Apoptosis in cervical squamous carcinoma: predictive value for survival following radiotherapy

Prognostic cell biological markers in cervical cancer patients primarily treated with (chemo)radiation: a systematic review

The aim of this study was to systematically review the prognostic and predictive significance of cell biological markers in cervical cancer patients primarily treated with (chemo)radiation. A PubMed, Embase, and Cochrane literature search was performed. Studies describing a relation between a cell biological marker and survival in ≥50 cervical cancer patients primarily treated with (chemo)radiation were selected. Study quality was assessed, and studies with a quality score of 4 or lower were excluded. Cell biological markers were clustered on biological function, and the prognostic and predictive significance of these markers was described. In total, 42 studies concerning 82 cell biological markers were included in this systematic review. In addition to cyclooxygenase-2 (COX-2) and serum squamous cell carcinoma antigen (SCC-ag) levels, markers associated with poor prognosis were involved in epidermal growth factor receptor (EGFR) signaling (EGFR and C-erbB-2) and in angiogenesis and hypoxia (carbonic anhydrase 9 and hypoxia-inducible factor-1α). Epidermal growth factor receptor and C-erbB-2 were also associated with poor response to (chemo)radiation. In conclusion, EGFR signaling is associated with poor prognosis and response to therapy in cervical cancer patients primarily treated with (chemo)radiation, whereas markers involved in angiogenesis and hypoxia, COX-2, and serum SCC-ag levels are associated with a poor prognosis. Therefore, targeting these pathways in combination with chemoradiation may improve survival in advanced-stage cervical cancer patients.

hCG beta expression by cervical squamous carcinoma--in vivo histological association with tumour invasion and apoptosis

AIMS

To investigate the correlation of beta-subunit of human chorionic gonadotrophin (hCG beta) expression by cervical carcinomas with measures of tumour apoptosis.

METHODS AND RESULTS

Eighty-nine cervical carcinoma patients' samples were subject to hCG beta immunohistochemistry and scored with respect to intensity of immunopositivity and percentage of positive cells. Apoptosis was evaluated by three independent parameters: morphological characteristics [haematoxylin and eosin (H&E)], terminal deoxynucleotidyl transferase biotin-dUTP nick end labelling (TUNEL) and poly (ADP-ribose) polymerase (PARP) immunopositivity. Of the 12 adenocarcinomas, only one (8%) was hCG beta+. However, 87% (61/70) of the squamous cell and 100% (7/7) of adenosquamous cell carcinomas were hCG beta+. hCG beta reactivity and intensity was predominantly confined to peripheral tumour cells at the stromal-epithelial interface. Correlation analysis showed that H&E and PARP apoptotic immunopositivity negatively correlated with hCG beta expression (P < 0.001 and P = 0.028 respectively), whereas TUNEL did not (P = 0.12). However, immunopositivity for apoptotic cells by TUNEL was significantly less in tumours where hCG beta expression was greater (scoring >or= 6) and vice versa. hCG beta immunopositivity was also observed in newly formed blood vessels, as well as tumour cells within lymphatic vessels. When tumour vascularization was taken into account, samples with noted vascularization positively correlated with hCG beta scoring.

CONCLUSIONS

hCG beta expression correlates with reduced tumour cell apoptosis and may be involved in tumour vascularization and dissemination.

Radiation Therapy Induced Changes in Apoptosis and Its Major Regulatory Proteins, Bcl-2, Bcl-XL, and Bax, in Locally Advanced Invasive Squamous Cell Carcinoma of the Cervix

BACKGROUND AND PURPOSE

Radiation therapy (RT) for cancer induces cell death by apoptosis. The major apoptotic regulatory molecules include Bcl-2, Bcl-XL (antiapoptotic), and Bax (proapoptotic) proteins. Invasive squamous cell carcinoma of the cervix is mainly treated by radiation, and hence our aim was to evaluate the changes induced by RT in the apoptotic index (AI) and to correlate this to the levels of the major pro- and antiapoptotic molecules.

MATERIALS AND METHODS

Paired biopsies were obtained in 30 cases of invasive carcinoma cervix before and after 10 Gy RT. The TUNEL assay was performed to detect apoptotic nuclei and Bcl-2, Bcl-XL, and Bax proteins detected by immunohistochemistry (IHC). Statistical analysis was performed using the Spearman rank correlation coefficient test.

RESULTS

Following RT, there was a significant increase in the mean AI [2.25 (+/-2.28) in post-RT vs 0.90 (+/-0.53) in the pre-RT group]. Bax, a major proapoptotic protein, was significantly increased following RT (P < 0.05), whereas the antiapoptotic Bcl-XL showed a significant decrease (P = 0.006). There was no significant change in Bcl-2 expression. The Bcl-2 and Bax IHC scores and the Bcl-2/Bax ratio did not correlate with AI in the 2 groups. There was an inverse correlation of Bcl-XL to AI in the pre-RT group (P = 0.003) but not in the post-RT group.

CONCLUSIONS

RT for invasive squamous cell carcinoma of cervix results in increased apoptotic cell death with the up-regulation of Bax, a proapoptotic protein, and the down-regulation of Bcl-XL, an antiapoptotic protein, without any significant change in the levels of Bcl-2.

Markers of apoptosis in stage IB squamous cervical carcinoma

AIMS

To examine the prognostic relevance of the expression of the Bcl-2, Bcl-xL, and Bax proteins in stage IB squamous cervical carcinoma (SCC).

METHODS

In total, 220 patients who underwent radical hysterectomy and bilateral lymphadenectomy at the Norwegian Radium Hospital for stage IB SCC between 1987 and 1993 were studied. Immunohistochemistry using monoclonal antibodies against Bcl-2, Bcl-xL, and Bax was used to examine protein expression. Ten patients who underwent hysterectomy for uterine prolapse served as controls.

RESULTS

Cytoplasmic expression of Bcl-2, Bcl-xL, and Bax was low (< 5% positive cells) in 159 of 220 (73%), 193 of 220 (87%), and 39 of 220 (18%) tumours, respectively, and high (> or = 5% positive cells) in 61 of 220 (27%), 27 of 220 (13%), and 181 of 220 (82%) tumours, respectively. In univariate analysis, all classic clinicopathological parameters but none of the investigated proteins were associated with prognosis. In multivariate analysis, only deep stromal invasion was independently related to survival.

CONCLUSION

Bcl-2, Bcl-xL, and Bax were not independently associated with prognosis in stage IB SCC.

Pathology of the cervix: recent developments

In the UK, cervical carcinoma is still the eleventh most common cause of cancer in women--it comprises 2% of all female cancers, and accounts for 927 deaths in 2002 alone. The most effective treatments to date are surgery in the form of loop excision of the transformation zone (LLETZ) for pre-invasive disease, LLETZ or simple hysterectomy with laparoscopic pelvic lymphadenectomy for International Federation of Gynecology and Obstetrics (FIGO) Stages IA1 and IA2 microinvasive carcinomas, and Wertheim's hysterectomy or Coelio-Schauta for FIGO Stage IB disease along with concurrent chemoradiotherapy in patents with at least FIGO Stage IB disease. However, radical trachelectomy, which involves a radical excision of the cervix with simultaneous laparoscopic or extraperitoneal lymphadenectomy, may be used selectively in patients with up to FIGO Stage IB1 cancers, as this may preserve fertility in younger women. This paper briefly discusses the role of human papilloma viruses (HPV) and human immunodeficiency virus (HIV) in the development of cervical pre-cancer, and some of the improvements in the techniques used in the cervical carcinoma screening programme. In addition, the diagnosis, staging, spread and prognostic factors involved in invasive cervical carcinoma are mentioned. We will also discuss the role of immunohistochemistry in the diagnosis of invasive cervical carcinoma and recent advances in the molecular pathology of cervical carcinomas.

Proliferation to apoptosis ratio as a prognostic marker in adenocarcinoma of uterine cervix

OBJECTIVES

To determine the Mitotic Index (MI), Apoptotic Index (AI), the ratio of the two indices (MI/AI) in normal endocervical glands, adenocarcinoma in situ (AIS) and invasive adenocarcinoma of cervix, and to evaluate the relationship among these indices with various clinicopathological features.

METHODS

The MI, AI and MI/AI ratio in cervical adenocarcinoma were evaluated based on: (1) cell morphology in hematoxylin and eosin-stained sections; (2) immunohistochemical study for Ki67 antigen and terminal deoxynucleotidyl transferase (TdT)-mediated dUTP nick end labeling (TUNEL). Eighty cases of invasive adenocarcinoma and eighteen cases of adenocarcinoma in situ (AIS) adjacent to invasive adenocarcinoma were included. Adjacent normal endocervical epithelium in 26 cases of adenocarcinoma was included as control.

RESULTS

The MI, AI and MI/AI in normal endocervical glands, AIS and invasive carcinomas showed statistically significant differences (P<0.001). A significant positive correlation was found between AI and MI, as assessed by morphological features (P<0.001) and immunohistochemistry (P=0.006). The MI/AI ratio, determined by morphology, significantly correlated with staging (P=0.023) and survival (P=0.0045). Multivariate survival analysis showed that both MI/AI ratio determined by morphology (P<0.001) and stage of tumor (P=0.03) had independent prognostic value in invasive adenocarcinoma.

CONCLUSIONS

Tumor proliferation significantly correlated with apoptotic activity in cervical adenocarcinoma. The MI/AI ratio was an independent prognostic factor associated with patient survival. Histological determination of MI/AI ratio proved to be an economical and potentially useful adjunct in predicting clinical outcome of patients with cervical adenocarcinoma.

The prognostic relevance of apoptosis-related proteins in classical Hodgkin's lymphomas

Neoplastic cells in classical Hodgkin's lymphomas (cHL) seem to correspond to defective germinal center B-cells, which escape from apoptosis. Epstein-Barr virus (EBV) may be implicated in this protective mechanism. The aim of the present study was to determine the expression of apoptosis-related proteins in cHL among adult patients and correlate them with EBV expression, clinical findings and survival. EBV was detected by in situ hybridization (Epstein-Barr Encoded RNA, EBER, probe). Immunohistochemistry was used on paraffin sections to detect LMP-1/EBV, CD15 and the apoptosis-related proteins (bcl-2, bax, bcl-X, mcl-1 and CD95). Seventy-eight patients seen at our Institution were studied: 36 male and 42 female. Median age was 31 years (15-75 years). Histological types of cHL were: 61 nodular sclerosis (47 NS1 and 14 NS2), 15 mixed cellularity (MC), 1 lymphocyte depletion and 1 unclassified. In 50 cases there was EBV expression (64%). At least one apoptosis-associated protein was expressed in 92% and CD15 in 57.7% of the cases. In the univariate analysis, the following variables were related to a better overall survival: expression of CD15 (p = 0.023), expression of mcl-1 protein (p = 0.029), expression of bcl-2 protein (p = 0.028, only in a Cox model after stratification for histology) and expression of LMP-1 (p = 0.042). EBV expression presented a borderline inverse correlation with bcl-2. A prognostic index (PI) developed in the present study revealed that simultaneous expression of bcl-2, mcl-1 and LMP-1 was significant and independently correlated with an excellent survival.

Evaluation of p53 and Bcl-2 expression as prognostic markers in invasive cervical carcinoma stage IIb/III patients treated by radiotherapy

OBJECTIVE

The objective was to evaluate the immunohistochemical expression of p53 and Bcl-2 proteins as prognostic markers in locally advanced [FIGO Stage IIb/III] invasive squamous cell carcinoma of the uterine cervix. It was also our aim to determine if they had any relationship to each other and to the pretreatment levels of apoptosis determined morphologically.

METHODS

Seventy-six consecutive cases of invasive squamous cell carcinoma of the cervix diagnosed in 1995 were analyzed retrospectively for the apoptotic index and p53 and Bcl-2 expression determined immunohistochemically and correlated to the patient outcome at the end of a 5-year follow-up period.

RESULTS

The overall cumulative 5-year survival was 52.63%. p53 immunoreactivity was seen in 53.9% cases with variable levels of expression. By univariate analysis, p53 positivity correlated with poor survival [chi-square P = 0.029; log-rank test P = 0.0468] but not upon multivariate analysis. The apoptotic index which ranged from 0 to 40 and Bcl-2 expression seen in 38.1% cases showed no correlation to survival. Neither p53 nor Bcl-2 expression correlated with the apoptotic index or with each other. Seven cases with the immunophenotype p53-/Bcl-2+ had an excellent survival.

CONCLUSIONS

Neither p53 nor Bcl-2 expression are independent predictors of prognosis in locally advanced cervical squamous cancers. However, evaluation of their combined expression may affect clinical outcome and needs further investigation.

Association between high initial tissue levels of cyclin d1 and recurrence of nasopharyngeal carcinoma

OBJECTIVES/HYPOTHESIS

Cyclin D1 expression and the rate of apoptosis have been reported to serve as important prognostic indicators in human cancers. The purpose of the present study was to determine the prognostic significance of both initial cyclin D1 expression and the apoptotic index in nasopharyngeal carcinoma.

STUDY DESIGN

Cohort study.

METHODS

Cyclin D1 protein levels and apoptosis in tumors and their corresponding adjacent, histologically normal tissues were determined at the time of initial diagnosis using immunohistochemical staining, Western blot analysis, and in situ end labeling, respectively, in 64 patients with T1-T4/N0-N2, poorly differentiated squamous cell carcinoma of the nasopharynx. All cases were treated by routine radiation therapy with a total median dose of 70 Gy and followed up for 10 years.

RESULTS

High levels of cyclin D1 were found in 35 of 64 tumor specimens (54.7%); no cyclin D1--positive cells were determinable in normal epithelium of the nasopharynx. Rates of early local recurrence (within 5 y) were significantly higher (P <.01) for patients with high levels of cyclin D1 before radiation therapy (24 of 35 patients [68.6%]) as compared with patients with low or no expression (3 of 29 [10.3%]). Furthermore, patients bearing high levels of cyclin D1 had a poorer prognosis concerning 10-year survival than the others (P <.001), whereas overexpression of cyclin D1 did not correlate with the initial TMN classification (P >.05). According to the rate of spontaneous apoptosis in tumors below or above the median, patients were divided into two groups. There was no statistically significant difference for the overall survival between the two groups (P >.05).

CONCLUSIONS

The present study demonstrates that cyclin D1 can be used as an indicator of recurrence and subsequent prognosis in nasopharyngeal carcinoma after radiation therapy. At the same time, the apoptotic state before radiation therapy is of no value in predicting the prognosis of patients with nasopharyngeal carcinoma.

Tumor apoptosis in cervical cancer: its role as a prognostic factor in 42 radiotherapy patients

To investigate tumor apoptosis as a prognostic factor for outcome following radiation therapy, comparisons were made of apoptotic index (AI) as a predictor of short- vs. long-term response and pretreatment vs. radiation-induced apoptosis. Forty-two patients with proven squamous cell carcinoma of the uterine cervix were treated by radiation alone. Apoptosis was measured by light microscopic observation of hematoxylin and eosin-stained sections from biopsies taken before treatment and 4 and 24 hr after 2 Gy. Patients were evaluated at the end of the external radiation for determination of short-term response and for long-term outcome as well (median follow-up of 27 months). Patients with high spontaneous AI showed poor short-term response, local control, and survival. The significance of AI as a predictor of short-term response was lost after allowing for differences in tumor size. The positive predictive value of AI for local control and survival was independent of tumor size and stage. High AI was associated with poor local control and long-term prognosis in advanced squamous cell carcinoma of the cervix. The in vivo radiation-induced AI after 4 or 24 hr did not predict radiation therapy outcome.

Expression of Bax and apoptosis-related proteins in human esophageal squamous cell carcinoma including dysplasia

The rate of tumor growth depends on the balance between proliferation and death of tumor cells. It is known that Bax, caspase-3, and p53 proteins are death-promoting factors, whereas Bcl-2 protein is a death antagonist. We immunohistochemically examined the expression of Bax and apoptosis-related proteins such as caspase-3, p53, and Bcl-2 in 76 patients with human esophageal squamous cell carcinoma (SCC) including dysplasia to determine the relationship of expression of each protein to tumor behavior and patients' prognosis. No significant relationships in immunopositivity were found among these proteins in SCCs. Cytoplasmic Bax expression was exhibited in 63 cases of SCCs (82.9%). The apoptotic index of caspase-3-positive lesions was significantly higher than that of caspase-3-negative lesions in both dysplasia and SCC (P =.016, P =.012). On the other hand, the apoptotic index (1.18%) was significantly correlated with Bax overexpression in dysplasia (P =.006), but not in SCC lesions (P =.129). The patients with Bax-positive SCCs were found to have a poor prognosis by the Kaplan-Meier method (P =.043). These findings suggested that Bax expressed in dysplasia may play a role as an apoptotic factor, but that it may be functionally inactive in some cancerous lesions and thus not contribute to suppression of the tumor progression in some cases of human esophageal SCCs.