High EPHB2 mutation rate in gastric but not endometrial tumors with microsatellite instability.

The EPH/EFN family of receptor tyrosine kinases regulates cell adhesion and migration and has an important role in controlling cell positioning in the normal intestinal epithelium. Inactivation of EPHB2 has recently been shown to accelerate tumorigenesis in the colon and rectum, and we have previously demonstrated frequent frameshift mutations (41%) in an A9 coding microsatellite repeat in exon 17 of EPHB2 in colorectal tumors with microsatellite instability (MSI). In this study, we extended these analyses to extracolonic MSI cancers, and found frameshift EPHB2 mutations in 39% (25/64) of gastric tumors and 14% (8/56) of endometrial tumors. Regression analysis of these EPHB2 mutation data on the basis of our previously proposed statistical model identified EPHB2 as a selective target of frameshift mutations in MSI gastric cancers but not in MSI endometrial carcinomas. These results suggest a functional role for EPHB2 in gastric tumor progression, and emphasize the differences between the tumorigenic processes in MSI gastrointestinal and endometrial cancer.

Lower frequency of allele loss on chromosome 18q in human breast cancer than in colorectal tumors.

Inactivation of tumor suppressor genes is thought to be a critical step in tumorigenesis. The DCC (deleted in colorectal carcinoma) gene, located on the long arm of chromosome 18, has been shown to be frequently deleted in colorectal tumors. To investigate the involvement of allelic deletions on chromosome 18q in breast cancer tumorigenesis we analyzed 28 primary breast tumors and 28 colorectal tumors (24 carcinomas, 4 adenomas) with four different polymorphic DNA markers detecting RFLPs on chromosome 18q. In breast cancer we found loss of heterozygosity (LOH) in 4 of 27 (15%) informative cases whereas 15 of 25 (60%) colorectal tumors showed allelic deletions. In all cases of allelic loss the DCC locus or its proximal vicinity (locus SSAV1) were involved. LOH on chromosome 18q occurs both in breast and colorectal cancer, yet the frequency of these deletions in breast tumors is lower than in colorectal tumors. Moreover, in breast cancer these mutations were only detected in large and undifferentiated tumors.

On the histogenesis and morphology of ovarian carcinomas.

The modern classification of ovarian tumors based on histogenetic principles is clinically important in the evaluation of prognosis and differential therapy. Ninety percent of malignant ovarian tumors belong to the category of "common carcinomas." All of these tumors originate from the coelomic epithelium at any of various stages of its differentiation into the derivatives of the Müllerian duct, giving rise to a large group of tumors that can be subdivided into serous papillary cyst-adenocarcinomas arising from surface-like epithelium, mucinous cystadenocarcinomas arising from endocervical-like epithelium, endometrioid carcinomas from endometrium-like epithelium, clear-cell carcinomas from endocervical or endometrium-like epithelium, malignant cystadenofibromas from undetermined pluripotent Müllerian epithelium, and (malignant) Brenner tumors from heterotopic epithelium resembling Wolffian differentiation, as seen in the urothelium. The well differentiated stages of these carcinomas can be readily distinguished by comparing them with the derivates of the Müllerian epithelium. The poorly differentiated types, on the other hand, may provide no criteria for comparison, but can still be classified as belonging to the group of common epithelial tumors. Adenocarcinomas of one type may also contain portions of another related type, e.g., serous papillary carcinomas may contain mucinous glands or groups of clear cells and vice versa. Serous papillary carcinomas form the largest group containing about 50% of all ovarian carcinomas. The endometrioid carcinomas comprise roughly 20%, the mucinous carcinomas 10%, and the VXGHb-cell carcinomas roughly 10%. Five percent of all carcinomas are unclassifiable and the remaining 5% constitute the group of rare ovarian carcinomas: the malignant cystadenofibromas, adenosarcomas, malignant mesenchymal mixed tumors, and malignant Brenner tumors. The three main groups can be histologically subdivided into three grades: those of high, moderate and poor differentiation. In addition, a borderline tumor representing a pre-stage of invasion and metastasis has been recognized. The prognosis with serous papillary carcinomas is poor, with an overall 5-year survival rate of 20%; the 5-year survival rate for mucinous carcinomas is 40%-60%, for endometrioid carcinomas 55%, and for clear-cell carcinomas 40%. Statistically significant data for predicting the prognosis for rare carcinomas are not available.

In vitro fertilization: the degree of endometrial insufficiency varies with the type of ovarian stimulation.

Fifty-eight patients in an in vitro fertilization program who did not have embryo transfers had endometrial biopsies performed on the second day after ovulation. The patients had been stimulated with clomiphene citrate (CC) and human chorionic gonadotropin (hCG) (group I); with CC, human menopausal gonadotropin (hMG), and hCG (group II), or with hMG and hCG (group III). Only 17 patients (30%) showed a normal luteal phase histology. The remaining 41 patients (70%) showed variety of endometrial abnormalities. Patients stimulated with hMG and hCG (group III) had a normal luteal phase at a significantly higher rate (48% versus 16%). Women below the age of 35 had a significantly higher rate of normal luteal phase histology than women older than 35 years. The study establishes abnormal endometrial histology as a possible cause of the low pregnancy rate of in vitro fertilization. The degree of endometrial histologic abnormality varies considerably with the type of ovarian stimulation used.

The endometrium of infertility. A review.

Almost all functional disturbances involved in sterility result in morphological changes in the endometrium. Since hormone levels fluctuate depending upon various biorhythms, the histological examination of the endometrial biopsy is the most reliable parameter for evaluating the cause of infertility. A major subdivision can be made into anovulatory and ovulatory infertility. The anovulatory cycle is most frequently caused by a polycystic ovary syndrome, less frequently by gonadal dysgenesis, receptor or enzyme deficiencies, ovarian neoplasms, autoimmune reactions, or the luteinized unruptured follicle syndrome. Histologically the endometrium, depending upon the amount of estrogen secreted and reacting, is atrophic, resting, deficiently or irregularly proliferated or hyperplastic at the end of a menstrual cycle. A limited and deficient luteinization within a non-ovulating insufficient follicle may also result in abortive secretion which must be differentiated from deficient secretion following ovulation. In ovulatory infertility an absolute or relative progesterone deficiency results in a deficient secretory phase with delayed maturation of glands and stroma. The delay in maturation may be dissociated in the presence of an insufficient corpus luteum with absolute progesterone deficiency or coordinated when progesterone secretion is normal but counteracted by too much estrogen, as from a preceding persistent follicle. Since in these instances ovulation is delayed, the coordinated delay in maturation of the endometrium is only apparent. A truly delayed coordinated maturation may occur when the progesterone cannot fully act because of a preceding deficient proliferation. In addition, cyclic asynchrony with shortened or prolonged menstrual cycles may cause infertility by altering the endometrium so the blastocyst cannot implant. Rare non-functional endometrial changes as causes of infertility may be tuberculous endometritis, polyps or true neoplasms.

On the origin and histological structure of adenocarcinoma of the endocervix in women under 50 years of age.

In the last 10 years 28 adenocarcinomas of the endocervix developing in women up to the age of 50, have been encountered at our clinic. Of these women, 23 (82%) had taken oral contraceptives, in most instances continuously for up to 19 years, and for a median of 10 years. During the same period of time, 12 adenocarcinomas in situ of the endocervical mucosa were seen, 11 of which developed after 1 to 20 years of use of oral contraceptives. In contrast, only 40% of women with invasive squamous carcinoma under age 50 had used oral contraceptives. Fourteen of the 23 patients with invasive adenocarcinomas and 9 patients with adenocarcinoma in situ had taken contraceptives containing a potent gestagen, Norgestrel; the others had taken either Norethisterone acetate or Lynestrenol, usually in relatively high doses. Microscopically, the adenocarcinoma in the 28 women occurred in 3 forms, two of which did not appear in the 5 noncontraceptive users. In the women taking oral contraceptives, microglandular hyperplasia of the endocervix was diagnosed either prior to or coincident with the adenocarcinoma. The clinical observations are supported by experimental findings: 2 of 12 rhesus monkeys treated for 10 years with medroxyprogesterone acetate at doses 50 times those prescribed for women developed a similar type of adenocarcinoma. The longterm use of synthetic gestagens may be causally related to the development of endocervical adenocarcinoma.

PIP: In the last 10 years, 28 adenocarcinomas of the endocervix developing in women up to the age of 50 have been encountered at the author's clinic. Of these women, 23 (82%) had taken oral contraceptives (OCs), in most instances continuously for up to 19 years, and for a median of 10 years. During the same period of time, 12 adenocarcinomas in situ of the endocervical mucosa were seen, 11 of which developed after 1-20 years of use of OCs. In contrast, only 40% of women with invasive squamous carcinomas under age 50 had used OCs. 14 of the 23 patients with invasive adenocarcinomas and 9 patients with adenocarcinomas in situ had taken OCs containing a potent gestagen, Norgestrel; the others had taken either Norethisterone acetate or Lynestrenol, usually in a relatively high dose. Microscopically, the adenocarcinoma in the 28 women occurred in 3 forms, 2 of which did not appear in the 5 noncontraceptive users. In the women taking OCs, microglandular hyperplasia of the endocervix was diagnosed either prior to or coincident with the adenocarcinoma. The clinical observations are supported by experimental findings: 2 of 12 rhesus monkeys treated for 10 years with medroxyprogesterone acetate at doses 50 times those prescribed for women developed a similar type of adenocarcinoma. The longterm use of synthetic gestagens may be causally related to the development of endocervical adenocarcinoma.

[The stromal and myogenic sarcomas of the uterus (author's transl)]. / Die stromatogenen und myogenen Sarkome des Uterus.

Stromal sarcomas of the uterus generally originate as homologous tumors from endometrial stromal cells with fixed potentialities. They may be composed of one type of cell or of several types, or rarely they may consist only of endometrial granulocytes. From the same source but with a more favorable prognosis is endolymphatic stromatosis, which arises primarily in the myometrium but does not diffusely invade it, as the stromal sarcoma does. By contrast, heterologous malignant mesenchymal mixed tumors of the endometrium originate from Müllerian epithelium derived fro the mesoderm, and are therefore pluripotential. In this group we find rhabdomyosarcomas and chondroblastomas which have a very poor prognosis. The myogenic sarcomas are three times more common, and arise from smooth muscle cells of the myometrium or its blood vessels. The degree of nuclear pleomorphism may vary considerably, from normal to giant cell types, and may differentiate also as clear-cell myoblasts. They portend a somewhat more favorable prognosis than the stromal sarcomas.

Immunohistochemical studies on uterine tumors. I. Invasive squamous cell carcinomas of the cervix and their precursors.

40 invasive carcinomas and 80 preinvasive lesions of the uterine cervix were studied immunohistochemically; 40 benign lesions served as controls. On histological and immunohistochemical examination, invasive and preinvasive carcinomas were subdivided in the squamous (large cell, ectocervical) type and the reserve cell (small, large or clear cell, endocervical) type. Immunohistochemically, 100% of the invasive and preinvasive squamous cell carcinomas were positive with anticytokeratins 13, 14, 16 and negative with anticytokeratin 8 and anti-CEA. Most of the invasive and preinvasive reserve cell carcinomas showed a coexpression of cytokeratins 13, 14, 16, 8 and CEA. The subdivision of invasive carcinomas of the ecto- and endocervix into squamous cell and reserve cell types made by means of their structural differences is substantiated and re-evaluated by their immunohistochemical reactions. Both types of carcinomas retain the complex pattern of cytokeratins shown by their cells of origin. The reserve cell carcinomas, in addition, acquire a coexpression for CEA that indicates malignant transformation. The subdivision is of clinical importance because both types of carcinomas vary in their mode and speed of invasion and spread and in their association with HPV infection.

Intermediate filaments of normal and neoplastic tissues of the female genital tract with emphasis on problems of differential tumor diagnosis.

Cytokeratins of normal epithelia and of some neoplasms of the female genital tract were studied by immunofluorescence microscopy of frozen sections and by two-dimensional gel electrophoresis of cytoskeletal proteins from microdissected tissues. All normal epithelia were stained with the monoclonal cytokeratin antibody KG 8.13 whereas certain monoclonal antibodies stained only simple epithelia. As revealed by gel electrophoresis the normal epithelia of the ovarian surface, oviduct, endometrium and endocervix contained cytokeratin polypeptides Nos. 7, 8, 18 and 19. In contrast, stratified exocervical epithelium showed a much more complex pattern (polypeptides No. 1, 2, 4, 5, 6, 11, 13, 14, 15, 16, 17 and 19). A similar pattern was found in the vagina. All epithelial neoplasms studied, regardless of the degree of histologic differentiation, were stained with antibody KG 8.13 as well as with conventionally obtained guinea pig antibodies to bovine muzzle prekeratins. The ovarian, endometrial and endocervical epithelial tumors maintained the pattern of their cells of origin, i.e. they expressed only cytokeratins Nos. 7, 8, 18 and 19. In one type of endocervical adenocarcinoma an additional cytokeratin polypeptide (No. 17) was detected. In contrast, the epithelial tumors of the lower genital tract showed a more complex pattern which also showed some differences with respect to that described for the corresponding normal tissue. Thus, in non-keratinizing squamous cell cervical carcinomas, cytokeratins Nos. 5, 6, 7, 8, 13, 14, 15, 16, 17, 18 and 19 were present, whereas the keratinizing cervical cancers showed polypeptides Nos. 5, 6, 13, 14, 16, 17 and 19.(ABSTRACT TRUNCATED AT 250 WORDS)

Prognostic parameters in patients with advanced ovarian malignant tumors.

The role of a number of parameters was evaluated in 172 patients with advanced ovarian tumors. The clinical stage appears to be one of the most important of these parameters. Thus 3 years survival of patients in stage II was 40% whereas of those in stage IV only 5%. Granulosa cell tumors and mucinous cystadenocarcinomas presented the best prognosis while patients with undifferentiated and endometrioid carcinomas had a shorter survival. Patients with well differentiated tumors had a 3 year survival of 28% and those with poorly differentiated neoplasms 10%. Women under the age 50 showed a better prognosis than those over 50. The 3 year survival rate with residual tumors measuring less than 2 cm in diameter was 55% and that with residual tumors of more than 2 cm 18%. These parameters should therefore be carefully considered when therapy is being planned and when results of various therapeutic procedures are being compared.

The endometrium in natural and artificial luteal phases.

The normal human endometrium reacts precisely and sensitively to any hormonal stimulation with predictable changes. If the corpus luteum develops normally after ovulation, the progesterone secreted induces specific changes in endometrial glandular and stromal cells that can be dated by daily fine-structural alterations. With corpus luteum deficiency the endometrial differentiation is delayed and remains incomplete. The defect in the differentiation of glands and stroma varies in their distribution and intensity and may be dissociated or coordinated depending upon the cause of the corpus luteum deficiency. The administration of natural progesterone in the second half of the cycle prolongs the luteal phase and may result in hypersecretion of glands. In contrast, therapy with synthetic gestagens depresses glandular secretion, induces glandular atrophy and decidualization of the stroma. The various synthetic gestagens differ both quantitatively and qualitatively in their action; depending upon the dosage given the endometrium remains in abortive or arrested secretion. Clomiphene depresses normal secretion by its antioestrogenic effect which causes deficient oestrogen priming. On the other hand, clomiphene counteracts excessive oestrogen and will normalize the secretion in a deficient luteal phase that was preceded by follicular persistency. In the artificial cycle, depending upon the state of endogenous hormonal stimulation, the patients will benefit either from clomiphene or gonadotrophin to maintain or normalize their secretory endometrium.

Changes in the endometrium caused by endogenous hormonal dysfunction.

The endometrium responds precisely and predictably to every hormonal dysfunction that may result from absent, deficient or excessive hormone production caused by an arrest of follicular maturation at different stages. Anovulatory failures may be due to arrest of follicular development and may cause endometrial atrophy or deficient proliferation. Arrest of follicular regression may result in irregular proliferation or various degrees of hyperplasia. Ovulatory failures may be due to arrest of corpus luteum maturation and followed by deficient secretion with dissociated or coordinated delay in differentiation. Arrest of corpus luteum regression may cause secretory hypertrophy. Both, anovulatory and ovulatory functional disturbances, are followed by prolonged and irregular endometrial shedding with necrosis, since regular dissociation of endometrial stromal cells is impaired. Almost all such functional deviations may cause infertility.

Histopathology of functional and neoplastic changes in cervix and endometrium.

Over 90% of all cervical carcinomas originate from hyperplastic reserve cells of the endocervix. When cell cycles of the pluripotent reserve cells are shortened or damaged by hormonal overstimulation or toxic chemicals, DNA repair after viral infection is no longer possible. The immortalized cells may then become malignant with precancerous and carcinomatous differentiation to squamous, adenosquamous or adenocarcinomas. To determine the type of HPV infection is clinically important for estimating prognosis and for planning further therapy. In recent years HPV 18-associated endocervical adenocarcinomas have increased considerably in number as compared with squamous cell carcinomas. In endometrial carcinomas the estrogen-stimulated endometrioid types must be distinguished from the gestagen-stimulated mucinous, clear-cell and serous-papillary types because prognosis as well as operative and adjuvant therapy differ considerably. The endometrioid carcinomas and their preceeding atypical hyperplasia are frequently associated with bcl-2, c-myk and c-ki-ras oncogenes. The mixed Muellerian types, in contrast, and their preceeding mucinous, clear-cell and serous-papillary metaplasias very often show genetic defects, LOH, mutations, amplifications and deletions, especially of p53. The endometrial carcinomas occurring in the reproductive age period are of endometrioid type and frequently present microsatellite instabilities. In rapidly proliferating tissues like the endometrium there appears to be a close correlation between functional and neoplastic changes. A simple explanation for that might be found in the greatly enhanced mitotic activity in a hormonally stimulated endometrium with shortening of cell cycles, leaving insufficient time for DNA repair. Since, however, carcinogenesis is a multi-factorial event, to correlate endometrial function with morphology can contribute only one aspect to the understanding of neoplastic change. In discussing hormonal function it is important to realize that the endocervix and the endometrium differ not only in their cellular structure, but they react antagonistically to hormonal stimulation: excessive (endogenous or exogenous) estrogen results in hyperproliferation of endometrial epithelial cells, but in the cervix in differentiation of the endocervical cells with mucus production. Extensive synthetic gestagens lead to hyperproliferation of endocervical epithelial cells (reserve cells as well as glandular epithelial cells), but in the endometrium cause atrophy (see Table 1).

[Regarding the causes of inflammatory reactions in the endometrium associated with intrauterine devices (author's transl)]. / Zur Ursache entzündlich Reaktionen des Endometriums auf Intrauterinpessare.

PIP: We examined 1048 endometrial biopsies after medicated IUDs had been inserted. In 161 cases, there was a perifocal or diffuse endometritis, and in all these, the endometrium was functionally underdeveloped. This was due largely to the prior use of oral contraceptives. Less often, the functional underdevelopment was due to endogenous hormonal disturbances. Accordingly, the lowered resistancy of the functionally underdeveloped state of the endometrium can be considered as an important cause of the endometritis. (author's)^ieng

[Incidence of spontaneous abortion with and without previous use of contraceptive agents based on morphological studies]. / Häufigkeit von Spontanaborten mit und ohne vorherige Einnahme von Ovulationshemmern anhand morphologischer Untersuchungen.

PIP: Morphological studies were performed on the placenta and endometrium in 213 cases of spontaneous abortion. 113 of the women had used oral contraceptives (o.c.s); 100 served as a control group. The pathological changes of the placenta and endometrium were more frequent in the o.c. group. Such pathological changes are more dependent on the type of o.c. used than on the length of the interval between discontinuation of o.c. use and conception. Irregularities in placental and endometrial development were found even after a 12 month interval among those who used preparations with a primarily gestagenic effect, above all those preparations containing norgestrel. Pathological changes of the placenta were more frequent than underdevelopment of the endometrium among the o.c. group. It is possible that many of the placental changes were also related to endometrial underdevelopment. Of 67 women who used preparations with primarily gestagenic effect, 13, all of whom had used o.c.s containing norgestrel, showed placental damage with normal endometrial development, while 2 showed normal placental development in conjunction with abnormal endometrial development. This would indicate that ovular or ovarian damage is also involved in the incidence of spontaneous abortion among o.c. users. Most disturbances in endometrial function were observed within 6 months after discontinuing o.c. use, while placental changes could be observed even after a 12 month interval. This implies that the endometrium recovers more rapidly from changes during o.c. use than do the ovaries.^ieng