Cathepsin D expression detected by immunohistochemistry has independent prognostic value in axillary node-negative breast cancer

Prognostic role of high cathepsin D expression in breast cancer: a systematic review and meta-analysis

Background:

High cathepsin D has been associated with poor prognosis in breast cancer; however, the results of many studies are controversial. Here, we assessed the association between high cathepsin D levels and worse breast cancer prognosis by conducting a meta-analysis.

Methods:

A comprehensive search strategy was used to search relevant literature in PUBMED and EMBASE by September 2018. The meta-analysis was performed in Review Manager 5.3 using hazard ratios (HRs) with 95% confidence intervals (CIs).

Results:

A total of 15,355 breast cancer patients from 26 eligible studies were included in this meta-analysis. Significant associations between elevated high cathepsin D and poor overall survival (OS) (HR = 1.61, 95% CI: 1.35–1.92, p < 0.0001) and disease-free survival (DFS) (HR = 1.52, 95% CI: 1.31–2.18, p < 0.001) were observed. In the subgroup analysis for DFS, high cathepsin D was significantly associated with poor prognosis in node-positive patients (HR = 1.38, 95% CI: 1.25–1.71, p < 0.00001), node-negative patients (HR = 1.78, 95% CI: 1.39–2.27, p < 0.0001), early stage patients (HR = 1.73, 95% CI: 1.34–2.23, p < 0.0001), and treated with chemotherapy patients (HR = 1.60, 95% CI: 1.21–2.12, p < 0.001). Interestingly, patients treated with tamoxifen had a low risk of relapse when their cathepsin D levels were high (HR = 0.71, 95% CI: 0.52–0.98, p = 0.04) and a high risk of relapse when their cathepsin D levels were low (HR = 1.50, 95% CI: 1.22–1.85, p = 0.0001).

Conclusions:

Our meta-analysis suggests that high expression levels of cathepsin D are associated with a poor prognosis in breast cancer. Based on our subgroup analysis, we believe that cathepsin D can act as a marker for poor breast cancer prognosis and also as a therapeutic target for breast cancer.

PTHrP, A Biomarker for CNS Metastasis in Triple-Negative Breast Cancer and Selection for Adjuvant Chemotherapy in Node-Negative Disease

Background

Triple-negative breast cancer (TNBC) is characterized by poor prognosis and lack of targeted therapies and biomarkers to guide decisions on adjuvant chemotherapy. Parathyroid hormone-related protein (PTHrP) is frequently overexpressed in breast cancer and involved in proliferation and metastasis, two hallmarks of poor prognosis for node-negative breast cancer. We investigated the prognostic value of PTHrP with respect to organ-specific metastasis and nodal status in TNBC.

Methods

We assessed PTHrP expression using immunohistochemistry in a clinically annotated tissue microarray for a population-based study of 314 patients newly diagnosed with TNBC, then analyzed its correlation to progression and survival using Kaplan-Meier and Cox regression analyses. The Cancer Genome Atlas (TCGA) validation analysis was performed through Bioconductor. All statistical tests were two-sided.

Results

PTHrP overexpression (160 of 290 scorable cases, 55.2%) was statistically significantly associated in univariate analysis with decreased overall survival (OS) in our cohort (P = .0055) and The Cancer Genome Atlas (P = .0018) and decreased central nervous system (CNS)-progression-free survival (P = .0029). In multivariate analysis, PTHrP was a statistically significant independent prognostic factor for CNS-progression-free survival in TNBC (hazard ratio [HR] = 5.014, 95% confidence interval [CI] = 1.421 to 17.692, P = .0122) and for OS selectively in node-negative TNBC (HR = 2.423, 95% CI = 1.129 to 5.197, P = .0231). Strikingly, PTHrP emerged as the only statistically significant prognostic factor (HR = 2.576, 95% CI = 1.019 to 6.513, P = .0456) for OS of low-clinical risk node-negative patients who did not receive adjuvant chemotherapy.

Conclusions

PTHrP is a novel independent prognostic factor for CNS metastasis and adjuvant chemotherapy selection of low-clinical risk node-negative TNBC. Its predictive value needs to be prospectively assessed in clinical trials.

p53, cathepsin D, Bcl-2 are joint prognostic indicators of breast cancer metastatic spreading

Background

Traditional prognostic indicators of breast cancer, i.e. lymph node diffusion, tumor size, grading and estrogen receptor expression, are inadequate predictors of metastatic relapse. Thus, additional prognostic parameters appear urgently needed. Individual oncogenic determinants have largely failed in this endeavour. Only a few individual tumor growth drivers, e.g. mutated p53, Her-2, E-cadherin, Trops, did reach some prognostic/predictive power in clinical settings. As multiple factors are required to drive solid tumor progression, clusters of such determinants were expected to become stronger indicators of tumor aggressiveness and malignant progression than individual parameters. To identify such prognostic clusters, we went on to coordinately analyse molecular and histopathological determinants of tumor progression of post-menopausal breast cancers in the framework of a multi-institutional case series/case-control study.

Methods

A multi-institutional series of 217 breast cancer cases was analyzed. Twenty six cases (12 %) showed disease relapse during follow-up. Relapsed cases were matched with a set of control patients by tumor diameter, pathological stage, tumor histotype, age, hormone receptors and grading. Histopathological and molecular determinants of tumor development and aggressiveness were then analyzed in relapsed versus non-relapsed cases. Stepwise analyses and model structure fitness assessments were carried out to identify clusters of molecular alterations with differential impact on metastatic relapse.

Results

p53, Bcl-2 and cathepsin D were shown to be coordinately associated with unique levels of relative risk for disease relapse. As many Ras downstream targets, among them matrix metalloproteases, are synergistically upregulated by mutated p53, whole-exon sequence analyses were performed for TP53, Ki-RAS and Ha-RAS, and findings were correlated with clinical phenotypes. Notably, TP53 insertion/deletion mutations were only detected in relapsed cases. Correspondingly, Ha-RAS missense oncogenic mutations were only found in a subgroup of relapsing tumors.

Conclusions

We have identified clusters of specific molecular alterations that greatly improve prognostic assessment with respect to singularly-analysed indicators. The combined analysis of these multiple tumor-relapse risk factors promises to become a powerful approach to identify patients subgroups with unfavourable disease outcome.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2713-3) contains supplementary material, which is available to authorized users.

Proteases as prognostic markers in human and canine cancers

The extracellular matrix (ECM) is composed of several types of proteins, which interact and form dynamic networks. These components can modulate cell behaviour and actively influence the growth and differentiation of tissues. ECM is also important in several pathological processes, such as cancer invasion and metastasis, by creating favourable microenvironments. Proteolysis in neoplastic tissues is mediated by proteinases, whose regulation involves complex interactions between neoplastic cells and non-neoplastic stromal cells. In this review, we discuss aspects of proteinase expression and tumor behaviour in humans and dogs. Different classes of proteases are summarized, with special emphasis being placed on molecules that have been shown to correlate with prognosis, reinforcing the need for a better understanding of the regulation of this microenvironment and its influences in tumor progression and metastasis, which should significantly aid the development of improved prognosis and treatment.

Expression of cathepsin D and E-cadherin in primary laryngeal cancers correlation with neck lymph node involvement

OBJECTIVE

The aim of this study was to investigate the relation between Cathepsin D (Cath-D) and E-Cadherin (E-Cad) expression levels in tumor tissue and neck lymph node metastasis. This attempt should be made to identify new factors that one could be useful in predicting clinical behavior.

STUDY DESIGN

In this study, we investigated rates of dying for E-Cad and Cath-D in paraphin blocks of larynx and neck dissection specimens taken from 56 selected patients. Laryngeal specimens dyed by ECad and Cath-D immunohistochemically. Immunoreactivity classified for E-Cad as positive (75% and above), reduced (25-75%) and negative (below 25%). Immunoreactivity classified for Cath-D:dye absorption rates higher than 50% evaluated positive and absorption rates lower than 50% evaluated negative. We compared the rates of dying for E-Cad and Cath-D groups to with or without neck lymph node metastasis in specimens.

RESULTS

Neck metastasis were found in 41% of patients, in 55.6% of patients, if the E-Cad was negative, 40.6% if it was reduced, 33.3% if it was positive in specimens. The neck metastasis was found in 35.4% of patients with Cath-D expression negative, while 75% of patients was found with Cath-D expression positive.

CONCLUSION

Neck metastasis was found higher in E-Cad reduced group than positive group. Neck node metastasis was significantly higher in Cath-D positive group than Cath-D negative group. Cath-D and E-Cad essays may useful in identifying neck lymph node involvement. Cath-D expression levels are more in this predictive factor than E-Cad levels for possibility of neck lymph node metastasis in LSCC.

Reevaluating cathepsin D as a biomarker for breast cancer: serum activity levels versus histopathology

Cathepsin D is a lysosomal hydrolase involved in intra- and extracellular proteolysis. This enzyme is aberrantly produced and processed in malignancy, and most notably is over-secreted into the tumor cell microenvironment. This hyper-secretion may lead to excessive degradation of the extracellular matrix, and contribute to tumor progression and metastases. These phenomena have been established in vitro, and there is evidence that Cathepsin D is similarly dysregulated in human breast cancer patients. Because breast cancer lacks an effective screening or surveillance biomarker, here we address the hypothesis that serum Cathepsin D activity may be useful to assess the presence or progression of breast cancer in females. While representative histologic sections from various disease-specific cohorts confirm previous findings that increased Cathepsin D production and secretion correlate with tumor progression, we report no difference in serum Cathepsin D activity between patients who are disease free, patients with pre-invasive or limited invasive disease, and patients with metastatic disease. Furthermore, in patients with known metastatic disease, there were no clinical variables associated with significantly different serum Cathepsin D activity. However, the immunohistochemical localization of Cathepsin D expression in histopathologic sections from breast cancer patients correlates with disease progression. Based on the serum results, and in contradistinction to Cathepsin D localization in breast cancer tissues, our findings support using Cathepsin D as a reliable histopathology biomarker for disease progression, but not for serum screening.

Expression of bcl-2 in breast cancer: correlation with clinicopathological characteristics and survival

Breast cancer is the most common malignancy in women. It is an immensely heterogeneous disease, characterised by a broad variety of clinical development. The research in recent years has focused on finding new markers of prognosis. This study investigates the role of expression of the bcl-2 protein in breast cancer. We analysed bcl-2 expression in 57 women with primary breast carcinoma who were treated with neoadjuvant (primary) chemotherapy, followed by a surgical procedure. The bcl-2 expression was correlated with other clinicopathological characteristics of the tumour- histological grade, stage, expression of hormonal receptors, proliferation rate, and with the survival of the patients. No significant association of bcl-2 expression with either overall survival or disease free survival was found.

Expression of cathepsin D and galectin 3 in tubular carcinomas of the breast

Tubular carcinoma (TC) is a distinctive type of grade I (G1) ductal carcinoma with particularly favourable outcome and low rate of axillary metastases. To the best of our knowledge, few data are available in the literature concerning the expression of molecules mediating intercellular and cell-matrix interactions in TC. We examined with immunohistochemical methods the expression of galectin 3 and cathepsin D in 17 TC and in 33, 31 and 28 ductal carcinomas of G1, grade II (G2) and grade III (G3), respectively. Results were compared using Chi-square test. Galectin 3 expression was higher in TC than in G1 carcinomas (p<0.05). The pattern of immunostaining was also different with a focal cytoplasmic apical reinforcement in TC. However, cathepsin D stromal and epithelial expression was similar in TC and G1 cases (p>0.05), and lower than in G2 and G3 patients at a stromal level. The higher expression of galectin 3 in TC and its focal staining (apical) pattern suggests that within the group of G1 carcinomas, galectin 3 expression varies according to histological type, and may correlate with prognosis and metastatic potential. We also suggest that cathepsin D could not be involved in neoplastic progression and metastasis in low-grade (G1) ductal breast carcinomas.

Cathepsin D serum levels are not a valid serum marker in renal cell carcinoma

BACKGROUND

It was the aim of this study to evaluate the serum levels of cathepsin D (Cath D) as a diagnostic tool in patients with renal cell carcinoma (RCC) in comparison with healthy volunteers.

METHODS

Cath D serum levels were measured in serum samples obtained preoperatively from 32 patients with histologically confirmed RCC versus 30 healthy individuals using an enzyme immunoassay. Additionally, for the tumor group, Cath D serum levels were correlated with tumor stage and grade as determined according to the 2002 TNM classification.

RESULTS

The serum Cath D concentration was not significantly different in patients with RCC compared with healthy individuals (mean 16.58 vs. 16.64 ng/ml; p = 0.43). Furthermore, there was no significant association between Cath D serum levels and several patient or tumor characteristics such as tumor stage, tumor grade, lymph node status, presence of metastasis, gender or age.

CONCLUSIONS

In contrast to overexpression of Cath D in primary RCC tissue, serum Cath D is not altered in RCC patients when compared with healthy volunteers. In this small cohort, Cath D serum levels did not reveal additional clinical information in patients diagnosed with a small renal mass. Further prospective multicenter studies might shed more light on the value of Cath D in the diagnostics of RCC.

Lymph node status as a guide to selection of available prognostic markers in breast cancer: the clinical practice of the future?

Prognosticators evaluating survival in breast cancer vary in significance in respect to lymph node status. Studies have shown e.g. that HER2/neu immunohistochemistry or HER2/neu gene amplification analysis do perform well as prognosticators in lymph node positive (LN +) patients but are less valuable in lymph node negative (LN -) patients. We collected data from different studies and tried to evaluate the relative significance of different prognosticators in LN+/LN- patient groups. In LN+ patients HER2/neu and E-cadherin immunohistochemistry were the statistically most significant prognosticators followed by proliferation associated features (mitotic counts by SMI (standardised mitotic index) or MAI (mitotic activity index), or S-phase fraction). Bcl-2 immunohistochemistry was also significant but p53 and cystatin A had no significance as prognosticators. In LN- patients proliferation associated prognosticators (SMI, MAI, Ki-67 index, PCNA immunohistochemistry, S-phase fraction) are especially valuable and also Cathepsin D, cystatin A, and p53 are significant, but HER2/neu or bcl-2, or E-cadherin less significant or without significance. We find that in studies evaluating single prognosticators one should distinguish between prognosticators suitable for LN+ and LN- patients. This will allow the choice of best prognosticators in evaluating the prospects of the patient. The distinction between LN+ and LN- patients in this respect may also be of special value in therapeutic decisions.

Cathepsin D Expression in Renal Cell Cancer–Clinical Implications

BACKGROUND

Whereas the expression of Cathepsin D (Cath D) is suggested to enhance the biological aggressiveness of human malignancies, its role in renal cell carcinoma (RCC), however, has not been investigated.

METHODS

By tissue microarray analysis, tumor and benign tissue samples from 176 RCC patients were investigated for Cath D expression by immunohistochemistry and Western blots. Expression levels were correlated to clinical variables and to the postoperative outcome.

RESULTS

High Cath D expression levels were detected in 29%/9% of tumor and benign tissue samples, respectively (p < 0.0001). In case of a high vs. low Cath D expression level, development of distant metastases was observed in 12% vs. 88% of cases (p < 0.05). With a median follow-up of 50 (2-146) months, high level Cath D expression was correlated with an improved long-term survival when compared with patients presenting with decreased expression [median long-term survival: 82 vs. 53 months in case of a high vs. low expression level] (p < 0.05).

CONCLUSIONS

The Cath D staining pattern predicted a reduced risk for metastatic spread and tumor dependent death, hereby indicating its role as a biological variable revealing additional prognostic information for renal cell cancer patients. Increased expression of Cath D in tumor vs. benign tissue samples might indicate a role for the development and progression of RCC.

Clinicopathological study of the expression of hsp27, pS2, cathepsin D and metallothionein in primary invasive breast cancer

Expression of the hormone-related proteins hsp27, pS2, and also of cathepsin D (CD) and metallothionein (MT) was studied by immunohistochemistry and analyzed against clinical data in breast cancer. Archived material of paraffin-embedded breast carcinoma tissues from a cohort of 134 patients with primary invasive breast cancer was used. Hsp27 and pS2 (>10% of tumor cells stained) were found to be expressed in 63.6% and 37.6% of cases, respectively, and were correlated negatively with grading (P=0.006 and 0.01) and positively with estrogen receptors (ER) (P=0.04 and 0.04). pS2 expression was correlated with lymph node status (P=0.02), tumor size (P=0.01), progesterone receptor (PR) content (P=0.02), hsp27 (P=0.015) and bcl-2 protein (P=0.001). An inverse relationship between pS2 expression and the expression of p53 protein (P=0.005) and proliferation-associated index MIB1 (P<0.0001) was noted. Stromal cathepsin D was positively correlated with tumor grade (P=0.01), PCNA (P=0.007), MIB1 (P=0.001) and p53 (P=0.01), and negatively with ER (P=0.04) and bcl-2 (P<0.0001). MT was correlated positively with stromal CD (P=0.007) and inversely with PgR (P=0.04). Univariate analysis showed CD expression to be a positive prognostic factor for survival (P=0.035), with borderline significance, while MT was more strongly positive (P=0.01). However, none of the proteins studied was found to be related to disease outcome in univariate analysis. Our data show that hsp27, pS2 and stromal CD expression may reflect tumor differentiation and the functional status of ER in breast cancer, but stromal CD and tumor MT expression were the only factors found that may be of limited prognostic value.

Keeping Data Continuous when Analyzing the Prognostic Impact of a Tumor Marker: An Example with Cathepsin D in Breast Cancer

The prognostic value of cathepsin D has been recently recognized, but as many quantitative tumor markers, its clinical use remains unclear partly because of methodological issues in defining cut-off values. Guidelines have been proposed for analyzing quantitative prognostic factors, underlining the need for keeping data continuous, instead of categorizing them. Flexible approaches, parametric and non-parametric, have been proposed in order to improve the knowledge of the functional form relating a continuous factor to the risk. We studied the prognostic value of cathepsin D in a retrospective hospital cohort of 771 patients with breast cancer, and focused our overall survival analysis, based on the Cox regression, on two flexible approaches: smoothing splines and fractional polynomials. We also determined a cut-off value from the maximum likelihood estimate of a threshold model. These different approaches complemented each other for (1) identifying the functional form relating cathepsin D to the risk, and obtaining a cut-off value and (2) optimizing the adjustment for complex covariate like age at diagnosis in the final multivariate Cox model. We found a significant increase in the death rate, reaching 70% with a doubling of the level of cathepsin D, after the threshold of 37.5 pmol mg(-1). The proper prognostic impact of this marker could be confirmed and a methodology providing appropriate ways to use markers in clinical practice was proposed.

Immunohistochemical expression of uPA, PAI-1, cathepsin D and apoptotic cells in ductal carcinoma in situ of the breast

BACKGROUND

We examined the relationship between biological markers, apoptotic indices and pathologic subtypes of ductal carcinoma in situ (DCIS) of the breast. The tumor-biological factors can be divided into invasive and proliferative markers. We chose urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor type 1 (PAI-1) and Cathepsin D as invasive markers, and Ki-67 and C-erbB2 oncoproteins as proliferative factors for our study.

METHODS

We used immunohistochemical methods to investigate the expression of uPA, PAI-1, Cathepsin D, Ki-67, C-erbB2 and ssDNA (single-stranded DNA for apoptotic cells) in 20 cases of DCIS. Tumor histological grade and the immunohistochemical expression of invasive and proliferative markers were compared.

RESULTS

Histological grade is associated with C-erbB2, MIB-1, apoptotic index (AI) and expression of PAI-1 in cancer and stroma. The correlation coefficient of the MIB-1 index and AI was 0.867. Of these invasive markers, only expression of PAI-1 in tumor and in stroma was associated with C-erbB2.

CONCLUSION

Our results show that the apoptosis index is closely related to the MIB-1 index, and also suggest that the immunohistochemical detection of PAI-1 in the cytoplasm of both carcinoma cells and stromal cells of DCIS is related to histological grade and expression of the proliferative markers MIB-1 and C-erbB2. Therefore, we infer that both invasiveness and proliferation are affected by the tumorigenesis of DCIS.

Molecular prognostic factors for breast cancer metastasis and survival

The biological characteristics of the tumor are used to estimate prognosis and select appropriate systemic therapy for patients with early-stage breast cancer. Well-established molecular prognostic factors include the estrogen and progesterone receptors, proliferation markers, and the HER2 gene. Novel tumor markers with potential clinical utility include molecules involved in cell transformation, invasion, and metastases. We review the available data supporting the utility of established prognostic and predictive molecular factors, and discuss challenges for integrating novel molecular markers into clinical practice.

Cathepsin D expression in colorectal adenocarcinomas and adenomas

The aim of this study was to investigate the role of cathepsin D in colorectal cancer. For this purpose cathepsin D expression was evaluated by means of immunohistochemistry in stromal and tumor cells of 31 colorectal carcinomas and 29 adenomas. Cytoplasmic cathepsin D expression of tumor cells was present in 90.3% of the carcinoma cases and various degrees of stromal cell cathepsin D expression were present in all cases. In the adenomas, the epithelial cells and stromal cells expressed cathepsin D in 68.96% and 96.55% of cases, respectively. The staining intensity was always weaker in the adenomas. When the stromal and tumor cell cathepsin D expression in the adenocarcinoma and adenoma cases were compared, a statistically significant difference was observed in the staining of stromal cells. Furthermore, stromal cathepsin D expression in the adenocarcinomas was related to tumor stage when the carcinomas were divided into low and high stage. Cathepsin D expression in stromal cells may be an important indicator of poor prognosis in colorectal adenocarcinomas.

Potential markers predicting distant metastasis in axillary node-negative breast carcinoma

Prognostic parameters for axillary node-negative (ANN) breast cancer are still rare. Our aim was to establish potential markers that predict distant metastasis in ANN breast carcinoma and permit detection of the patients with high metastasis risk. A case control study was designed that comprised 64 ANN patients who developed distant metastasis during a 5-10 year follow-up period, 64 ANN patients with recurrence-free survival and 64 node-positive (ANP) comparitors. Immunohistochemistry and/or in situ hybridization were used to detect nm23, Cathepsin-D (Cath-D), Epidermal Growth Factor Receptor (EGFR) and Laminin Receptor (LR) in 192 cases. A significantly lower expression of both nm23 mRNA and protein was found in the ANN-group with poor prognosis compared with the ANN-group with good prognosis (p < 0.01). The protein levels of Cath-D, EGFR and LR were significantly higher in the ANN-group with poor prognosis and in the ANP-group compared with the ANN-group with good prognosis (p < 0.01 or p < 0.05), but no differences were found between the poor ANN-group and the ANP-group. Multiple regression analysis showed a close correlation of nm23, Cath-D and EGFR expression with occurrence of distant metastasis of ANN breast carcinoma. All markers except nm23 correlated with conventional histopathologic criteria such as tumor grade, margin and vessel invasion. The results suggest the combined detection of nm23, Cath-D and EGFR as predictive markers of distant metastasis in ANN breast cancer patients. Quantitative analysis together with clinicopathologic factors could contribute to estimate the potential risk of metastasis and select individual therapy regimen.

Immunohistochemical cathepsin-D expression in breast cancer: correlation with established pathological parameters and survival

Breast cancer is an increasingly important cause of illness and death among women. In recent years, several novel prognostic determinants of breast cancer have been identified, including Cathepsin-D (CD) protein. CD protein expression was analyzed immunohistochemically (IHC) in tumor specimens (315 patients) of infiltrating ductal breast carcinoma. These patients also had axillary lymph node sampling. Overexpression of CD was observed in 39% of the tumors. IHC results were compared with the histological grade. Seventy nine percent (n = 95; 79%) tumor positivity was seen in grade II tumors, followed by grade I (n = 13; 11%) and grade III tumors (n = 12; 10%). Axillary lymph node metastasis had no significant correlation with CD positivity (p > 0.05). Bone metastases were significantly correlated with CD positivity (p < 0.05). CD positivity showed no significant correlation with disease-free and overall survival (p > 0.05). At a median follow-up of 48 (4 years) months in CD-positive patients, overall survival was 3.17 years, and disease-free survival 2.67 years. The overall survival of CD-negative tumor patients was 3.50 years, and disease-free survival was 2.93 years. We conclude that in comparison with cytosol-based quantitative studies, CD expression is not a good prognostic marker when, as in all ICH studies, only the expression in the tumor is considered.

Prognostic factors in node-negative breast cancer: a review of studies with sample size more than 200 and follow-up more than 5 years

OBJECTIVE

To review the published literature on prognostic factors in patients with node-negative breast cancer, focusing principally on recent studies with large sample sizes and extended follow-up periods.

SUMMARY BACKGROUND DATA

Although numerous studies have examined prognostic factors in patients with breast cancer, relatively few have dealt specifically with node-negative disease, and interpretation has been limited by small sample size and limited follow-up times.

METHODS

A review of the Medline database from 1996 to 2000 was undertaken, with additional papers published before 1996 identified through review articles. For inclusion in the analysis, papers needed to meet the following core criteria: 200 or more node-negative patients with invasive breast carcinoma; median follow-up time at least 5 years; method of testing and cut-off points specified; overall survival and/or disease-free survival specified; and relative risk or statistical probability values given for comparisons.

RESULTS

Three or more papers that met the core criteria were retrieved for each of 11 potential prognostic factors. Of these, tumor size, tumor grade, cathepsin-D, Ki-67, S-phase fraction, mitotic index, and vascular invasion showed a significant association with survival outcomes; HER2/neu and DNA ploidy showed no significant association; and estrogen receptor status and p53 showed mixed results. Lack of standardization in measurement techniques for many of the markers, including cathepsin-D, Ki-67, HER2/neu, and p53, limited their current clinical usefulness.

CONCLUSIONS

In large studies with extended follow-up periods, tumor size, tumor grade, cathepsin-D, Ki-67, S-phase fraction, mitotic index, and vascular invasion showed a significant association with survival outcome measures in patients with early-stage node-negative breast cancer. Because of technical difficulties and variations in the measurement of many of these factors, tumor size and tumor grade remain the only markers that currently have broad clinical usefulness for this patient group.

Expressions of chromogranin A and cathepsin D in human primary hepatocellular carcinoma

AIM: To determine the expression and clinical significance of chromogranin A and cathepsin D in hepatocellular carcinoma (HCC).

METHODS: Double immunofluorescence staining techniques combined with laser confocal scanning microscopy (LSCM) was used to investigate chromogranin A and cathepsin D expressions in 85 HCC patients.

RESULTS: Cathepsin D was expressed in 3 normal liver tissues, while in HCC the staining showed regional variation and the fraction of strongly stained cells increased as the tumors became less differentiated and usually clinically more malignant. Cells which showed strong positivity for cathepsin D were present in 71/85 (83.5%) cases. Strong expression of cathepsin D in cancer cells was related to histopathological features. They were more common in grade 3-4 (26/28, 92.9%) and grade 2 (46/53, 86.8%) tumors than in grade 1 tumors (1/4, 25.0%) (P < 0.01). No significant correlation was found between age and cathepsin D expression. In patients with positive cathepsin D reaction, the mean age was 52.1 ± 2.8 years (range 32-68 years) and in the group with negative reaction, the mean age was 51.3 ± 4.5 years (range 28-71 years). No obvious relationship was observed between CgA expression in cancer cells and the histopathological features. The CgA positive rate was 75.0% (3/4) in grade 1, 71.7% (38/53) in grade 2, and 71.4% (20/28) in grade 3-4 (P > 0.05) tumors. The coexpression of CgA and cathepsin D was found by double labeled immunofluorescence staining techniques. The processing of cathepsin D was disturbed in HCC cells and accumulated in the cells. Cathepsin D had proteolytic activity and autocrine mitogenic effect, suggesting their functions in invasion. These findings demonst rated that the expression of cathepsin D in HCC had prognostic value.

CONCLUSION: Chromogranin A and cathepsin D are expressed in a high proportion of HCC and the existence of cathepsin D in HCC might be related to processing of CgA. This is clearly a subject for further studies because of its potential clinical applications.

Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999

BACKGROUND

Under the auspices of the College of American Pathologists, a multidisciplinary group of clinicians, pathologists, and statisticians considered prognostic and predictive factors in breast cancer and stratified them into categories reflecting the strength of published evidence.

MATERIALS AND METHODS

Factors were ranked according to previously established College of American Pathologists categorical rankings: category I, factors proven to be of prognostic import and useful in clinical patient management; category II, factors that had been extensively studied biologically and clinically, but whose import remains to be validated in statistically robust studies; and category III, all other factors not sufficiently studied to demonstrate their prognostic value. Factors in categories I and II were considered with respect to variations in methods of analysis, interpretation of findings, reporting of data, and statistical evaluation. For each factor, detailed recommendations for improvement were made. Recommendations were based on the following aims: (1) increasing uniformity and completeness of pathologic evaluation of tumor specimens, (2) enhancing the quality of data collected about existing prognostic factors, and (3) improving patient care.

RESULTS AND CONCLUSIONS

Factors ranked in category I included TNM staging information, histologic grade, histologic type, mitotic figure counts, and hormone receptor status. Category II factors included c-erbB-2 (Her2-neu), proliferation markers, lymphatic and vascular channel invasion, and p53. Factors in category III included DNA ploidy analysis, microvessel density, epidermal growth factor receptor, transforming growth factor-alpha, bcl-2, pS2, and cathepsin D. This report constitutes a detailed outline of the findings and recommendations of the consensus conference group, organized according to structural guidelines as defined.

The role of cathepsin D and PAI-1 in primary invasive breast cancer as prognosticators and predictors of treatment benefit with adjuvant tamoxifen

In the last few years there has been an increased interest in treatment predictive factors in breast cancer patients. The aim of the study was to analyse the role of cathepsin D and plasminogen activator inhibitor-1 (PAI-1) expression as independent prognosticators and to assess their predictive value with respect to tamoxifen treatment. This study comprises 1851 patients with primary breast cancer diagnosed during 1988-1992. Their median age was 62 years (range: 24-91). The end-point was distant disease recurrence-free interval. Adjuvant treatment with tamoxifen was given to 1136 patients (61%). The median follow-up time was 59 months (range: 39-88). Cathepsin D content was shown to be a significant independent prognosticator in multivariate Cox analysis (P=0.02). The optimal cut-off level was 10 fmol/mg protein, other cut-off levels did not improve the results. The level of cathepsin D also appeared to predict the benefit of tamoxifen among oestrogen receptor (ER)-positive patients although this result did not reach statistical significance (P=0.09). In a multivariate Cox analysis including 497 patients PAI-1 content was shown to be a significant independent prognosticator (P=0.003) but did not appear to predict the benefit of tamoxifen treatment. The optimal cut-off level appeared to be 3 ng/mg protein, which was close to the median value 2.5 ng/mg (range: 0-51). We conclude that cathepsin D is a significant independent prognosticator and may possibly also predict the benefit of tamoxifen amongst ER-positive patients. PAI-1 was also found to be a strong independent prognosticator but no treatment interaction with adjuvant tamoxifen was found.

Cells producing cathepsins D, B, and L in human breast carcinoma and their association with prognosis

Lysosomal proteinases, cathepsins D, B, and L have been associated with malignant tumor progression and with prognosis in various human carcinomas. In the current study, the immunohistochemical localization of cathepsins in tumor cells was correlated with cathepsin protein concentration in breast carcinoma cytosols from 77 patients. Significant correlation was found for cathepsin D (P < .041) and borderline correlation for cathepsin B (P < .055) but not for cathepsin L. We hypothesize that the poor correlation of cysteine cathepsins was attributable to the fact that they were present not only in malignant epithelial cells, but also in infiltrating macrophages and stromal fibroblasts. In addition, tumor-surrounding myoepithelial cells (42% of tumors) and myofibroblasts (26% of tumors) as well as endothelial cells of neovasculature (10% of tumors) all stained specifically for cathepsin B. Two thirds of tumors co-expressed cathepsins B and L in tumor cells, whereas only 17% of tumors co-expressed all 3 cathepsins. Intense immunostaining for cathepsin D of tumor cells was observed in tumors at high TNM stage and tumors having positive lymph nodes. The expression of cathepsin B was independent of established prognostic factors, whereas intense cathepsin L staining in tumor cells was associated with high histological grade. With respect to prognosis of patient survival, only tumor cell-associated cathepsin D (P = .042) and myoepithelial cell-associated cathepsin B (P = .061) showed borderline significance. Cathepsins B and L immunostaining in tumor cells was not prognostic. In contrast, cytosolic levels of cathepsin B correlated with higher rate of relapse. Taken together, these results show the diversity in the cellular distribution of cathepsins in human breast carcinoma, presumably reflecting specific regulation and function of each of the cathepsins during tumor progression.

A comparison of the pattern of cathepsin-D expression in fibroadenoma, fibrocystic disease, preinvasive and invasive ductal breast carcinoma

In the metastatic process, proteolytic enzymes play an important role in mediating the passage of cancer cells through the basement membrane and extracellular matrix. We have compared cathepsin-D (CD) expression in a range of benign and malignant breast lesions so as to investigate its role in breast cancer progression. One hundred and sixty-two breast samples, comprising 18 fibroadenomas, 22 fibrocystic disease, 96 invasive ductal carcinoma and 26 lesions with intraductal carcinoma components, were evaluated for CD expression by the standard avidin-biotin-immunoperoxidase complex method on formalin-fixed, paraffin-embedded histological sections using a commercial antibody against human cathepsin-D. Of the invasive ductal carcinomas, 61.5% showed stromal cell CD positivity, whereas 48.9% expressed CD positivity in neoplastic cells. There was significant correlation between neoplastic cell and stromal CD positivity. The prevalences of CD positivity in both neoplastic and stromal cell components were significantly higher (P < 0.05 and P < 0.01, respectively) in histological grade III tumors compared to grades I and II carcinomas. CD expression by either neoplastic or stromal cells did not show significant correlation with patient age and tumor size. Only 15% of intraductal carcinomas were CD positive and expression was limited to neoplastic cells. Neither epithelial nor stromal cells in fibrocystic lesions and fibroadenomas were CD positive, but a weak to moderate positivity was observed within myoepithelial cells in mammary ducts. These findings provide insights into the mechanism whereby tumors with high histological grade mediate invasion into tissue. The role of stromal cells in tumor progression and the means of their recruitment deserve further study.

Cathepsin D expression by cancer and stromal cells in breast cancer: an immunohistochemical study of 1348 cases

This study was aimed at investigating the influence of cathepsin D (CD) expression by cancer cells and stromal cells on breast cancer prognosis. This is a study of 1348 node-positive (NPBC) and node-negative (NNBC) breast cancers diagnosed between 1980 and 1986 and with a minimum follow-up of 5.2 years. CD expression was assessed by immunohistochemistry on archival material using a polyclonal antibody. The expression by cancer and stromal cells was assessed separately and correlated with distant metastasis free (DMFS) and overall survival (OS). Cancer cells expressed CD (more than 10% cells expressing CD) in 38.9% of cases and reactive stromal cells in 43.6%. CD expression by reactive stromal cells, and not cancer cells, correlated with several factors of poor prognosis by cancer cells. A strong association was also found with expression of other proteases (stromelysin-3, gelatinase A, and urokinase Plasminogen Activator) by these same reactive stromal cells. CD expression by cancer cells did not predict DMFS or OS but, by univariate analysis, CD expression by reactive stromal cells was associated with earlier recurrence and shorter survival in NNBC (p = 0.0425) and NPBC patients submitted to adjuvant chemotherapy (p = 0.0234). However, CD expression by reactive stromal cells remained a significant predictor of recurrence by multivariate analyses only in a subgroup of NPBC submitted to adjuvant chemotherapy. Overall, those data support the concept that proteases produced by reactive stromal cells are under cancer cell stimulation and that CD by stromal cells, and not cancer cells, influences the prognosis, but only in a subgroup of patients with breast cancer.

Cathepsin-D, urokinase plasminogen activator and type-1 plasminogen activator inhibitor in early breast cancer: an immunohistochemical study of prognostic value and relations to tenascin-C and other factors

Cytosolic determinations of cathepsin-D (cath-D), urokinase plasminogen activator (uPA) and its specific inhibitor PAI-1 have shown an association with adverse prognosis in breast cancer. Our aim was to study the distribution of these markers in small axillary node-negative breast carcinomas using immunohistochemistry and relate the semiquantitative results to known prognostic factors, the expression of tenascin-C (Tn-C) in invasion border of the tumour and prognosis. All the 158 women (159 tumours) were treated with breast conserving surgery and postoperative radiotherapy. Cytoplasmic immunoreactivity for cath-D was seen in carcinoma cells in 47% and in stromal cells in 44%. Nearly all tumours expressed uPA and PAI-1, which were categorized to cytoplasmic expression in carcinoma cells and diffuse stromal expression and quantified -/+/++/ and further dichotomized for purposes of analysis. Expression of uPA and PAI-1 in stromal fibroblasts was recorded as -/+. Cytoplasmic and stromal cell cath-D contents were associated with grade, proliferation, Tn-C expression in the tumour invasion border and the development of distant metastasis. In multivariate analysis stromal cath-D proved to be an independent prognostic factor for metastasis. Stromal expression of uPA was associated with an increased risk of local recurrence; otherwise high levels of uPA did not associate with other prognostic factors nor with prognosis. Fibroblastic expression of PAI-1 showed an association with both local and distant disease recurrence. However, no consistent association between the immunohistochemically quantified uPA and PAI-1 and prognosis was found. In conclusion, immunohistochemical determination of cath-D seems to be a viable method to predict a higher risk of metastasis but not local recurrence in small axillary node-negative breast carcinomas.

Low levels of cathepsin D are associated with a poor prognosis in endometrial cancer

Total cytosolic cathepsin D (Cat D) levels were estimated by an immunoradiometric assay in a series of 156 consecutive patients with surgical stages I-III primary endometrial adenocarcinoma. Simultaneously, the tissue content of both oestrogen (ER) and progesterone (PR) receptors, and p185HER-2/neu, DNA content (ploidy), and the fraction of S-phase cells (S-phase) were also estimated. Tumoral Cat D content ranged from 0 to 243 pmol mg(-1) protein (median 44 pmol mg(-1) protein) and was not associated with any of the established clinicopathological and biological prognostic variables, with the exception of a weak positive correlation with the tumoral p185HER-2/neu levels. Univariable analysis performed on a subset of 97 patients, followed for a minimum of 2 years or until death, showed that patient age at diagnosis, high histological grade, advanced surgical stage, vascular invasion, positive peritoneal cytology, low levels of Cat D, negative ER and PR status, aneuploidy, and high S-phase were predictive of the presence of persistent or recurrent disease. However, multivariable analysis revealed that only histological grade, surgical stage, Cat D and PR were significantly associated with the patient's outcome. From these findings, we conclude that Cat D is an independent prognostic factor in endometrial adenocarcinoma, its low levels being associated with a worse clinical outcome.

Cathepsin D in host stromal cells is associated with more highly vascular and aggressive invasive breast carcinoma

AIMS

To determinate the relationship between tumoral angiogenesis and cathepsin D (CD) expression in tumour and host stromal cells of invasive breast carcinoma, and to examine its association with classical prognostic factors such as lymph node status, histological grade, tumour size, mitotic rate, peritumoral lymphovascular invasion and oestrogen receptor (ER) status.

METHODS AND RESULTS

Sections from 102 invasive breast carcinoma were cut from the archival formalin-fixed, paraffin-embedded tissue blocks and stained using immunohistochemistry for the endothelial cell adhesion molecule (CD31) and CD. Microvessel density was assessed by counting vessels in the three most vascular areas at x400 field. The counts were expressed as the highest counts within any x400 field. The evaluation of immunostaining for CD was performed separately in both the parenchymal and stromal cells. Microvessel density was correlated positively with histological grade and peritumoral lymphovascular invasion, and correlated inversely with ER status. Positive CD staining of tumour cells was more frequent in positive ER tumours and was not significantly associated with the other classical prognostic factors. However, moderate to strong staining of host cells was correlated with higher histological grade, higher mitotic index and lack of ER protein. There was a statistically significant association between CD expression of host stromal cells and higher vessel count.

CONCLUSIONS

CD in host stromal cells is associated with more aggressive tumours and with a higher intratumoral microvessel density. Evaluation of CD in combination with angiogenic activity may be of some help in more accurately predicting the biological behaviour of breast carcinoma.

Cathepsin-D in primary breast cancer: prognostic evaluation involving 2810 patients

There is controversy regarding the prognostic value of cathepsin-D in primary breast cancer. An increased level of cathepsin-D in tumour extracts has been found to be associated with a poor relapse-free and overall survival. Studies performed with immunohistochemistry or Western blotting have produced diverse results. We have analysed 2810 cytosolic extracts obtained from human primary breast tumours for cathepsin-D expression, and have correlated their levels with prognosis. The median follow-up of the patients still alive was 88 months. Patients with high cathepsin-D levels had a significantly worse relapse-free and overall survival, also in multivariate analysis (P < 0.0001). Adjuvant therapy which was associated with an improved prognosis in node-positive patients in univariate analysis, also significantly added to the multivariate models for relapse-free and overall survival. There were no statistically significant interactions between the levels of cathepsin-D and any of the classical prognostic factors in analysis for relapse-free survival, suggesting that the prognostic value of cathepsin-D is not different in the various subgroups of patients. Indeed, multivariate analyses in subgroups of node-negative and -positive patients, pre- and post-menopausal patients, and their combinations, showed that tumours with high cathepsin-D values had a significantly poor relapse-free survival, with relative hazard rates ranging from 1.3 to 1.5, compared with tumours with low cathepsin-D levels. The results presented here on 2810 patients confirm that high cytosolic cathepsin-D values are associated with poor prognosis in human primary breast cancer.

Immunoradiometric and immunohistochemical analysis of Cathepsin D in ovarian cancer: lack of association with clinical outcome

The aim of this study was to analyse the clinical significance of Cathepsin D (Cath D) content as determined by an immunoradiometric assay in a series of primary untreated ovarian cancers from 162 patients. In addition, immunohistochemical analysis of Cath D was also performed on a subset of 86 tumours. Cath D levels were distributed in an asymmetrical way and were skewed towards the lower values (median value 20.8 pmol mg(-1) protein, range 2.0-99.0 pmol mg(-1) protein). No correlation was found between Cath D levels and clinicopathological parameters. However, the percentage of Cath D positivity was significantly higher in oestrogen receptor-positive (57%) compared with oestrogen receptor-negative (36%) cases (P= 0.01). The percentage of Cath D-positive staining was not significantly different for both epithelial (27%) and stromal components (40%). Immunoradiometrically detected Cath D levels were not different according to Cath D stromal immunostaining (P= 0.18), while higher Cath D levels were measured in Cath D-positive than in Cath D-negative tumour epithelial cells (P = 0.027). Survival analysis was conducted on 161 primary untreated ovarian cancer patients. The 5-year overall survival rate was 57% and 55% in Cath D-positive and Cath D-negative patients respectively (P = 0.69). As far as time to progression was concerned, there was no significant difference in the survival rate of patients with either high or low Cath D content (P = 0.56). Similar results have been obtained in the subset of patients in which Cath D was analysed by immunohistochemistry. In conclusion, Cath D measurement in tumour extracts appears to have a limited usefulness in improving the prognostic characterization of ovarian cancer patients.

Prognostic significance of stromelysin 3, gelatinase A, and urokinase expression in breast cancer

This study was aimed at testing the hypothesis that the expression of proteases essentially produced by reactive stromal cells (stromelysin-3 [ST3], gelatinase A [GELA], and urokinase [uPA]) is predictive of prognosis in patients with breast cancer. This was a study of patients with node-positive and node-negative breast cancer diagnosed from 1980 to 1986 and with an average of 10 years follow-up. ST3 (665 cases), GELA, and uPA (575 cases each) expression was obtained by in situ hybridization on formalin-fixed, paraffin-embedded material using mRNA antisense probes. ST3 was expressed by 86.6% of the cases; GELA, 77.7%; and uPA, 64.7%. A significant correlation (P < .05) was found between high (more than 10%) ST3 expression and a younger age, lymph node involvement, poor nuclear grade, ductal histology, aneuploidy, and HSP-27 expression. High GELA expression was significantly associated with c-erbB2, ductal histology, and HSP-27 expression. High uPA expression correlated with poor nuclear grade, ductal histology, lack of estrogen and progesterone receptors, and p53 protein accumulation. High level of expression of all three proteases correlated significantly with each other and with cathepsin D expression by reactive stromal cells. By univariate analysis, both ST3 and uPA expression significantly predicted a shorter recurrence-free survival (ST3, P = .0199; uPA, P = .0269). By multivariate analyses, the prognostic significance was lost, most particularly at longer term. This study adds support to the concept that protease expression by reactive stromal cells is related to cancer cell characteristics but that their contribution to cancer progression is marginal.

Prognostic Factors for Node-negative Breast Cancers: Results of a Study Program by the Japanese Breast Cancer Society

BACKGROUND: Prognostic factors for predicting the recurrence of node-negativebreast cancers have been controversial. The present study was performed to elucidate practically useful prognostic factors using formalin-fixed paraffin sections. METHODS: This was a case-controlled multi-institutional study that composed 40 patients with recurrent node-negative breast cancer and 80 patients with node-negative breast cancer but without recurrence after radical surgery. Tumors weresmaller than 3 cm in diameter and were treated surgically between January 1, 1985 and December 31, 1990. The recurrent and non-recurrent cases were matched with regard to their age, adjuvant chemotherapy and the year in which surgery was performed. Fourteen immunohistochemical factors and 8 histological factors of theprimary tumor were studied on formalin-fixed, paraffin-embedded sections by immunohistochemical and histochemical analyses. RESULTS: According to univariate analysis, factors such as progesterone receptor (PgR), MIB-1, CD44v6, CD44v9 and platelet-derived endothelial cell growth factor (PDECGF) were significantly different between the recurrent and non-recurrent groups (p &ly; 0.1; Wilcoxon-Mann-Whitney analysis). Chi-squared test showed significant differences in MIB-1, cdc2 and stromal plasminogen activator receptor (suPAR). Histologically, mitotic count was also significantly different between the two groups (p < 0.005). Multivariate analysis revealed that positivity for cdc2 (p=0.01), high mitotic count (p=0.04) and negativity for CD44v9 (p=0.02)were independent prognostic factors among variables selected by univariate analysis, and that positivity for MIB-1 (p=0.03) and cdc2 (p =0.01), and negativity for CD44v9 (p =0.03) were independent prognostic factors among the immunohistochemical markers examined. CONCLUSION: Our results indicated that positivity for MIB-1 and cdc2, high mitotic count and negativity for CD44v9 could serve as independent factors for predicting the recurrence of node-negative breast cancer.

Prognostic value of cathepsin D expression and association with histomorphological subtypes in breast cancer

This study investigated the prognostic value of immunohistochemically detected cathepsin D expression in 103 invasive ductal carcinomas of the breast at stages pT1 and 2. We also assessed the association between cathepsin D expression and histomorphological tumour subtypes (invasive ductal carcinoma with extensive intraductal component, multifocal tumour). Cathepsin D expression was examined at two cut-off levels (positive and highly positive) and separately identified within the epithelial and stromal component of all tumours. Positive and highly positive epithelial expression was detected in 32 (31.1%) and 20 (19.4%) patients respectively. Stromal expression was found in 35 (34%) and 19 (18.4%) cases respectively. Epithelial cathepsin D expression was associated with stage and nuclear grade, but not with lymph node or oestrogen receptor status. Positive and highly positive epithelial cathepsin D expression showed significant prognostic value for overall survival (P = 0.003 and 0.01) and recurrence-free interval (P = 0.04 and 0.02). Cathepsin D expression in stromal cells was not associated with either several established prognostic factors or survival. Multivariate analysis revealed that cathepsin D expression failed to be an independent predictor of patients' outcome. Cathepsin D expression shows no significant association with histomorphological subtypes of breast cancer. Our study supports the prognostic impact of immunohistochemically detected cathepsin D expression in the epithelial component of breast cancer.

Cathepsin D detected by automated and quantitative immunohistochemistry in breast carcinomas: correlation with overall and disease free survival

AIM

To determine the prognostic significance and clinical relevance of cathepsin D detected by immunocytochemical assays (ICAs) in breast carcinomas.

METHODS

151 patients presenting with palpable or impalpable breast carcinomas and who had not received any kind of adjuvant chemotherapy or endocrine therapy who were operated from January 1986 to May 1987 were studied. ICAs of tumour specimens were performed in optimal technical conditions (frozen sections, automated immunoperoxidase technique (Ventana), and computer assisted analysis of digitised coloured microscopic images (SAMBA)) to determine cathepsin D immunocytochemical expression. Results of quantitative ICAs were correlated with overall and disease free survival over 8.4 years of follow up in axillary lymph node positive and negative patients.

RESULTS

Cathepsin D immunocytochemical expression in tumours of 15% or more was significantly associated with poor overall survival in the whole group and in node positive patients (Kaplan Meier, log rank test p = 0.003 and p = 0.007); however, it was not correlated with survival in node negative patients. Cathepsin D immunocytochemical expression (> 15%) correlated with short disease free (p = 0.015) and short recurrence free survival (p = 0.021) in the group as a whole but not when node positive and negative patients were evaluated separately.

CONCLUSIONS

In optimal conditions (automated and quantitative ICAs on frozen sections) cathepsin D immunohistochemical expression is a significant prognostic indicator in terms of overall, disease free, and recurrence free survival; however, there is no correlation when node negative patients are considered separately.

Lack of prognostic value of cathepsin D levels for predicting short term outcomes of breast cancer patients

The value of cathepsin D determinations done on tumor cytosols in evaluating the prognosis of breast cancer patients has been debated in the literature. Our previous work suggested that cathepsin D determinations were not of prognostic value, but in that study we used immunoblotting and immunohistochemical methods rather than the more widely used double antibody immunoradiometric (IRMA) assay for measuring cathepsin levels. Here we report our results determining cathepsin D using components of a commercially available IRMA system on a large patient sample (n = 1984). Reagents from a commercially available IRMA kit were used to analyze cathepsin D levels in the cytosols of 1984 patients with breast cancer. All patients had invasive breast cancer with known tumor size and with some axillary nodes pathologically examined. Only patients with T1 and T2 tumor sizes were included. Median follow-up was 37 months. The hypothesis that high cathepsin D levels correlated with poorer outcome (poorer DFS or OS) was not confirmed, either in all patients, or in node-positive or node-negative subsets. Only in patients treated with adjuvant therapy were higher cathepsin D levels correlated with negative outcome (worsened OS, but not DFS), although given the large number of subsets analyzed this correlation may be spurious. Multivariate analyses using interaction terms did not support the concept that high cathepsin D levels correlate with resistance to adjuvant therapy. In this study evaluating the value of cathepsin D using components from a kit widely used for measuring cathepsin D levels, we conclude that cathepsin D is of doubtful value in predicting risk of early relapse or death for patients with newly diagnosed invasive breast cancer.

Abnormal expression of four novel molecular markers represents a highly aggressive phenotype in breast cancer. Immunohistochemical assay of p53, nm23, erbB-2, and cathepsin D protein

BACKGROUND

In view of the cumulative results to date, p53, nm23, erbB-2, and cathepsin D are the most promising investigational prognostic factors in breast cancer.

OBJECTIVES

The clinical utility of these molecular markers to predict recurrence was evaluated.

METHODS

Archival pathology tissues of 100 breast cancer patients were analyzed by immunohistochemical assay. Molecular biologic data were merged with clinicopathologic variables.

RESULTS

Thirty-two patients (32%) had recurrence of disease at a median follow-up of 48 months (range 26-72 months). Investigational factor expression had statistical correlation for recurrence with increasing coexpression: one variable 20.6%, two variables 34.2%, three variables 47.1%, four variables 80.0% (P = 0.003). In univariate analysis, lymph node metastasis, tumor size, erbB-2 protein overexpression, and loss of nm23 protein expression were significant variables to determine recurrence; in multivariate analysis, node status and tumor size emerged as the most significant variables for recurrence.

CONCLUSIONS

Coexpression of the studied investigational variables functioned as significant prognostic correlates for recurrence. These findings suggest that the studied investigational prognostic factors possess the ability to discriminate a highly aggressive phenotype in breast cancer.

Influence of cathepsin D expression in lung adenocarcinoma on prognosis: possible importance of its expression in tumor cells and stromal cells, and its intracellular polarization in tumor cells

BACKGROUND

Cathepsin D, an aspartic lysosomal proteinase, has been described to be closely associated with tumor progression and prognosis in some human malignancies. The purpose of this study was to determine clinicopathological and prognostic significance of cathepsin D expression in lung adenocarcinoma.

METHODS

Expression of cathepsin D in 152 lung adenocarcinoma patients was immunohistochemically studied using the antihuman cathepsin D antibody.

RESULTS

Eighty patients (53%) showed negative immunoreactivities in tumor cells. The cathepsin D-positive patients (72 patients, 47%) were divided into two subgroups; granular type expression (48 patients, 31%) with its polarized expression mainly in the luminal side of the cytoplasm of tumor cells and basal type expression (24 patients, 16%) with its polarized expression mainly in the basal or infranuclear side of the cytoplasm. Patients with basal type expression showed significantly more marked scar formation (P = 0.042), and especially among the patients with stage I disease, those with basal type tended to show poorer prognosis (P = 0.071) than the others. Cathepsin D was also expressed in stromal cells within the tumor tissues, and 86 patients (57%) with moderate to massively infiltrating cathepsin D-positive stromal cells showed a lower grade of differentiation (P = 0.005) and higher scar grade (P = 0.0003) than those with few cathepsin D-positive stromal cells. Cathepsin D status in stromal cells was significantly associated with prognosis (P = 0.014), and in a multivariate analysis, its expression status in stomal cells was marginally an independent prognostic factor only among the stage I patients.

CONCLUSIONS

In determining significance of cathepsin D expression in this disease, it is important to consider separately its expression cell type and its polarization pattern in tumor cells within the tumor tissue. How ever, only cathepsin D status in stromal cells within the tumor tissue is a marginal marker influencing prognosis among stage I patients.

Quantitative analysis of p185(HER-2/neu) protein in breast cancer and its association with other prognostic factors

The total cellular p185(HER-2/neu) protein (p185) content was measured by ELISA in 346 invasive primary breast cancers, and the results were compared with those of estrogen (ER) and progesterone (PR) receptors, pS2 and Cathepsin D (Cat D) content. At a cut-off level of 260 fmol/mg protein, 53 of the 346 tumors (15%) were p185-positive. A significant positive correlation was observed between p185 levels and those of Cat D, and a weaker, though significant, positive correlation with ER, and pS2 levels, but not with those of PR. However, when only the 293 p185-negative tumors were considered, the correlation between p185 and ER improved substantially, and statistical significance was reached for PR. p185-positive tumors exhibited lower ER and PR content and higher Cat D content than p185-negative tumors. The pS2 content, in contrast, did not undergo significant variation. Tumors considered to be p185-positive were significantly more frequently positive for Cat D at the cut-off of 45 pmol/mg protein, and were more frequently negative for ER and/or PR, but only significant at the cut-off of 15 fmol/mg or higher for both steroid receptors. Finally, p185 status was not associated with menopausal status, tumor size, axillary-lymph-node invasiveness or distant metastases. These results suggest that 260 fmol/mg protein as the cut-off for p185 allows the identification of a tumoral sub-population with a more aggresive phenotype.

Correlation of two methods for determination of cathepsin D in breast carcinoma (immunohistochemistry and ELISA in cytosol)

We have studied the correlation of two methods (immunohistology and ELISA in cytosol) of cathepsin D (CD) determination in breast carcinoma patients. Fifty six specimens of tumor tissue were collected consecutively, and CD expression in tumor tissue and tissue macrophages was determined by standard immunohistochemistry using the aNCL-CDm anti-cathepsin D mouse monoclonal antibody (Novocastra Laboratories Ltd., Newcastle, UK). Additionally, CD concentration was determined by ELISA in cytosol of the same breast carcinoma specimens. CD positivity was correlated with tumor size, histological grade of tumor, and the cytosol progesterone adn estrogen receptor concentrations. There was no statistically significant correlation between examined parameters and either CD positivity by immunohistochemistry or cytosol CD concentration. The correlation between CD expression in tumor cells of breast carcinoma by immunohistochemistry and cytosol CD positivity was not found either. However, there was a significant association between abundance of CD positive stromal macrophages and cytosol CD concentration in all histological tumor types (p < 0.05). CD positive macrophages were abundant in most of cytosol CD positive specimens. These results suggest that breast cancer cytosol CD concentration is the cumulative result of CD content in both carcinoma cells and stromal macrophages.

Relationship between cathepsin-D content and disease-free survival in node-negative breast cancer patients: a meta-analysis

Several reports have evaluated the correlation between cathepsin-D and overall survival or disease-free survival in node-negative breast cancer patients. Because conflicting data have so far been reported, a meta-analysis was conducted to clarify this problem. Eleven studies were included in our meta-analysis (total of 2690 patients). A specific meta-analytical methodology for censored data was used, and disease-free survival was the primary end point. Patients with low cathepsin-D levels had a significantly better disease-free survival than patients with high cathepsin-D values (meta-analytical odds ratio from 0.59 to 0.60 over the interval from 1 to 7 years). A secondary meta-analysis conducted exclusively on the data from eight studies based on cytosol assay gave substantially similar results. One limitation of our study is that the cut-off values to define high and low cathepsin-D concentrations were not identical in the various studies included in our meta-analysis (range from 20 to 78 pmol mg(-1) protein), thus introducing a possible bias in the statistical analysis of the data. However, a simulation based on the well-accepted method of the so-called publication bias showed that more than 100 null studies would be required to lead our results to a statistical level of non-significance. Considering the results of our meta-analysis, we conclude that the data presently available confirm a statistically significant association between high cathepsin-D values and poor disease-free survival in node-negative breast cancer patients.

Immunocytochemical localization of Cathepsin D and CA 125 in ovarian cancer

OBJECTIVE

To study the expression of Cathepsin D (Cath D) and CA 125 antigens and ER and PR receptors on freshly obtained surgical specimens of ovarian carcinomas and their relationship with menopausal status, tumor histology, primary tumor size and lymph node invasion.

METHODS

The tumors obtained from 100 women were measured and cut in half. The cut surface of one half was pressed against glass slides which were air dried and stained using the Avidin-Biotin peroxidase method for Cath D and CA 125 antigens. The slides were viewed under the light microscope for the characteristic brown granules in the cytoplasm or membrane of the malignant cells. The other half of the tumor was subjected to routine histological examination and part used for the demonstration of ER and PR receptors. The results were analyzed using chi 2 analysis.

RESULTS

Cath D positivity was as common as CA 125 positivity. Cath D positivity is more frequently associated with serous carcinomas than with others. No relationship was observed between ER/PR positivity and Cath D or CA 125 positivity.

CONCLUSION

The high incidence of Cath D positivity makes it a possible complementary method for following up ovarian carcinoma patients especially those who are CA 125 negative.

Immunohistochemical evaluation of cathepsin D expression in colorectal cancer

Determination of cathepsin D has been proven to be prognostically relevant in breast cancer. Cathepsin D, a lysosomal proteinase, is suggested to be causally involved in tumor invasion. In this study we investigated cathepsin D expression immunohistochemically in 106 colorectal adenocarcinomas with the intention to evaluate its prognostic significance in this type of cancer. The majority of colorectal adenocarcinomas (93/106) stained positive for cathepsin D, while normal colon was almost completely negative. A trend toward stronger staining intensity was found in Dukes' stage C and D tumors (p < 0.1), but cathepsin D expression was found to have no influence on survival in this tumor type nor did it correlate with other known prognostic factors, e.g., histological differentiation, lymph vessel invasion, or rate of proliferation. Staining of lymph node metastases did not differ significantly from that of their primary tumors. Stronger staining intensity of tumor tissue in the neighborhood of inflammatory cells may be due to paracrine activation.