Association of Viral Infections with Risk of Human Lymphomas, Egypt.

BACKGROUND: The aim of this study was to determine and evaluate the association of different viral infections, with hepatitis B and C viruses, Epstein-Barr virus, cytomegalovirus and human herpes virus-8 (HBV, HCV, EBV, CMV, HHV-8) with the risk of lymphomas (Hodgkin and non-Hodgkin) among Egyptian patients, and correlate with the histopathological staging and typing as well as the prevalence of combined infections. MATERIALS AND METHODS: A total of 100 newly diagnosed lymphoma patients with 100 healthy age and sex matched normal controls were assayed for viral infection using enzyme linked immunosorbant assay (ELISA) followed by real time polymerase chain reaction (RT-PCR). RESULTS: Our results showed a high statistical significant difference between cases and controls as regards clinical and laboratory findings (<0.001 and=0.003). A high statistical difference was seen for the association of most viruses and lymphoma cases (<0.001) except for positive HBs Ag, positive CMV IgG and HHV-8 (p=0.37, 0.70 and 1.0 respectively). No statistical significant difference was found between Hodgkin (HL) and non-Hodgkin (NHL) as regards viral prevalence except HCV antigen, 57.1% for HL and 26.5% for NHL (p = 0.03). Only, HBV DNA showed a high significant value among infiltrated bone marrow cases (p=0.003) and finally, a high significant association of 2 combined viral infections with infiltrated bone marrow lymphoma cases (p=0.04). CONCLUSIONS: Our results showed that infection with HBV, HCV, CMV and EBV were associated with increased risk of lymphoma among the Egyptian population. Detection of new associations between infectious agents and risk of cancer development will facilitate progress in elaboration of prophylactic measures, early diagnostic methods and, hopefully, novel therapy of malignant tumours.

FHIT, EGFR, and MSH2: possible etiopathologic, prognostic, and predictive role in non-small cell lung carcinoma in Egyptian patients.

The high incidence and mortality of lung carcinoma in Egypt necessitates studying the factors that may be implicated in non-small cell lung carcinoma (NSCLC) pathogenesis and could affect patient management. The aim was to study FHIT, epidermal growth factor receptor (EGFR), and MSH2 protein expression in Egyptian patients with NSCLC. Immunohistochemical staining for FHIT, EGFR, and MSH2 was performed on 64 specimens from NSCLC patients and correlated with prognostic parameters, response to therapy, and overall survival. FHIT loss was observed in 64% of NSCLC patients and was significantly associated with SCC (P=0.003) and poor tumor grade (P=0.043). EGFR overexpression was observed in 47% of NSCLC patients and was significantly associated with SCC (P=0.002). MSH2 was reduced in 23.4% of NSCLC patients and was significantly associated with adenocarcinoma (P=0.024). In a univariate analysis, a significant relationship was seen between the poor overall survival in NSCLC patients and high T-stage (P=0.029), presence of metastasis (P=0.014), advanced-stage grouping (P=0.004), and FHIT loss (P=0.033). Further, FHIT loss was significantly related to disease progression in patients treated with chemotherapy (P=0.038). We conclude that all 3 markers play a role in the development of NSCLC in Egyptian patients. We suggest that FHIT loss be used as a predictor for progression in chemotherapy-treated NSCLC patients.

Role of Ki67 in predicting resistance to adjuvant tamoxifen in postmenopausal breast cancer patients.

INTRODUCTION: Breast cancer (BC) is a major health problem in Egypt and worldwide. Its prognosis depends not only on tumor stage but also on tumor biology. AIM: To correlate the expression of Ki67 with the clinical outcomes of early hormone-receptor positive postmenopausal BC patients who are receiving tamoxifen. METHODS: This cohort study included 70 patients. They were followed up for a minimum of 2 years. Ki67 was assessed on paraffin-embedded blocks using immunohistochemistry methods. RESULTS: The median Ki67 value was 22.5% (IQR, 10%-50%). Ki67 was significantly higher in patients with HER2 positive tumors compared to HER2 negative tumors. After a median follow up period of 53 months, 22 patients (31%) developed disease recurrence either loco-regional or distant in 5.7% and 30%, respectively. Recurrent patients had significantly higher tumor stage, nodal stage and Ki67 values compared to non-recurrent cases. The 2-, 3- and 5-year overall survival (OS) and disease-free survival (DFS) rates were 100% & 91%, 98% & 84% and 77% & 59%, respectively. DFS was significantly worse with higher TNM stage, lower ER expression and higher Ki67 values. OS was significantly worse in patients with Ki67 values ≥ 30%. Ki67 ≥ 30% was an independent predictor of recurrence, poor DFS and OS. CONCLUSION: High Ki67 expression is predictive of poor prognosis and of resistance to adjuvant tamoxifen therapy in postmenopausal BC. We recommend considering Ki67 as one of the risk factors that guide adjuvant treatment decisions.

Clinicopathologic significance of molecular classification of breast cancer: relation to nottingham prognosis index.

PURPOSE: The aim of this work is to determine the possible relationship between the different profiles of molecular expression of hormone receptors and Her-2÷neu receptors to clinical and histopathological known prognostic variables for breast cancer. MATERIALS AND METHODS: A total of 110 breast carcinoma tumor samples were included. In this study 4 groups or immunohistochemical profiles were defined, based on expression of hormone receptors (estrogen and÷or progesterone) and÷or Her2÷neu (Luminal A, Luminal B, HER2 overexpressing profile, and triple-negative profile). We studied whether there were differences between them regarding clinical and histopathological variables with a known prognostic significance in addition to Nottingham Prognosis Index (NPI). RESULTS: In this series, 65 cases corresponded to Luminal A (59.1%), 18 cases (16.4%) were Luminal B, in 14 cases (12.7%) HER2 was over-expressed, while 13 cases (11.8%) were of the triple negative subtype. It is worth noting the relationship between the triple negative and HER2 over-expressing immunophenotypes and the high NPI (>3.4) in comparison with the Luminal A and Luminal B immunophenotypes (p=.029). The association of the former two types with higher tumor grade was also observed, but such association did not reach statistical significance. CONCLUSION: The subgroups without hormone receptor expression, with Her2÷neu overexpression or without (triple-negative group), have characteristics associated with variables of a poorer prognosis. KEY WORDS: Breast cancer- Hormone receptors- Her2neu- Classification- Nottingham prognosis index.

Clinical significance of altered nm23-H1, EGFR, RB and p53 expression in bilharzial bladder cancer.

BACKGROUND: Clinical characterization of bladder carcinomas is still inadequate using the standard clinico-pathological prognostic markers. We assessed the correlation between nm23-H1, Rb, EGFR and p53 in relation to the clinical outcome of patients with muscle invasive bilharzial bladder cancer (MI-BBC). METHODS: nm23-H1, Rb, EGFR and p53 expression was assessed in 59 MI-BBC patients using immunohistochemistry and reverse transcription (RT-PCR) and was correlated to the standard clinico-pathological prognostic factors, patient's outcome and the overall survival (OS) rate. RESULTS: Overexpression of EGFR and p53 proteins was detected in 66.1% and 35.6%; respectively. Loss of nm23-H1and Rb proteins was detected in 42.4% and 57.6%; respectively. Increased EGFR and loss of nm23-H1 RNA were detected in 61.5% and 36.5%; respectively. There was a statistically significant correlation between p53 and EGFR overexpression (p < 0.0001), nm23 loss (protein and RNA), lymph node status (p < 0.0001); between the incidence of local recurrence and EGFR RNA overexpression (p= 0.003) as well as between the incidence of metastasis and altered Rb expression (p = 0.026), p53 overexpression (p < 0.0001) and mutation (p = 0.04). Advanced disease stage correlated significantly with increased EGFR (protein and RNA) (p = 0.003 & 0.01), reduced nm23-H1 RNA (p = 0.02), altered Rb (p = 0.023), and p53 overexpression (p = 0.004). OS rates correlated significantly, in univariate analysis, with p53 overexpression (p = 0.011), increased EGFR (protein and RNA, p = 0.034&0.031), nm23-H1 RNA loss (p = 0.021) and aberrations of > or = 2 genes. However, multivariate analysis showed that only high EGFR overexpression, metastatic recurrence, high tumor grade and the combination of > or = 2 affected markers were independent prognostic factors. CONCLUSION: nm23-H1, EGFR and p53 could be used as prognostic biomarkers in MI-BBC patients. In addition to the standard pathological prognostic factors, a combination of these markers (> or = 2) has synergistic effects in stratifying patients into variable risk groups. The higher is the number of altered biomarkers, the higher will be the risk of disease progression and death.

Evaluation of bone marrow in 143 lymphomas: the relative frequency and pattern of involvement, secondary myelopathies, pitfalls and diagnostic validity.

UNLABELLED: The aim of the present study is to assess the frequency of bone marrow (BM) involvement by both bone marrow aspirate and biopsy (BMA and BMB, respectively) procedures in established cases of lymphomas at initial presentation, and to study the relative frequency of marrow disease in relation to lymphoma types, patterns of infiltration and the 2ry associated changes, as well as the diagnostic challenges. Moreover, the diagnostic validity of BMA is tested taking the results of the BMB as the true test results, in order to determine the role of each procedure in the diagnostic approach of marrow infiltration. PATIENTS AND METHOD: This is a retrospective study carried out on 143 nonconsecutive Egyptian patients with lymphomas obtained from a private series during the years 2005 to 2008. Criteria of inclusion included the availability of full medical records and material (medical and pathological), patient consent, nodal disease with no therapy prior to BM sampling, except in 7 patients who had another 2nd BMB following therapy. BMA and BMB were performed as part of the routine workup for diagnosis and staging of lymphoma. The patients had a male to female sex ratio of 2.6:1 and a wide age range from 4 to 74 years. RESULTS: In the present series, 64 cases out of the 143 lymphoma patients studied (44.8%) had a BM disease. Involvement was mostly bilateral (80%). Patients older than 40 years showed higher incidence of bone marrow involvement. There was complete concordance (100%) between both diagnostic procedures in the detection of 76 marrow disease-free lymphoma patients. BMA showed no false positive results and a low rate of deference that makes of it an ideal screening test. Three deferred smears of CLL for BMB diagnosis were all positive for involvement. However, in a total number of 64 BMB positive patients, aspirates could only identify lymphoma involvement in 42 lymphoma patients and missed 22 patients with a BM disease, with an overall sensitivity rate of 65.6%. BMB had a high diagnostic viability and is an easily applied reproducible procedure for diagnosis of BM involvement based on a more detailed informative analysis of both architectural and individual cytomorphologic changes. CONCLUSION: The relatively high level of BM involvement in Egyptian lymphoma patients was directly proportional to high-risk factors. The diagnostic validity of BMB is higher than that of BMA. However, BMA serves as a good positive test in screening lymphomas for marrow disease. A negative BMA does not exclude involvement. Thus, smears should be taken as a complimentary procedure.

Review article composite lymphoma.

Background : Composite lymphoma (CL) is a rare disease that has been identified in recent literature. The term composite lymphoma was first proposed to denote the occurrence of more than one lymphoma in a single patient; however, the present accepted definition is the occurrence of 2 or more distinct lymphoma types in a single anatomic site. The condition could be concurrent or sequential. Unlike disease progression or transformation in lymphoma, CL should include two distinct clones proven by morphological and laboratory tests. Pathogenesis : No single definite mechanism has been suggested to explain the pathogenesis of the different types of CL. The etiology is variable, complex and differs according to the types of lymphomas involved. Several theories were proposed including clonal selection with additional mutational accumulation, genomic instability with genetic predisposition, common precursor cell and the aid of a viral factor, mostly EBV. Diagnosis : The morphologic criteria must be confirmed by one or more tests including immunohistochemistry, flow cytometry, gene rearrangement by PCR, cytogenetics, FISH, in-situ hybridization, DNA sequencing and cDNA microarray . Results are more accurate using the laser capture microdissection method. Many combinations of CL are reported, including : Multiple B-cell lymphomas; B-cell and T-cell lymphomas; NHL and HL; or complex B-cell, T-cell and HL cases. Conclusion : Due to the great advancement in molecular characterization of lymphoma, CL is being increasingly identified. It must be carefully diagnosed, because the multiple disease entities may have entirely different natural histories, prognosis and treatment modalities. Also, careful study of such cases may clarify the possible pathogenic mechanisms of the interrelationship of clonal evolution in lymphoma. Key Words : Composite lymphoma -EBV.

Evaluation of MIB-1 and p53 overexpression as risk factors in large cell non-Hodgkin lymphoma in adults.

BACKGROUND: Improvement of current results of therapy for large cell non-Hodgkin lymphoma patients can be achieved by optimization of initial treatment or application of risk-adapted therapy. The international prognostic index ( IPI), introduced to identify high-risk patients, was recently criticized because it was based on clinical risk factors only, ignoring important tumor molecular risk factors and it fails to identify a sector of high-risk patients, who ultimately relapse. OBJECTIVE: The aim of this study is to evaluate the value of two tumor biomarkers:MIB-1 and p53 as potential risk factors in diffuse large cell lymphoma. MIB-1 measures tumor cell proliferation, whereas p53 is related to tumor progression and response to chemotherapy. PATIENTS AND METHODS: The study was done on 69 adult patients with diffuse large cell NHL ( 58 B-phenotype and 11 T-phenotype). Clinical risk assessment was determined by the IPI and patients with a score of 3 or more were considered high-risk. Expression of MIB-1 and p53 was determined by immunohistochemistry and nuclear staining was quantitated by image analysis. Immunoexpression was considered high for MIB-1 nuclear count 50% and p53 counts 20%. Evaluation included both response to chemotherapy ( mostly CHOP), as well as 2- year overall survival analysis. RESULTS: The IPI was the only clinical variable which had a significant impact on survival. Overexpression of both MIB-1 and p53 was associated with poor response to treatment, as well as unfavorable survival. Combined risk factor analysis revealed that only MIB-1 was an independent variable. MIB-1 could also identify some high-risk patients previously categorized in the IPI lowrisk group. CONCLUSIONS: MIB-1 is an independent biologic risk factor for large cell NHL. In order to optimize risk assessment of these patients, it is recommended to construct a new prognostic index by adding MIB-1 overexpression to the other clinical factors of standard IPI. This may allow better identification of high-risk patients and help to guide planning of effective initial treatment. Key Words:NHL - MIB-1 - p53 - CHOP - Risk factors.

The role of cyclins and cyclins inhibitors in the multistep process of HPV-associated cervical carcinoma.

BACKGROUND: Human papillomavirus (HPV) types 16 and 18 are associated with cervical carcinogenesis. This is possibly achieved through an interaction between HPV oncogenic proteins and some cell cycle regulatory genes. However, the exact pathogenetic mechanisms are not well defined yet. METHODS: We investigated 110 subjects (43 invasive squamous cell carcinoma (ISCC), 38 CIN III, 11 CIN II, 18 CIN I) confirmed to be positive for HPV16 and/or 18 as well as 20 normal cervical tissue (NCT) samples for abnormal expression of cyclin D1, cyclin E, CDK4, cyclin inhibitors (p21 (waf), p27, p16 (INK4A)) and Ki-67 using immunohistochemistry and differential PCR techniques. RESULTS: There was a significant increase in the expression of Ki-67, cyclin E, CDK4, p16 (INK4A) (p=0.003, 0.001, 0.001) and a significant decrease in p27 (Kip1) from NCT to ISCC (p=0.003). There was a significant correlation between altered expression of p27 (KIP1) and p16(INK4A) (p<0.001), cyclin D1 and CDK4 (p=0.001), cyclin E and p27 (Kip1) (p=0.011) in all studied groups. In ISCC, there was significant relationship between standard clinicopathological prognostic factors and high Ki-67 index , increased cyclin D1 and cyclin E, reduced p27 (Kip1) and p21 (waf). CONCLUSION: 1) Aberrations involving p27 (KIP1), cyclin E, CDK4 and p16 (INK4A) are considered early events in HPV 16 and 18-associated cervical carcinogenesis (CINI & II), whereas cyclin D1 aberrations are late events (CINIII & ISCC) 2) Immunohistochemical tests for p16 (INK4A) and cyclin E could help in early diagnosis of cervical carcinoma 3) Only FIGO stage, cyclin D1, p27 (Kip1) and Ki-67 are independent prognostic factors that might help in predicting outcome of cervical cancer patients.

Prognostic factors of Hodgkin's lymphoma and their impact on response to chemotherapy and survival.

OBJECTIVE: The aim of this study was to compare the standard prognostic factors of Hodgkin's lymphoma (HL) in relation to response to first line chemotherapy, disease free survival (DFS) and overall survival (OS). PATIENTS AND METHODS: The study was performed on a group of 100 adult patients diagnosed as HL and who were treated and followed-up in the years 1999 to 2001, in the Medical Oncology Department at National Cancer Institute (NCI), Cairo. The first line chemotherapy was COPP in 40%, ABVD in 35% and COPP/ABV hybrid in 25%. Patients were classified into early stage disease: Stages I, IIA and IIB without poor risk factors, n=43 and advanced stage disease: Stages III, IV and IIB with poor risk factors, n=57 analysis of the prognostic factors for early versus advanced-stage disease was done by univariate and multivariate regression analysis. RESULTS: Complete remission (CR) was attained in 69% of the patients after first line chemotherapy; being 87.8 % and 54.7% for early and advanced disease, respectively, (p=0.0001). The CR rates after different chemotherapy regimens were 81.8%, 90% and 90% for the ABVD, COPP and COPP/ABV hybrid regimens in the early-disease group; respectively; in contrast to the corresponding figures of 54.5%, 50% and 61.5% in the advanced- stage group. The DFS at 4 years, was 94 %, 55% and 54.5% for the patients treated with ABVD, COPP and COPP/ABV hybrid, respectively (p=0.2). The DFS and OS in this series of patients were 61.3% and 53.7%, being 69.8% and 70.7% for the early and 45.1% and 38.9% for the advanced-disease, respectively The OS of the whole group was significantly related to age (p=0.04), sex (p=0.005), early versus advanced disease (p=0.0001) and B symptoms (p=0.0006). CONCLUSIONS: The adequate response and DFS of the early compared to the advanced-stage disease supported the evolving role of risk adapted chemotherapy for HL. The prognostic factors proved to be of significant impact in our series. The results of this study pointed to the need for an improved treatment strategy in this potentially curable disease,especially for the advanced disease.

Hepatitis C virus-NS3P in relation to p53, p21waf, mdm2, p21-ras and c-erbB2 in hepatocarcinogenesis.

BACKGROUND: The non-structural protein 3 (NS3P) of hepatitis C virus (HCV) genome was linked to the neoplastic transformation of normal hepatocytes in chronically infected patients. However, the exact mechanisms involved in this process are unidentified yet, especially in the Egyptian population where the commonest type is genotype 4. METHODS: We investigated 32 HCV reverse transcriptase-polymerase chain reaction (RT-PCR) positive hepatocellular carcinoma (HCC) cases and 18 morphologically normal hepatic tissues distant to tumors (MNT) for the correlation between HCV-NS3P, p53, p21(waf), mdm2, p21ras and c-erbB2 and DNA content by immunohistochemistry and image analysis. RESULTS: The NS3P expression was lower in HCC (65.6%) than in MNT (94.4%) patients. The expression level of studied genes in HCC was: p53 (56.25%), p21(waf) (43.7%), mdm2 (59.4%), p21-ras (73.3%) and c-erbB2 (75%). Whereas in MNT, it was 22.2, 61.1, 44.4, 41.2 and 77.8%, respectively. The NS3P expression showed a significant correlation with the presence of cirrhosis, chronic active hepatitis (CAH) and tumor grade (P < 0.05). c-erbB2 overexpression and p21(waf) loss were higher in MNT than in HCC patients, however, this did not reach a statistically significant level. There was a statistically significant correlation between NS3P, c-erbB2 and p21(waf) (P < 0.01). There was also a significant correlation between p21(waf) loss and CAH (P = 0.01) as well as between mdm2, c-erbB2 and cirrhosis (P = 0.025 and 0.001) in HCC cases. There was a statistically significant difference in the ploidy status between HCC and MNT, but there was no significant relationship between the ploidy status and other clinicopathological features. CONCLUSION: The carcinogenic effect of NS3P is probably exerted at an early stage of HCC possibly through a pathway involving c-erbB2 and p21(waf) alterations. In contrast, p53, p21ras and mdm2 alterations are late events in hepatocarcinogenesis and are usually associated with an aggressive phenotype.