values for deoxyribonucleic acid index and an S-phase fraction of greater or less than 18% for that parameter. Multivariate analysis revealed stage, S-phase fraction, residual tumor, and grade to be independently associated with time to recurrence, and stage, age, S-phase fraction, and largest metastases were factors associated with survival. Deoxyribonucleic acid ploidy did not significantly improve either model. These results suggest that abnormalities of deoxyribonucleic acid content and the proliferative activity of tumor cell populations are reflective of their biologic activity.