Detection of ovarian cancer cells: comparison of a telomerase assay and cytologic examination

Change of telomerase activity in peripheral blood of patients with head and neck squamous cell carcinoma pre and post curative treatment

BACKGROUND

There is no clinically applicable tumor marker for head and neck cancers. Telomerase is detected in approximately 90% of all malignant tumors, it may predict poor or favorable outcomes, thus being both a highly attractive biomarker and a target for the development of molecular-based cancer diagnostics, prognostics, and therapeutics.

AIM

Primary aim was to detect a change of telomerase activity before and after curative treatment.

MATERIALS AND METHODS

Patients with biopsy proven head and neck squamous cell carcinoma, stage I-IVB treated with a curative intent, performance status 0-2 and malignancy at one primary site were included in the study. Telomerase levels were tested in tissue biopsy. Plasma telomerase levels were tested at baseline, 5 days and at 3 months after treatment using ELISA.

RESULTS

Raised plasma telomerase activity was seen in all the patients with cancer at baseline. The mean plasma telomerase level at baseline was 861.4522 ng/ml, at 5 days after completion of curative treatment was 928.92 ng/ml and at 3 months of follow up was 898.87 ng/ml. The mean tissue biopsy telomerase level was 19768.53 ng/mg. There was a significant increase in baseline telomerase levels in cancer patients compared to normals (volunteers) (t = -3.52, p = 0.001).There was a significant increase in plasma levels of telomerase at 3 months compared to baseline values (z = -1.98, p = 0.04). The increase in telomerase level did not correlate with the response of the treatment.

CONCLUSION

In patients with head and neck squamous cell carcinomas treated with a curative intent, the change in levels of telomerase correlates neither with the disease status nor with prognostic factors.

Ascites in Ovarian Carcinoma - Reliability and Limitations of Cytological Analysis

OBJECTIVE

The objective of this study was to examine the validity of ascitic fluid cytology in the detection of pathological findings, to examine the percentage of false positive and false negative results in the cytology of ascitic fluid and to determine the validity of peritoneal cytology in relation to the histopathological type of the ovarian tumour.

METHODS

This retrospective study included 170 peritoneal cytology findings. The study was conducted from January 2010 to December 2012. The experimental group included 76 cytology findings obtained from patients diagnosed with ovarian carcinoma, whereas the control group was composed of 94 cytology findings of benign ovarian tumours and liver cirrhosis ascites. The patients with ovarian carcinoma had grades III, as well as grades I and IIc but only in cases where operative and pathological finding indicated a ruptured or perforated tumour capsule.

RESULTS

The sensitivity of peritoneal cytology is 68.92%, specificity is 93.61%, positive predictive value is 89.65% and negative predictive value is 78.57%. In 30.02% of patients, the peritoneal cytology showed false negative results, while in 6.38%, the results were false positive. The highest percentage of false negative findings was 77%, found in endometrioid carcinoma.

CONCLUSION

Peritoneal cytology of ascitic fluid is highly specific but has relatively low sensitivity, particularly in the case of endometrioid ovarian carcinoma. In order to increase sensitivity, peritoneal cytology should be combined with monoclonal antibodies and other biochemical and immunohistochemical markers.

Activin and inhibin, estrogens and NFκB, play roles in ovarian tumourigenesis is there crosstalk?

Ovarian cancer may be the most frequently lethal gynaecological malignancy but the heterogeneous nature of the disease and the advanced stage at which it is usually diagnosed, have contributed to the paucity of information relating to its aetiology and pathogenesis. Members of the TGF-β superfamily, estrogen and NFκB have all been implicated in the development and progression of cancers from a wide range of tissues. In the ovary, TGF-β superfamily members and estrogen play key roles in maintaining normal function. To date, little is known about the capacity of NFκB to influence normal ovarian function except that it is ubiquitously expressed. In this review we will highlight the roles that inhibin/activin, estrogen and NFκB, have been attributed within carcinogenesis and examine the potential for crosstalk between these pathways in ovarian cancer pathogenesis.

Prevalence of telomerase activity in human cancer

Telomerase activity has been measured in a wide variety of cancerous and non-cancerous tissue types, and the vast majority of clinical studies have shown a direct correlation between it and the presence of cancerous cells. Telomerase plays a key role in cellular immortality and tumorigenesis. Telomerase is activated in 80-90% of human carcinomas, but not in normal somatic cells, therefore, its detection holds promise as a diagnostic marker for cancer. Measurable levels of telomerase have been detected in malignant cells from various samples: tissue from gestational trophoblastic neoplasms; squamous carcinoma cells from oral rinses; lung carcinoma cells from bronchial washings; colorectal carcinoma cells from colonic luminal washings; bladder carcinoma cells from urine or bladder washings; and breast carcinoma or thyroid cancer cells from fine needle aspirations. Such clinical tests for telomerase can be useful as non-invasive and cost-effective methods for early detection and monitoring of cancer. In addition, telomerase activity has been shown to correlate with poor clinical outcome in late-stage diseases such as non-small cell lung cancer, colorectal cancer, and soft tissue sarcomas. In such cases, testing for telomerase activity can be used to identify patients with a poor prognosis and to select those who might benefit from adjuvant treatment. Our review of the latest medical advances in this field reveals that telomerase holds great promise as a biomarker for early cancer detection and monitoring, and has considerable potential as the basis for developing new anticancer therapies.

Telomerase detection in the diagnosis and prognosis of cancer

Telomerase, a critical enzyme responsible 'for cellular immortality, is usually repressed in somatic cells except for lymphocytes and self-renewal cells, but is activated in approximately 85% of human cancer tissues. The human telomerase reverse transcriptase (hTERT) is the catalytic component of human telomerase. In cancers in which telomerase activation occurs at the early stages of the disease, telomerase activity and hTERT expression are useful markers for the detection of cancer cells. In other cancers in which telomerase becomes upregulated upon tumor progression, they are useful as prognostic indicators. However, careful attention should be paid to false-negative results caused by the instability of telomerase and of the hTERT mRNA and the presence of PCR inhibitors, as well as to false-positive results caused by the presence of alternatively spliced hTERT mRNA and normal cells with telomerase activity. Recently, methods for the in situ detection of the hTERT mRNA and protein have been developed. These methods should facilitate the unequivocal detection of cancer cells, even in tissues containing a background of normal telomerase-positive cells.

Telomerase expression in sebaceous lesions of the skin

BACKGROUND

Recent studies have demonstrated telomerase expression in ophthalmologic sebaceous carcinoma and have suggested possible diagnostic utility in distinguishing these neoplasms from sebaceous adenomas. The aim of this study was to evaluate telomerase expression via human telomerase reverse transcriptase (hTERT) immunohistochemical staining in a spectrum of sebaceous lesions of the skin.

METHODS

Paraffin-embedded sections from sebaceous hyperplasia (11), nevus sebaceus (22), sebaceous adenoma (19), sebaceoma (11), and sebaceous carcinoma (14) were evaluated for intensity (0 to 3+) and pattern of anti-hTERT staining.

RESULTS

Strong (2 to 3+) hTERT staining was observed in nucleoli of germinative cells and immature sebocytes in all sebaceous lesions, whereas mature sebocytes were negative. The distribution pattern paralleled features seen by routine haematoxylin and eosin-stained sections.

CONCLUSIONS

All hyperplastic and neoplastic sebaceous skin lesions expressed hTERT in this immunohistochemical study. The pattern of staining was predictive of the histologic pattern of the process but does not significantly add to our diagnostic armamentarium of sebaceous lesions.

Molecular targets in gynaecological cancers

The application of high throughput expression profiling and other advanced molecular biology laboratory techniques has revolutionised the management of cancers and is gaining attention in the field of gynaecological cancers. Such new approaches may help to improve our understanding of carcinogenesis and facilitate screening and early detection of gynaecological cancers and their precursors. Individualised prediction of patients' responses to therapy and design of personalised molecular targeted therapy is also possible. The studies of various molecular targets involved in the various signal pathways related to carcinogenesis are particularly relevant to such applications. At the moment, the application of detection and genotyping of human papillomavirus in management of cervical cancer is one of the most well established appliances of molecular targets in gynaecological cancers. Methylation, telomerase and clonality studies are also potentially useful, especially in assisting diagnosis of difficult clinical scenarios. This post-genomic era of clinical medicine will continue to make a significant impact in routine pathology practice. The contribution of pathologists is indispensable in analysis involving tissue microarray. On the other hand, both pathologists and bedside clinicians should be aware of the limitation of these molecular targets. Interpretation must be integrated with clinical and histopathological context to avoid misleading judgement. The importance of quality assurance of all such molecular techniques and their ethical implications cannot be over-emphasised.

hTERT expression in melanocytic lesions: an immunohistochemical study on paraffin-embedded tissue

BACKGROUND

Telomerase plays a role in the immortalization of cells and carcinogenesis. Previous studies have yielded conflicting results on whether human telomerase RNA (hTER) expression differs in nevi, atypical nevi and melanomas using polymerase chain reaction-based telomeric repeat amplification protocol or in situ hybridization assays. The aim of this study was to evaluate human telomerase reverse transcriptase (hTERT) staining in melanocytic lesions on paraffin-embedded tissues.

METHODS

Paraffin-embedded sections from 12 acquired nevi, seven dysplastic nevi, 11 Spitz nevi, eight primary invasive melanomas, and three metastatic melanomas were studied for staining intensity (0-3+) and percentage of labeled cells with anti-hTERT.

RESULTS

hTERT staining was observed in most cells (>75%), in all but three lesions, and was of greater intensity in the nucleus, especially the nucleolus, compared with the cytoplasm. Spitz nevi tended to have weaker hTERT staining (mean = 1.7) compared with acquired nevi (mean = 2.2), dysplastic nevi (mean = 2.4), primary melanomas (mean = 2.4), or metastatic melanomas (mean = 3).

CONCLUSIONS

Although telomerase activity was weaker in Spitz nevi, there was overlap with other nevi and primary invasive melanomas in our small series. Thus, hTERT expression does not appear to be a reliable adjunct to the histological diagnosis of primary melanocytic lesions.

Clinical usefulness of telomerase for the detection of colon cancer in ulcerative colitis patients

BACKGROUND AND AIM

Colorectal carcinoma (CRC) is a complication of ulcerative colitis (UC). Although stool occult blood and colonoscopy are used to detect CRC in UC, these methods have drawbacks, in that bleeding is associated with UC and the underlying mucosa is irregular, making it difficult to detect dysplasia. Telomerase and its catalytic subunit, telomerase reverse transcriptase (hTERT), are specifically expressed in cancers, making them candidate markers for the early detection of cancer. We previously reported that assays of telomerase in pancreatic juice may be useful for the early detection of pancreatic cancer. The aims of our study were to determine whether assays for telomerase and TERT may be useful in the diagnosis of CRC developed in UC patients.

METHODS

Luminal washings and biopsies were collected during colonoscopy in 66 patients; 34 with CRC, 21 with UC, and 11 controls. Telomerase activity was detected by telomeric repeat amplification protocol (TRAP) and hTERT mRNA was assayed by reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

Telomerase activity was detected in biopsies from 33 of 34 (97%) CRC patients, 14 of 21 (67%) UC patients, and three of 11 (27%) normal controls. Expression of hTERT mRNA was observed in biopsies from 32 of 34 (94%) CRC patients, 12 of 21 (57%) UC patients, and five of 11 (45%) controls. In analyses of washing fluid, 21 of 34 (62%) of CRC patients were positive for telomerase, but all UC patients and controls were negative. The sensitivity of telomerase for CRC was 97% in tissues and 62% in washing fluid. The specificity of telomerase in washing fluid was 100%, whereas the specificity of telomerase or hTERT mRNA in tissues was 47% each.

CONCLUSIONS

For the detection of CRC arising in UC, telomerase and hTERT in colonic tissue showed high sensitivity, and telomerase in colonoscopic luminal washings revealed a high specificity. These might be candidate markers in clinical decision making for the diagnosis of CRC from UC.

Telomerase activity and hTERT mRNA expression in body fluids

Telomerase is a ribonucleoprotein enzyme associated with cellular immortality, and its activity is detectable in most human tumors and immortalized cells. In the present study, we examined telomerase activities and gene expression of human telomerase reverse transcriptase (hTERT) to detect malignant cells in body fluid. Twenty-eight cytological fluids were obtained from 28 patients, including 12 patients with benign cases and 16 patients with malignant tumors (14 ascitic fluids, 12 pleural fluids, 1 peritoneal washing, and 1 pericardial fluid). Telomerase activity was measured using a quantitative telomeric repeat amplification protocol (TRAP), and the hTERT messenger RNA (mRNA) expression was detected by reverse-transcription polymerase chain reaction (RT-PCR). Of the 16 malignant cases, telomerase activity was detected in 8 cases, and 10 cases involved expression of (hTERT) (mRNA). Neither telomerase activity nor hTERT mRNA expression was detected in benign cases. The telomerase activity and mRNA expression exhibited sensitivities of 50 and 62.5%, respectively, and both methods showed a specificity of 100%. The hTERT mRNA expression is a more sensitive marker than telomerase activity. Our results suggest that measurement of mRNA expression of hTERT in body fluid is useful as an adjunctive tool for cytological diagnosis.

Tumor cell-specific BRCA1 and RASSF1A hypermethylation in serum, plasma, and peritoneal fluid from ovarian cancer patients

Because existing surgical and management methods can consistently cure only early-stage ovarian cancer, novel strategies for early detection are required. Silencing of tumor suppressor genes such as p16INK4a, VHL, and hMLH1 have established promoter hypermethylation as a common mechanism for tumor suppressor inactivation in human cancer and as a promising target for molecular detection in bodily fluids. Using sensitive methylation-specific PCR, we screened matched tumor, preoperative serum or plasma, and peritoneal fluid (washes or ascites) DNA obtained from 50 patients with ovarian or primary peritoneal tumors for hypermethylation status of the normally unmethylated BRCA1 and RAS association domain family protein 1A tumor suppressor genes. Hypermethylation of one or both genes was found in 34 tumor DNA (68%). Additional examination of one or more of the adenomatous polyposis coli, p14ARF, p16INK4a, or death associated protein-kinase tumor suppressor genes revealed hypermethylation in each of the remaining 16 tumor DNA, which extended diagnostic coverage to 100%. Hypermethylation was observed in all histologic cell types, grades, and stages of ovarian tumor examined. An identical pattern of gene hypermethylation was found in the matched serum DNA from 41 of 50 patients (82% sensitivity), including 13 of 17 cases of stage I disease. Hypermethylation was detected in 28 of 30 peritoneal fluid DNA from stage IC-IV patients, including 3 cases with negative or atypical cytology. In contrast, no hypermethylation was observed in nonneoplastic tissue, peritoneal fluid, or serum from 40 control women (100% specificity). We conclude that promoter hypermethylation is a common and relatively early event in ovarian tumorigenesis that can be detected in the serum DNA from patients with ovary-confined (stage IA or B) tumors and in cytologically negative peritoneal fluid. Analysis of tumor-specific hypermethylation in serum DNA may enhance early detection of ovarian cancer.

Advantages of assaying telomerase activity in ascites for diagnosis of digestive tract malignancies

AIM: To evaluate the diagnostic value of assaying telomerase activity in ascites cells for the differential diagnosis of malignant and non-malignant ascites.

METHODS: Ascites from 40 patients with hepatocellular carcinoma (HCC), 31 with non-HCC gastrointestinal carcinoma (CA), and 24 with liver cirrhosis (LC) were analyzed for telomerase activity. The telomerase activities in cell pellets from ascites were measured according to the Telomeric Repeat Amplification Protocol (TRAP) and quantified with a densitometer.

RESULTS: Positive telomerase activity was detected in 16 of 31 (52%) CA patients, 10 of 40 (25%) HCC patients, and 1 of 24 (4%) LC patients (P < 0.001). The telomerase activity was higher in the ascites of CA patients than in the ascites of HCC or LC patients (CA: 22.9 ± 5.8, HCC: 6.7 ± 2.5, LC: 1.3 ± 1.3, P = 0.001). Cytology was positive in 18 CA patients (58%) and 1 HCC patient (2.5%), respectively. The positive telomerase activity was not related to patients’ age, gender, and ascitic protein concentration, but to white blood count (r = 0.31, P = 0.002), neutrophil count (r = 0.29, P = 0.005), and the C-reactive protein level (r = 0.29, P = 0.018). When the results of both cytological examination and telomerase assay were considered together, the sensitivity increased to 77% for CA patients, 25% for HCC patients, and 48% for all 71 gastrointestinal cancer patients.

CONCLUSION: Combining cytological examination of ascites with telomerase activity assay significantly improves the differential diagnosis between malignant and non-malignant ascites.

Detection of Residual Subclinical Ovarian Carcinoma after Completion of Adjuvant Chemotherapy

PURPOSE

We sought to test the hypothesis that the presence of telomerase activity in peritoneal washings of patients treated for ovarian carcinoma is a sensitive and specific indicator of the presence of residual disease. We hypothesized that this test, if added to second-look procedure protocols, could help determine whether residual disease is present or not in patients who have completed their adjuvant chemotherapy for ovarian carcinoma.

EXPERIMENTAL DESIGN

Peritoneal washings were obtained from 100 consecutive patients undergoing a second-look procedure after treatment for ovarian carcinoma (cases) and from 100 patients undergoing surgery for benign gynecological conditions (controls). The washings were assayed for telomerase activity using the telomerase repeat amplification protocol. The results were compared to the histological and cytological findings.

RESULTS

Among our 100 cases, 82 (82%) had either positive second-look procedures or expressed telomerase in their peritoneal washings. Fifty-three (53%) had positive second-look procedures, whereas 66 (66%) tested positive for telomerase. Twenty-nine of the 47 patients (62%) with negative second-look procedures tested positive for telomerase. Of the 53 patients with positive second-look procedures, 37 (70%) tested positive for telomerase. None of the 100 controls (0%) expressed telomerase in their peritoneal washings.

CONCLUSIONS

Telomerase activity in peritoneal washings of patients treated for ovarian carcinoma and undergoing a second-look procedure may provide a means of increasing the sensitivity of such procedures for the detection of residual disease while maintaining a high level of specificity.

A peritoneal dialysis patient with fatal culture-negative peritonitis. Case Discussion

Culture-negative peritoneal inflammation accounts for between 5 and 20% of cases of peritonitis in peritoneal dialysis patients. Diagnostic yields may be enhanced considerably by reculturing dialysate effluents using appropriate collection methods and optimal laboratory techniques (including prolonged low-temperature and anaerobic incubations). In patients with persistent culture-negative peritonitis, consideration should be given to the possibilities of unusual or fastidious microorganisms (especially fungi and mycobacteria) and non-infective causes (especially drug reactions, malignancy, visceral inflammation and retroperitoneal inflammation). In this paper, an illustrative case of persistent culture-negative peritonitis is presented followed by a discussion of the investigative approach to such patients, with particular emphasis on differential diagnosis and the limitations of currently available tests.

Detection of telomerase-positive circulating epithelial cells in ovarian cancer patients

The aim of this study is the detection of circulating tumor cells in peripheral blood of ovarian cancer patients. We applied immunomagnetic beads coated with an epithelial or leukocyte-specific antibody to isolate epithelial cells from peripheral blood and we measured their telomerase activity. Both enrichment methods showed high sensitivity and specificity to isolate ovarian tumor cells from peripheral blood. Our data also suggested that disseminated ovarian tumor cells isolated from ascites consistently express telomerase enzyme. We have tested epithelial cell enriched blood samples from 20 stage III patients, 8 stage IV patients and 30 healthy volunteers for telomerase activity. Telomerase activity was detectable in the blood samples of all stage IV patients (100%) and seven stage m patients (35%), but none of the healthy donors. Our results showed that CA-125 level, an established diagnostic marker for ovarian cancer, is significantly higher in telomerase-positive patients than telomerase-negative patients. In summary, our data demonstrated that this non-invasive blood test is sensitive and specific for detecting disseminated ovarian epithelial cells and telomerase is a potential marker for the detection of circulating ovarian tumor cells.

Molecular aspects of ovarian cancer

Ovarian cancer is caused by genetic alterations that disrupt proliferation, apoptosis, senescence and DNA repair. Approximately 10% of ovarian cancers arise in women who have inherited mutations in cancer susceptibility genes (BRCA1 or BRCA2). The ability to perform genetic testing allows identification of women at increased risk who can be offered prophylactic oophorectomy or other interventions aimed at preventing ovarian cancer. The vast majority of ovarian cancers are sporadic, resulting from the accumulation of genetic damage over a lifetime. Several specific genes involved in ovarian carcinogenesis have been identified, including the p53 tumour suppressor gene and HER2/ neu andPIC3KA oncogenes. The recent availability of expression microarrays has facilitated the simultaneous examination of thousands of genes, and this promises to extend further our understanding of the molecular events involved in the development of ovarian cancers. Hopefully, this knowledge can be translated into effective screening, treatment, surveillance, and prevention strategies in the future.

Telomerase as a diagnostic and therapeutic target for cancer

Telomerase is a ribonucleoprotein enzyme responsible for the elongation of telomeres at the ends of chromosomes. It is widely expressed in most cancers, while absent from most normal somatic cells. Telomerase is partially responsible for the cellular immortalization that allows human cancers to progress indefinitely. Due to its widespread occurrence in cancer and its crucial role in the maintenance of the tumor, telomerase is an attractive target for cancer diagnosis and treatment.

Telomere and telomerase in oncology

Shortening of the telomeric DNA at the chromosome ends is presumed to limit the lifespan of human cells and elicit a signal for the onset of cellular senescence. To continually proliferate across the senescent checkpoint, cells must restore and preserve telomere length. This can be achieved by telomerase, which has the reverse transcriptase activity. Telomerase activity is negative in human normal somatic cells but can be detected in most tumor cells. The enzyme is proposed to be an essential factor in cell immortalization and cancer progression. In this review we discuss the structure and function of telomere and telomerase and their roles in cell immortalization and oncogenesis. Simultaneously the experimental studies of telomerase assays for cancer detection and diagnosis are reviewed. Finally, we discuss the potential use of inhibitors of telomerase in anti-cancer therapy.

Telomerase Detection in Body Fluids

Background: Telomerase is a ribonucleoprotein that maintains chromosomal telomere length. Telomerase is not active in nonmalignant somatic cells, but is activated in most human cancers. Telomerase activity in easily obtainable body fluids that bathe tumors may be a useful cancer marker, especially when used in conjunction with conventional cytology.

Approach: Results from studies that assayed telomerase activity in easily obtainable body fluids are reviewed.

Content: The telomerase repeat amplification protocol (TRAP) assay has been used to measure telomerase activity in body fluids, including ascites, pleural effusions, pelvic washes, bronchial washings, bronchial lavage, urine, bladder washings, oral rinses, and plasma. Telomerase activity has sensitivities of 60–90% as a tumor marker with clinical specificities for cancer of ∼90%. Telomerase activity is more sensitive than conventional cytology, the sensitivity of which was 40–65% in various studies.

Summary: Telomerase activity in body fluids, as measured by the TRAP assay, is a sensitive potential tumor marker that might help increase the cancer detection rate and the cancer treatment success rate when combined with conventional cytology.

A quantitative method to measure telomerase activity by bioluminescence connected with telomeric repeat amplification protocol

Telomerase is expected to be a new biomarker for cancer diagnosis. The telomeric repeat amplification protocol (TRAP) is a sensitive method to detect telomerase activity. However, TRAP and its modified protocols are not always suitable for measuring telomerase activity of a large number of clinical samples to diagnosis cancer because these methods generally require a time-consuming detection step such as gel electrophoresis. To improve the procedure for mass diagnosis, we applied bioluminescence to replace the detection step. Telomerase activity is measured by evaluating the amount of inorganic pyrophosphate generated in PCR amplification of telomerase elongation product, with use of the sensitive enzymatic luminometric inorganic pyrophosphate detection assay (ELIDA). TRAP connected with ELIDA (TRAP-ELIDA) can quantitatively detect telomerase activity within linearity from 2 to 1000 cell equivalents. The ELIDA signals accorded with results of TRAP-SYBR green staining, and the results of ELIDA were significantly correlated to those of TRAP connected with an enzyme-linked immunosorbent assay (TRAP-ELISA) (r(2) = 0.992, P < 0.001). TRAP-ELIDA is a simple and sensitive method to quantify telomerase activity without time-consuming gel electrophoresis. Because TRAP-ELIDA measures telomerase activity with a luminometer, it could be applied to a large number of clinical samples at the same time.

Telomerase, immortality and cancer

Replication of eukaryotic linear chromosomes is incomplete and leaves terminal gaps. The evolutionary widely distributed solution to this "end replication" is twofold: chromosome ends are capped with telomeres, bearing multiple copies of redundant telomeric sequences, and the telomerase enzyme can add (lost) telomeric repeats. Telomerase in humans, as in all mammals, is ubiquitous in all embryonic tissues. In adults, telomerase remains active in germs cells, and, although down-regulated in most somatic tissues, telomerase is active in regenerative tissues and notably, in tumor cells. Telomerase activity is linked to cellular proliferation, and its activation seems to be a mandatory step in carcinogenesis. In contrast to mammals, indeterminately growing multicellular organisms, like fish and crustaceae, maintain unlimited growth potential or 'immortality' in all somatic tissues throughout their entire life. Also this cell immortalization is brought about by maintaining telomerase expression. Disease prognosis for human tumors includes evaluation of cell proliferation, based on the detection of proliferation markers with monoclonal antibodies. The significance of the classical marker Ki-67, and of a novel marker repp-86 are compared with semiquantitative telomerase assays. For tumor therapy, telomerase inhibitors are attractive tools. Results with telomerase knock-out mice have revealed promise, but also risk of this approach. On the other side, telomerase stimulation is attractive for expanding the potential of cellular proliferation in vitro, with possible applications for transplantation of in vitro expanded human cells, for immortalizing primary human cells as improved tissue models, and for the isolation of otherwise intractable products, like genuine human monoclonal antibodies.

Gene expression analysis of the catalytic subunit of human telomerase (hEST2) in the differential diagnosis of serous effusions

Diagnostic accuracy in effusion cytology based on morphologic examination is not always satisfactory. Therefore, various diagnostic adjuncts such as immunocytochemistry or deoxyribonucleic acid cytometry are employed in this diagnostic field. Recently, demonstration of telomerase activity has been proposed as a possible marker for malignancy. In this study a seminested reverse transcription-polymerase chain reaction (RT-PCR) strategy for expression analysis of the catalytic subunit of human telomerase (hEST2) was used in 58 serous effusions. RT-PCR results correlated with cytologic diagnoses in 14 of 17 malignant effusions. In eight effusions cytologically suspicious for malignancy, PCR results were in accordance with the clinical follow-up. However, hEST2 RT-PCR was also positive in six of 15 cytologically benign effusions that consisted predominantly of inflammatory and mesothelial cells. Using the telomeric repeat amplification protocol, it could be demonstrated that cultured, proliferating benign mesothelial cells may present a weak telomerase activity, as is known in other benign cells including activated lymphocytes. In conclusion, the simple and rapid method of hEST2 RT-PCR serves to support the cytologic diagnosis of malignancy, but false-positive PCR results resulting from activated lymphocytes and proliferating mesothelial cells must be considered.

Role of telomerase in cell senescence and oncogenesis

The ends of linear chromosomes are capped by specialized nucleoprotein structures termed telomeres. Telomeres comprise tracts of noncoding hexanucleotide repeat sequences that, in combination with specific proteins, protect against degradation, rearrangement, and chromosomal fusion events. Due to the polarity of conventional DNA synthesis, a net loss of telomeric sequences occurs at each cell division. It has been proposed that this cumulative telomeric erosion is a limiting factor in replicative capacity and elicits a signal for the onset of cellular senescence. To proliferate beyond the senescent checkpoint, cells must restore telomere length. This can be achieved by telomerase, an enzyme with reverse-transcriptase activity. This enzyme is absent in differentiated somatic tissues, but telomerase reactivation has been detected in most tumors. Much investigative effort is focusing on telomere dynamics with a view to possible manipulation of cellular proliferative potential. In this article, we review the role of telomeres and telomerase in senescence and tumor progression, and we discuss the potential use of telomerase in diagnosis and treatment.

Clinical applications of telomerase in cancer treatment

Telomerase activity has been found in most cancer cells, but not in the majority of normal differentiated tissues. Therefore, telomerase has been considered a relatively selective and widely expressed tumor marker to be used as a diagnostic tool, and in some cases, as a potential prognostic indicator. Telomerase activity can also be used to evaluate chemosensitivity of neoplastic cells obtained from cancer patients, by measuring residual telomerase activity after drug treatment. Finally, telomerase has been considered to represent a suitable target for designing new anticancer strategies. This review focuses on present and future clinical applications of telomerase studies in cancer management. Copyright 2000 Harcourt Publishers Ltd.

Telomerase activity in melanocytic lesions: A potential marker of tumor biology

Telomerase activation, being a cardinal requirement for immortalization, is a crucial step in the development of malignancy. With a view toward diagnostic and biological aspects in melanocytic neoplasia, we investigated the relative levels of telomerase activity in 72 nevi and 16 malignant melanomas by means of a modified telomeric repeat amplification protocol (TRAP) assay, including an internal amplification standard. We further compared telomerase activity with the expression of two different proliferation-specific proteins, Ki-67 and repp86, a protein expressed exclusively in the cell cycle phases S, G2, and M. Telomerase activity was associated with the overall growth fraction (Ki-67) but showed a closer correlation with the expression of repp86. Both telomerase activity and proliferation indices discriminated clearly between malignant melanomas and nevi, but not between common and dysplastic nevi. Nonetheless, a portion of nevi exhibited markedly elevated telomerase activity levels without proportionally increased proliferation. This was independent of discernible morphological changes. Clinicopathological correlations showed an association between high telomerase activity and early metastatic spread in melanomas, linking telomerase to tumor biology. Our results provide arguments in favor of an occasional progression from nevi to melanomas and imply that proliferation measurements in combination with telomerase assays may help to elicit early malignant transformation that is undetectable by conventional morphology.

2-5A antisense directed against telomerase RNA produces apoptosis in ovarian cancer cells

OBJECTIVE

RNase L is converted to an active form upon binding short 2',5'-oligoadenylates (2-5A). To direct RNase L to an RNA target, 2-5A is attached to an antisense oligonucleotide (2-5A antisense). This chimera can be directed against telomerase-an RNA-protein complex that elongates telomeric DNA and is involved in cellular immortalization. Our objective is to investigate the effect of 2-5A antisense by targeting telomerase RNA (hTR) in the ovarian cancer cell line, HEY-1B.

METHODS

Baseline RNase L levels and telomerase activities were measured in both HEY-1B and normal ovarian epithelial cells (NOE). Cells were treated daily with chimeric oligonuclotides (ODN) directed against four different hTR sites, or control ODNs including nonchimeric antisense, 2-5A fused to a mismatched sequence, or inactive 2-5A fused to antisense. At 48 h, apoptosis was evaluated using the TUNEL assay. After six daily ODN administrations, telomerase activity was redetermined, and at 7 days viability counts were obtained.

RESULTS

Both cell lines expressed similar levels of RNase L. Hey-1B displayed telomerase activity while NOE did not. After 7 days of transfection, 2-5A antisense ODNs caused profound cell death in the HEY-1B cells, but not in the NOE cells. This effect was seen regardless of hTR target site, and ODN controls showed no significant decrease in cell viability in either cell line. HEY1B cells treated with 2-5A antisense against hTR showed a decrease in telomerase activity and a profound induction of programmed cell death.

CONCLUSIONS

The results suggest that 2-5A antisense directed against telomerase RNA results in apoptotic cell death in ovarian cancer cells, but not normal ovarian epithelial cells. The 2-5A antisense strategy may hold a considerable advantage over the conventional antisense approach in targeting cancer-causing genes.

Analysis of telomerase activity in ovarian cystadenomas, low-malignant-potential tumors, and invasive carcinomas

OBJECTIVE

Inappropriate telomerase expression has been reported to be associated with the development and/or progression of malignancies. Therefore, the purpose of the study was to determine and evaluate the levels of telomerase activity in normal ovary, cystadenomas, low-malignant-potential tumors, and carcinomas of the ovary.

METHODS

In the present study, telomerase activity was examined in frozen tissue specimens of normal ovary (n = 6), ovarian cystadenomas (n = 13), ovarian low-malignant-potential (LMP) tumors (n = 12), and ovarian invasive carcinomas (n = 81). Clinicopathological information including age at diagnosis, histological grade, FIGO stage, presence of distant metastasis at diagnosis, and residual disease was available for all patients with ovarian carcinomas (n = 81). Telomerase activity was assessed by the telomeric repeat amplification protocol (TRAP). Arbitrary values were assigned to processivity of telomerase activities based on the molecular weights of the telomeric repeat DNA ladders, and were graded as "negative," "moderate" (< or =99 bp), or "high" (>100 bp) activities. The specificity of telomerase activity was determined by the pretreatment of telomerase-positive control or tumor samples with RNase that led to the abolition of the activity. In addition, to determine the possibility of false negativity due to the presence of telomerase inhibitors, TRAP assay was performed on each of the telomerase-negative specimens by mixing them individually with the telomerase-positive control.

RESULTS

Telomerase activity in the progression of ovarian carcinogenesis was evaluated. In comparison with normal ovary/cystadenoma (32%), a much higher frequency of the moderate activity was observed in LMP tumors (67%) or invasive carcinomas (57%), suggesting a close association between the latter two categories. The results reflect a subpopulation of telomerase-positive LMP tumor cells with the potential to develop invasive carcinomas. None of the specimens of the benign or LMP tumors exhibited high activity. In contrast, 18% of ovarian invasive carcinomas showed high telomerase activity (P = 0.013, Fisher exact test) and further 57%, moderate activity (75% in all). A statistically significant difference was observed in the expression of telomerase activity between normal ovary/benign cystadenomas and ovarian invasive carcinomas (P = 0.001, chi(2) test).

CONCLUSIONS

The study showed a high prevalence of telomerase activity in LMP tumors or invasive carcinomas, the high levels of telomerase activity being associated exclusively with the invasive ovarian carcinomas. Therefore, the levels of processivity of telomerase activity and evidence of its statistically significant association with ovarian carcinoma suggest its role in the progression of ovarian carcinogenesis.

Detection of telomerase activity in biopsy samples of colorectal cancer

BACKGROUND

Telomerase is a ribonucleoprotein that synthesizes telomeric DNA onto chromosomal ends. The expression of telomerase is thought to be required for cellular immortality and oncogenesis.

METHODS

To investigate the role of telomerase in the pathogenesis of colorectal cancer, we analysed telomerase activity in biopsy samples of colorectal cancer and colonic adenomas. Using a polymerase chain reaction-based assay, we examined telomerase activity in 52 samples of colorectal cancer, 12 colonic adenomas and 30 normal colonic mucosa samples obtained by endoscopic biopsy.

RESULTS

Telomerase activity was detectable in 88.5% (46/52) of colorectal carcinomas, in 50% (6/12) of colonic adenomas but not in normal colorectal mucosa. There was no correlation between telomerase activity and tumour location, type, size and differentiation (P > 0.05).

CONCLUSIONS

It was concluded that telomerase activation plays a role in the evolution of colorectal cancer, and that measurement of telomerase activity in biopsied colorectal mucosa samples may provide information both as a diagnostic marker to detect small numbers of cancer cells, and as a screening method for patients at high risk for colorectal carcinoma.

Applications of telomerase research in the fight against cancer

Telomerase, an enzyme that confers immortality upon cells and that is active in the majority of human tumors, has emerged as a powerful new marker and potential prognostic indicator and therapeutic target for cancer. Furthermore, investigations into the biology of telomerase have revealed important clues into the causes of cell death and have made progress toward answering one of the most important questions of cancer research - what gives a tumor cell an advantage over normal cells? In this article, we present the current state of telomerase research and critically assess both its potential and the pitfalls of its application in cancer diagnosis and treatment.

Three molecular determinants of malignant conversion and their potential as therapeutic targets

The past decade has been marked by an explosion of knowledge regarding the dysregulation of cancer at the molecular level. It has become apparent that oncogenes, tumor suppressor genes, and other ancillary molecules interact in complex pathways that govern cellular homeostasis. We review three molecular events that have been implicated in tumorigenesis and define pathways ripe for the development of new therapeutic approaches: 1) activation of telomerase, 2) dysregulation of the patched/sonic hedgehog pathway, and 3) mutation of the INK4 alpha-ARF locus.