Immunoexpression of B7-H3 in endometrial cancer: relation to tumor T-cell infiltration and prognosis.

OBJECTIVE: B7-H3, a member of the B7 family of immune regulatory ligands regulates T cell-mediated peripheral immune response. The purpose of this study was to correlate the expression of B7-H3 and number of lymphocytes in patients with endometrial cancer. MATERIAL AND METHODS: A total of 107 patients with primary endometrial carcinoma (type I/endometrioid, n=81; type II, n=18) and endometrial hyperplasia (n=8) were investigated. Expression of B7-H3 in endometrial hyperplasia, endometrial carcinoma, and the endothelium of tumor-associated vasculature was assessed using immunohistochemistry from paraffin-embedded tissue blocks. Detection of CD8-positive tumor-infiltrating lymphocytes (TIL) and CD8-positive tumor-associated lymphocytes (TAL) was correlated with the expression of B7-H3. RESULTS: Patients with high grade tumors and patients with type II carcinomas expressed significantly more B7-H3 than low grade and endometrioid tumors (p=<0.0001 and p=0.0001, respectively). The expression of B7-H3 in the endothelium of identified vasculature in the tumor specimens showed similar results with strong relation to high grade tumors (p=0.001) and type II carcinomas (p=0.004). We found a significant correlation between B7-H3 expression on cancer cells and tumor T-cell infiltration (TIL) (p=0.017). In a univariate survival analysis, overexpression of B7-H3 in tumor cells was associated with shortened overall survival (p=0.005). CONCLUSIONS: B7-H3 is overexpressed on cancer cells and in the endothelium of tumor-associated vasculature in high grade tumors (G3) and type II carcinomas. B7-H3 expression on cancer cells is correlated with the number of T cells infiltrating the tumor. Endometrium tumor development and progression may be associated with downregulation of T-cell-mediated antitumor immunity through B7-H3.

The preoperative assessment of deep myometrial invasion by three-dimensional ultrasound versus MRI in endometrial carcinoma.

OBJECTIVE: To evaluate the usefulness of three-dimensional ultrasound (3D US), magnetic resonance imaging (MRI) and three-dimensional power Doppler angiography (3D-PDA) in the preoperative assessment of myometrial invasion in endometrial carcinoma. DESIGN: A prospective observational study. SETTING: University hospital. POPULATION: Twenty consecutive patients diagnosed with endometrial carcinoma. METHODS: Preoperative 3 T MRI and 3D US examinations were performed, and the depth of myometrial invasion was assessed. The vascularity indices, vascularization index, flow index and vascularization flow index, were calculated by 3D-PDA. MAIN OUTCOME MEASURES: The results were compared with the final histopathology report after a surgical staging. RESULTS: In detecting deep myometrial invasion, the sensitivity of 3D US, MRI and their combination was 50, 91.7 and 100%, respectively. The specificity was 87.5, 50 and 50%, respectively. There were no significant differences in the 3D-PDA vascularity indices between the two groups. CONCLUSIONS: MRI appears to be more sensitive than 3D US in detecting deep invasion, while 3D US has a better specificity.

Evaluation of vascular space involvement in endometrial adenocarcinomas: laparoscopic vs abdominal hysterectomies.

Recent reports have described 'vascular pseudoinvasion' in total laparoscopic hysterectomies with endometrial carcinoma. To better understand this phenomenon, we compared pathologic findings in these laparoscopic and total abdominal hysterectomies performed for uterine endometrioid adenocarcinoma. Reports from 58 robotically assisted laparoscopic and 39 abdominal hysterectomies with grade 1 or 2 endometrioid endometrial adenocarcinomas were reviewed for stage, depth of invasion, vascular space involvement, uterine weight, and lymph node metastases. In addition, attention was given to possible procedural artifacts, including vertical endomyometrial clefts, and inflammatory debris, benign endometrial glands, and disaggregated tumor cells in vascular spaces. All foci with vascular involvement were reviewed by three gynecologic pathologists. Nine of the 58 (16%) laparoscopic and 3 of the 39 (7%) abdominal hysterectomies contained vascular space involvement based on the original pathology reports (P-value=0.0833). No one histologic feature consistently distinguished laparoscopic from abdominal cases on blind review of the available cases. Disaggregated intravascular tumor cells were significantly associated with reported vascular involvement in both procedures (P-values<0.001 and 0.016), most of which were corroborated on review. Laparoscopic procedures tend to have a higher index of vascular involvement, which is associated with lower stage, fewer lymph node metastases, and less myometrial invasion; however, pathologists cannot consistently determine the procedure on histologic findings alone. Moreover, there is significant inter-observer variability in distinguishing true from artifactual vascular space involvement, even among pathologists at the same institution. The clinical significance of apparent true vascular space involvement seen adjacent to artifacts is unclear, as is the impact of laparoscopic hysterectomy on recurrence risk.

Vascular endothelial growth factor-D over-expressing tumor cells induce differential effects on uterine vasculature in a mouse model of endometrial cancer.

BACKGROUND: It has been hypothesised that increased VEGF-D expression may be an independent prognostic factor for endometrial cancer progression and lymph node metastasis; however, the mechanism by which VEGF-D may promote disease progression in women with endometrial cancer has not been investigated. Our aim was to describe the distribution of lymphatic vessels in mouse uterus and to examine the effect of VEGF-D over-expression on these vessels in a model of endometrial cancer. We hypothesised that VEGF-D over-expression would stimulate growth of new lymphatic vessels into the endometrium, thereby contributing to cancer progression. METHODS: We initially described the distribution of lymphatic vessels (Lyve-1, podoplanin, VEGFR-3) and VEGF-D expression in the mouse uterus during the estrous cycle, early pregnancy and in response to estradiol-17beta and progesterone using immunohistochemistry. We also examined the effects of VEGF-D over-expression on uterine vasculature by inoculating uterine horns in NOD SCID mice with control or VEGF-D-expressing 293EBNA tumor cells. RESULTS: Lymphatic vessels positive for the lymphatic endothelial cell markers Lyve-1, podoplanin and VEGFR-3 profiles were largely restricted to the connective tissue between the myometrial circular and longitudinal muscle layers; very few lymphatic vessel profiles were observed in the endometrium. VEGF-D immunostaining was present in all uterine compartments (epithelium, stroma, myometrium), although expression was generally low. VEGF-D immunoexpression was slightly but significantly higher in estrus relative to diestrus; and in estradiol-17beta treated mice relative to vehicle or progesterone treated mice. The presence of VEGF-D over-expressing tumor cells did not induce endometrial lymphangiogenesis, although changes were observed in existing vessel profiles. For myometrial lymphatic and endometrial blood vessels, the percentage of profiles containing proliferating endothelial cells, and the cross sectional area of vessel profiles were significantly increased in response to VEGF-D in comparison to control tumor cells. In contrast, no significant changes were noted in myometrial blood vessels. In addition, examples of invading cells or tumor emboli were observed in mice receiving VEGF-D expressing 293EBNA cells. CONCLUSIONS: These results illustrate that VEGF-D over-expression has differential effects on the uterine vasculature. These effects may facilitate VEGF-D's ability to promote endometrial cancer metastasis and disease progression.

The reduction in pigment epithelium-derived factor is a sign of malignancy in ovarian cancer expressing low-level of vascular endothelial growth factor.

BACKGROUND: Angiogenesis is a critical factor in the progression of solid tumors and metastasis. The aim of this study was to characterise the roles of angiogenic and anti-angiogenic factors on ovarian cancer. METHODS: The expression levels of vascular endothelial growth factor (VEGF, angiogenic factor) and pigment epithelial growth factor (PEDF, anti-angiogenic factor) were measured by real-time polymerase chain reaction and Western blotting in ovarian tumors. Microvessel density (MVD) was evaluated by the total microvessel length in high-power field of tumor tissue preparations. RESULTS: MVD correlated with tumor malignancy. The tissues with the highest expression levels of VEGF (VEGF-H) were malignant tumors. The VEGF expression levels in some malignant tumors (VEGF-L) were as low as that in benign tumors. Therefore, the expression of PEDF was examined. The PEDF expression levels in VEGF-L malignant tumors were significantly lower than those in benign tumors. On the other hand, the PEDF expression levels in VEGF-H malignant tumor tissues were not significantly different from those in benign tumors. CONCLUSION: The reduction in PEDF expression levels may be, in part, responsible for tumor malignancy in VEGF-L ovarian tumors. Furthermore, PEDF may be a useful marker of malignancy in VEGF-L ovarian tumors.

Tumor-associated macrophages correlate with vascular space invasion and myometrial invasion in endometrial carcinoma.

OBJECTIVE: This study was conducted to determine whether tumor-associated macrophages (TAMs) correlate with clinicopathological features in endometrioid adenocarcinoma. METHODS: 76 cases of endometrioid adenocarcinoma treated initially by hysterectomy with pelvic lymphadenectomy were retrospectively retrieved, and their histological features were evaluated. Immunohistochemical staining for CD68, CD34, and Ki-67 was performed on paraffin-embedded sections. TAMs were counted in two areas: in the invasive margin (margin TAMs) and in the tumor (intratumor TAMs). RESULTS: Margin TAMs were significantly associated with FIGO stage (P=0.033), histological grade (P=0.008), myometrial invasion (P=0.0001), pelvic lymph node metastasis (P=0.027), and vascular space invasion (P=0.0001). Intratumor TAMs were significantly associated with intratumor Ki-67 (P=0.006) and microvessel density (P=0.020). Patients with high margin TAMs (> or = 20) had significantly worse progression-free survival (PS) and overall survival (OS) than those with low margin TAMs (< 20) (log rank test, P=0.0031 and P=0.0085, respectively). On multivariate analysis, high margin TAMs were significantly associated with vascular space invasion (P=0.013; HR, 6.05; 95% confidence interval [CI], 1.468-24.938) and myometrial invasion (P=0.041; HR, 4.03; 95% CI, 1.06-14.71). Vascular space invasion was only associated with PFS. CONCLUSION: Although on univariate analysis TAMs are associated with other poor prognosticators, on a multivariate analysis, TAMs appear only to be associated with MI and VI. TAMs may play a significant role in the biology of tumor progression of endometrial adenocarcinoma, but do not appear to be independent prognostic indicators of patient's survival.

Adjuvant radiation for early stage endometrial cancer with lymphovascular invasion.

OBJECTIVE: To determine the impact of the decrease in use of postoperative pelvic external beam radiation (EBRT) in favor of intravaginal RT (IVRT) alone in patients with early stage endometrial cancer who had lymphovascular invasion (LVI). METHODS: Between 11/1988 and 5/2005, 126 patients treated with simple hysterectomy and postoperative RT had a final pathologic diagnosis of stage IB-IIB adenocarcinoma of endometrioid histology with documented LVI. The patients were divided into two groups based on the era of treatment, (early era: 1988-1996, vs. late era: 1997-2005), in order to best capture the shift away from the routine use of EBRT in favor of surgical staging and IVRT. RESULTS: Of the 126 patients, 35% (n=44) were treated in the early era and 65% (n=82) in the late era. The two groups were balanced in regards to age, race, depth of myometrial invasion, histologic grade, and cervical involvement. Significantly more patients had surgical staging and received IVRT alone in the late than early era (p=0.0001, 0.004, respectively). The rate of pelvic control was 93% for the early era compared to 97% for latter era (p=0.3). There was no significant impact of the treatment era on vaginal control, disease-free survival, or overall survival. CONCLUSIONS: These data suggest that the mere presence of LVI need not trigger the use of pelvic EBRT. Instead, the decision on whether to omit EBRT in patients with LVI should be made in the context of a patient's competing risk factors and comorbid conditions.

Expression of aquaporin-1 in normal, hyperplasic, and carcinomatous endometria.

OBJECTIVE: To explore the relationship between aquaporin-1 (AQP1) and endometrial adenocarcinoma. METHOD: Intratumoral microvessel density (IMD) was assessed as well as AQP1 and vascular endothelial growth factor expression in samples from 117 women, 75 with endometrioid adenocarcinoma, 17 with endometrial hyperplasia, and 25 with normal proliferative endometria. RESULTS: AQP1 was located in the epithelial cells of microvessels and small vessels in all samples. The AQP1/IMD ratio was highest in samples from the first, less in samples from the second, and least in samples from the third group. In samples from endometrioid adenocarcinoma, the AQP1/IMD ratio was significantly correlated with histologic grade, surgical stage, myometrial invasion, and extrauterine metastasis. There was a positive correlation between AQP1 expression and IMD and between AQP1/IMD ratio and VEGF expression. CONCLUSION: AQP1 may be involved in the tumorigenesis and progression of endometrioid adenocarcinoma by promoting angiogenesis, and AQP1 level may be both a tumor indicator and a new therapeutic target.

Hypoxia and angiogenesis in endometrioid endometrial carcinogenesis.

BACKGROUND: Hypoxia-inducible factor 1alpha (HIF-1alpha) plays an essential role in the adaptive response of cells to hypoxia, triggering biologic events associated with aggressive tumor behavior. METHODS: Expression of HIF-1alpha and proteins in the HIF-1alpha pathway (Glut-1, CAIX, VEGF) in paraffin-embedded specimens of normal (n=17), premalignant (n=17) and endometrioid endometrial carcinoma (n=39) was explored by immunohistochemistry, in relation to microvessel density (MVD). RESULTS: HIF-1alpha overexpression was absent in inactive endometrium but present in hyperplasia (61%) and carcinoma (87%), with increasing expression in a perinecrotic fashion pointing to underlying hypoxia. No membranous expression of Glut-1 and CAIX was noticed in inactive endometrium, in contrast with expression in hyperplasia (Glut-1 0%, CAIX 61%, only focal and diffuse) and carcinoma (Glut-1 94.6%, CAIX 92%, both mostly perinecrotically). Diffuse HIF-1alpha was accompanied by activation of downstream targets. VEGF was significantly higher expressed in hyperplasias and carcinomas compared to inactive endometrium. MVD was higher in hyperplasias and carcinomas than in normal endometrium (p<0.001). CONCLUSION: HIF-1alpha and its downstream genes are increasingly expressed from normal through premalignant to endometrioid adenocarcinoma of the endometrium, paralleled by activation of its downstream genes and increased angiogenesis. This underlines the potential importance of hypoxia and its key regulator HIF-1alpha in endometrial carcinogenesis.

pRb2/p130 and VEGF expression in endometrial carcinoma in relation to angiogenesis and histopathologic tumor grade.

PURPOSE: Endometrial cancer is the most common gynecologic malignancy. Established prognostic factors are histologic grade, depth of myometrial invasion, and extrauterine spread including retroperitoneal lymph node metastases. Tumorigenesis is a multistep process involving different genetic changes resulting in uncontrolled cellular proliferation, inhibition of apoptosis, and enhanced vascular proliferation among other events. Angiogenesis, the formation of new blood vessels from a preexisting vascular network, is necessary for invasive tumor growth and metastasis and constitutes an important point in the control of cancer progression. The pathogenesis of the angiogenetic phenotype may involve the inactivation of different tumor suppressor genes. EXPERIMENTAL DESIGN: We investigated the relationship between the expression levels of VEGF and the retinoblastoma family member pRb2/p130 in endometrial carcinoma in relation to histopathologic tumor grade in a cohort of 50 patients. RESULTS: We found that VEGF and pRB2/p130 expression were inversely correlated. Additionally, high grade tumors presented a significantly lower number of cells expressing pRb2/p130 when compared to low grade tumors. A significant positive correlation was found, by means of the Spearman coefficient, between VEGF expression and binary grading (0.450, p-value < 0.005) which is an architectural grading system that uses low-magnification assessment of amount of solid growth, pattern of invasion, and presence of necrosis to divide endometrioid carcinomas into low- and high-grade tumors. Additionally, we also found a negative correlation between pRb2/p130 expression levels and binary grading (-0.595, p-value < 0.005). Interestingly, we also found that VEGF and pRb2/p130 expression levels were not related to staging (p-value > 0.005). CONCLUSIONS: These results open up a new perspective including novel markers that, combined together, may be useful in patient screening for endometrial cancer aggressiveness.

Relationship between angiogenesis and grade of histologic differentiation in endometrial adenocarcinoma.

The objective of the study was to quantify vessels and to relate them to the degree of histologic differentiation in endometrial adenocarcinoma. We studied 35 cases of which ten were G1, 13 G2 and 12 G3 adenocarcinomas. The control group consisted of 11 atrophic and 10 proliferative endometria. From each case two histologic sections were obtained: one for hematoxylin-eosin staining and the other for immunohistochemical study with anti-CD34. Vessel count was performed by morphometric study. Mean vessel count was 15.3 for G1; 19 for G2 and 22.7 for G3 adenocarcinomas; in the control group it was 11.6 for atrophic and 13.2 for proliferative endometria. Slightly differentiated adenocarcinoma presented greater angiogenesis than normal and well-differentiated carcinoma. In contrast, moderately differentiated carcinoma showed greater angiogenicity as related to normal endometrium, but did not differ from other tumoral endometria.

Thymidine phosphorylase expression in tumor-infiltrating macrophages may be correlated with poor prognosis in uterine endometrial cancer.

Expression of thymidine phosphorylase (TP), also known as platelet-derived endothelial cell growth factor, in several types of malignant tumors has been associated with angiogenesis and an unfavorable prognosis. We performed a retrospective study on the immunohistochemical expression of TP in patients with uterine endometrial cancer to investigate correlations between the expression of TP and the clinicopathologic features and the prognosis. The immunohistochemical staining for TP, CD68 (macrophage/monocyte-specific antibody), and von Willebrand factor was performed in surgically resected specimens from 101 patients with operable endometrial cancer. A semiquantitative grading system was used to examine the staining pattern for TP. Positive staining for both cancer cell and tumor stromal cell TP was noted in 41% of the cases. Most of tumor stromal cells expressing TP were shown to coexpress CD68. High angiogenesis was also associated with TP overexpression in either cancer cells or tumor stromal cells. When stromal macrophages/fibroblasts exhibited high TP expression, independent of whether cancer cells showed the positive TP expression, a significant decrease in disease-free survival and overall survival was observed, which was found to be an independent prognostic factor. Stromal macrophage/fibroblast TP expression remained significant on multivariate analysis. We conclude that (1) TP is present in both cancer cells and stromal macrophages/fibroblasts, (2) high angiogenesis correlated with TP overexpression, (3) TP produced by neighboring tumor-infiltrating macrophages may play a part in the regulation of the local invasion and distant metastatic behavior, and (4) TP overexpression in stromal macrophages/fibroblasts may be associated with a poor prognosis.

Significance of CD 105 expression for tumour angiogenesis and prognosis in endometrial carcinomas.

Angiogenesis is a key process in tumour growth and metastasis, and Factor-VIII microvascular density has been found to influence prognosis among endometrial carcinoma patients. The CD105/endoglin antibody has been reported to preferentially bind to activated endothelial cells in tissues participating in angiogenesis, and we therefore wanted to compare the prognostic significance of CD105/endoglin to that of Factor-VIII. In a population-based endometrial carcinoma study with long (median 11.5 years) and complete patient follow-up, mean intratumour microvascular density (MVD) assessed using CD105/endoglin was investigated and compared with previous data for MVD assessed using Factor-VIII. MVD by CD105/endoglin was significantly correlated with MVD by Factor-VIII (p=0.001). However, tumours within the two groups defined by the upper and lower quartiles for CD105/endoglin-MVD were both significantly more often metastatic (FIGO-stage III/IV; p=0.03), with high tumour cell proliferation by Ki67 (p=0.007) and with reduced survival (p=0.036) as compared with the intermediate groups. In Cox regression analysis, CD105/endoglin-MVD showed independent prognostic influence when analysed together with patient age, FIGO stage, histologic subtype, histologic grade and Factor-VIII-MVD, while the latter lost its prognostic impact when CD105/endoglin was included. In the subgroup with high MVD, there was a tendency towards improved response to radiation therapy. In conclusion, CD105/endoglin-MVD is significantly associated with FIGO stage, tumour proliferation and prognosis in endometrial carcinoma, indicating that this is a better angiogenic marker in these tumours.

Vascular endothelial growth factor activating matrix metalloproteinase in ascitic fluid during peritoneal dissemination of ovarian cancer.

The role of vascular endothelial growth factor (VEGF) during peritoneal dissemination of ovarian carcinoma and the association with tumor microvessel density (MVD) and matrix metalloproteinase (MMP) activity was investigated. To this end, MVD, tumor tissue and ascitic fluid levels of VEGF, and MMP activity of ascitic fluid were examined in patients with ovarian cancer and benign ovarian tumor. The effect of ascites on cell growth, cell invasion activity and angiogenesis was investigated in vitro. Ascitic fluid and tumor tissue samples were obtained from 15 patients with benign ovarian tumor and 24 patients with ovarian carcinoma. Tissue extract and ascitic fluid levels of VEGF were measured using enzyme immunoassay. Tumor microvessels were detected immunohistochemically. MMP activity was measured by gelatin zymography. For the in vitro experiment, the SKOV-3 human ovarian carcinoma cell line was utilized. Cell growth was examined using MTT-assay, cell invasion activity was measured by Matrigel in vitro invasion assay, and neovascularization was assessed using an angiogenesis kit. VEGF levels in tissue extract and ascitic fluid, MVD, expression of active form MMP-2 in ascitic fluid and ascites volume were higher in ovarian cancer patients than in benign ovarian tumor patients. In addition, these were elevated in stage III and IV diseases compared to stage I and II diseases in ovarian cancer patients. MVD and expression of active form MMP-2 in ascitic fluid were closely correlated with VEGF level in tissue extracts, and MVD and ascites volume were closely correlated with VEGF level in ascitic fluid. Cell invasive activity and angiogenesis activity increased when cells were exposed to ascites. These increases were apparent when exposed to ascites obtained from ovarian cancer patients and were related to VEGF concentrations of ascitic fluid and expression of active form MMP-2 in ascitic fluid. The increased VEGF secreted from tumor cells is suggested to enhance tumor growth through angiogenesis, to produce ascites and to elevate ascitic VEGF concentrations and expression of active form MMP-2. The progression of peritoneal involvement may be induced by elevated VEGF and expression of active form MMP-2, followed by increased VEGF in the primary tumor. Control of VEGF in the primary tumor may become an effective strategy against peritoneal dissemination of ovarian carcinoma.

Expression of thymidine phosphorylase and vascular endothelial growth factor in epithelial ovarian cancer: correlation with angiogenesis and progression of the tumor.

OBJECTIVE: The aim was first, to determine whether the expression of thymidine phosphorylase (TP) and vascular endothelial growth factor (VEGF) by epithelial ovarian cancer cells is correlated with the density of microvessels within the tumor and with ultrasonographic findings (B-mode classification and pulsed Doppler blood flow) and second, to speculate how these two angiogenesis factors participate in the tumorigenesis and tumor progression of epithelial ovarian cancer. METHODS: B-mode ultrasonography and color Doppler imaging and pulsed Doppler spectral analysis were used to scan patients with an overt ovarian mass immediately before laparotomy. Sections of malignant tumors were analyzed for the cellular expression of TP and VEGF and the intratumoral density of microvessels by immunohistochemistry using antibodies to TP, VEGF and Factor VIII related antigen, respectively. The main outcome measures were the histological classification of the tumor, the stage of the disease, whether or not the tumor cells were TP and VEGF positive or negative, the microvessel count and B-mode classification and the peak systolic velocity (PSV). RESULTS: Forty-four epithelial ovarian cancers were studied (6 of low malignant potential, 15 serous cystadenocarcinoma, 9 mucinous cystadenocarcinoma, 8 endometrioid adenocarcinoma, 4 clear cell carcinoma and 2 malignant Brenner tumor); 19 were Stage I, 6 Stage II, 15 Stage III and 4 Stage IV. Fourteen tumors (32%) were classified as TP positive and 21 (48%) as VEGF positive. The proportion of Stage I tumors that were TP positive (16%) was significantly lower (p = 0.022) than the corresponding value for Stages II-IV (44%), but the proportion with VEGF positive, the values for microvessel count and PSV were similar. Microvessel count did not significantly related to TP nor VEGF expression. The PSV was significantly higher in TP-positive tumors (p = 0.02) and VEGF-positive tumors (p = 0.006), respectively. There was a significant correlation between the microvessel count and the PSV (r = 0.34, p = 0.024). Moreover, specific B-mode classification significantly associated with disease stage and with TP expression, but not with VEGF expression. CONCLUSIONS: Angiogenesis is an early, critical step in the tumorigenesis of epithelial ovarian cancer, however, it does not provide significant information about tumor aggressiveness. When TP expression is superimposed upon the VEGF expression, the tumor might acquire the aggressive tumor phenotype.

[Expression of pituitary tumor-transforming gene in endometrial carcinoma].

OBJECTIVE: To study the expression of pituitary tumor-transforming gene (PTTG) and its relationship with the expression of basic fibroblast growth factor (bFGF) protein and microvessel density (MVD) in endometrial carcinoma. METHODS: Expressions of PTTG mRNA and protein were assessed by semi-quantitive RT-PCR and immunohistochemistry methods respectively in 50 cases of endometrial carcinomas, 15 cases of hyperplasia endometria and 12 cases of normal endometrial tissue. Expressions of bFGF protein were detected by immunohistochemistry. Microvessels were highlighted by staining endothelial cells with CD(34) antigen, and MVDs were counted. RESULTS: The expression rate and average quantity of PTTG mRNA were detected in a significantly greater proportion endometrial carcinomas (96%, 0.84 +/- 0.08) than in hyperplasia endometria (60%, 0.78 +/- 0.06) and normal endometrial tissue (33%, 0.48 +/- 0.12, P < 0.01, respectively). The expression of PTTG protein in endometrial carcinomas (70%) was significantly higher than in hyperplasia endometria (40%) and normal endometrial tissue (17%, P < 0.01). The expression of PTTG was related to surgical-pathological stage, myometrial infiltration depth, lymphatic metastasis and pathological subtype (P < 0.05, respectively), but was irrelevant to patients' age and pathological grade (P > 0.05, respectively). The average quantity of PTTG mRNA and expression rate of PTTG protein in tissues with bFGF protein coexpression (0.86 +/- 0.07, 87%) were higher than in those without bFGF protein coexpression (0.80 +/- 0.06, 42%, P < 0.01, respectively). The MVD in tissues with PTTG protein expression (62 +/- 18) was higher than in those without PTTG protein expression (51 +/- 12, P < 0.05). CONCLUSIONS: PTTG may play an important role in carcinogenesis and development of endometrial carcinoma. PTTG induces an angiogenesis through bFGF which is a key determinant step in tumor progression and metastatic spread.

Flexible hysteroscopy with narrow band imaging (NBI) for endoscopic diagnosis of malignant endometrial lesions.

Narrow band imaging (NBI) for detection of blood vessels and microstructures on the mucosal surface is used in gastrointestinal endoscopy since it can improve qualitative diagnosis and detection of lesion. However, there are no studies on flexible hysteroscopy using NBI. We performed flexible hysteroscopy with NBI for outpatients to investigate the sensitivity and specificity of endoscopic diagnosis of malignant endometrial lesions. Of patients who attended our hospital for suspected lesions in the uterine cavity between April 2009 and May 2010, 104 subjects underwent hysteroscopy with NBI, in addition to white light. Using the pathological diagnosis as the gold-standard, we evaluated the sensitivity and specificity of NBI hysteroscopy for detecting atypical endometrial hyperplasia (AEH) or carcinoma. The results were also compared with historical data (n=209) for conventional hysteroscopy using white light only in 2008. The sensitivities were 97.2% [95% confidence interval (95% CI): 90.3-99.7%] and 82.6% (95% CI: 74.4-89.0%) for NBI hysteroscopy and conventional hysteroscopy, respectively. The 95% CIs for the two methods did not overlap and the sensitivity of lesion detection was higher with NBI hysteroscopy. Specificities were comparable, 90.6% (95% CI: 75.0-98.0%) and 85.1% (95% CI: 76.3-91.6%) between the methods. NBI hysteroscopy has increased sensitivity for detection of atypical endometrial hyperplasia (AEH) or carcinoma. A comparison with historical data suggested that NBI may be useful for diagnosis of malignant endometrial lesions. As far as we are aware, this is the first evaluation of flexible hysteroscopy with NBI for diagnosis of malignant endometrial lesions.

Correlation of mast cell density, tumor angiogenesis, and clinical outcomes in patients with endometrioid endometrial cancer.

BACKGROUND: Tumor angiogenesis has been demonstrated in several kinds of neoplasms. There are evidence that mast cells can produce many kinds of chemical mediators with angiogenic properties. The specific role of mast cells in female genital tract cancer has not been well understood. The purpose of this study was to determine the correlation between the mast cell density, tumor angiogenesis, and clinical outcomes in patients with endometrioid adenocarcinoma of endometrium. METHODS: Histologically, four-micrometer-thick haematoxylin and eosin stained slides of the hysterectomy specimens were evaluated. Microvessels were highlighted by CD31 immunostain and mast cells were stained by 0.1% toluidine blue. All clinicopathological characteristics were reviewed to determine their possible correlation to microvessel density and number of mast cells. RESULTS: A total of 46 patients who underwent a complete staging surgery were eligible for this study. The median age of the patients was 55 years (range, 32-70 years). The median follow-up was 27.0 months (range 3.6-83.8). Microvessel appeared significantly to correlate with the number of parity. The mean microvessel count was likely to be higher in women with non-menopausal status (p=0.07), advanced FIGO stage (p=0.09), and lymph node metastasis (p=0.08). There was no significant correlation between microvessel counts, mast cell density, and disease recurrence. CONCLUSION: Our data suggested that the number of microvessel counts and mast cell density did not affect the clinical progression or recurrence of endometrioid endometrial cancer.

Correlation of mast cell density, tumor angiogenesis, and clinical outcomes in patients with endometrioid endometrial cancer.

BACKGROUND: Tumor angiogenesis has been demonstrated in several kinds of neoplasms. There is evidence that mast cells can produce many different chemical mediators with angiogenic properties. Since their specific role in female genital tract cancer has not been well understood, this study was conducted to determine correlations between among mast cell density, tumor angiogenesis, and clinical outcomes in patients with endometrioid adenocarcinoma of endometrium. METHODS: Histologically, four-micrometer-thick haematoxylin and eosin stained slides of hysterectomy specimens were evaluated. Microvessels were highlighted by CD31 immunostaining and mast cells were stained with 0.1% toluidine blue. All clinicopathological characteristics were reviewed to determine their possible correlation to microvessel density and number of mast cells. RESULTS: A total of 46 patients who underwent a complete staging surgery were eligible for this study. The median age was 55 years (range, 32-70 years) and the median follow-up was 27.0 months (range 3.6-83.8). Microvessels appeared to correlate to some extent with parity and the mean count was likely to be higher in women with non-menopausal status (p=0.07), advanced FIGO stage (p=0.09), and lymph node metastasis (p=0.08). However, there was no significant correlation between microvessel counts, mast cell density, and disease recurrence. CONCLUSION: Our data suggest that the number of microvessel counts and mast cell density do not affect clinical progression or recurrence of endometrioid endometrial cancer.

Myometrial invasion and lymph node metastasis in endometrioid carcinomas: tumor-associated macrophages, microvessel density, and HIF1A have a crucial role.

Myometrial invasion is an independent prognostic parameter of the endometrioid carcinomas which correlates with the risk of metastasis to pelvic and/or paraaortic lymph nodes. Recognition of myometrial invasion is sometimes difficult. In fact, myoinvasion is overdiagnosed in routine practice in as many as 25% of the cases. Recently, it has been observed that tumor-associated macrophages stimulate angiogenesis and promote cancer dissemination. Tumor macrophages (CD163), microvessel density (CD31), and hypoxia inducible factor 1 α subunit (HIF1A) were investigated in 64 primary endometrioid carcinomas with (50 cases) and without (14 cases) myometrial invasion as well as in the corresponding regional lymph nodes metastases of 20 of the myoinvasive tumors. Endometrioid carcinomas with myometrial invasion showed higher number of CD163-tumor macrophages and greater microvessel density than endometrioid carcinomas without myometrial invasion (P=0.000 and P=0.000, respectively). In carcinomas confined to the corpus uteri (stage I), expression of HIF1A was associated with deep myoinvasion (stage IC) (P=0.006). There was a significant relationship between microvessel density and CD163-macrophages both in the myoinvasive and nonmyoinvasive tumors. On the other hand, high-grade endometrioid carcinomas had more macrophage infiltrates and microvessels than low-grade tumors (P=0.03 and P=0.07). Also, there was a positive correlation between CD163-macrophages and microvessel density in the primary tumors and their corresponding regional lymph node metastases. These findings link increased microvessel proliferation to stromal macrophage infiltrate and suggest that enhanced tumor angiogenesis, triggered by stromal macrophages, regulates the progression of endometrioid carcinomas. The identical stroma microenvironment found in the primary and the corresponding metastatic tumor suggests that tumor stroma response is determined by the intrinsic biology of the tumor.