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BCL-2 EXPRESSION IN ENDOMETRIAL CARCINOMAIN RELATION TO DIFFERENT HISTOPATHOLOGIC
PROGNOSTIC FACTORS
251
Journal of Experimental Medical & Surgical Research
Cercetãri Experimentale & Medico-Chirurgicale
Year XVII · Nr.4/2010 · Pag.251 - 254E x p e r i m e n t a l
M e d i c a l S u r g i c a l
R E S E A R C H
J O U R N A L o f
Correspondence to: G Guset, MD, Obstetrics and Gynecology Department, Clinical Hospital, Arad, 3 Cornel Radu Street,310329 Arad, Romania; Phone +40744607047, E-mail [email protected]
SUMMARY:The bcl-2 protooncogene inhibits programmed cell death (apoptosis) and over-expression of bcl-2 might play a role in carcinogenesis and malignant progression of endometrialcarcinoma.. The aim of this study was to determine bcl-2 immunohistochemical expressionin patients with endometrial carcinoma and to correlate it with different histologicalparameters including histological type, tumor grade, depth of myometrial invasion,lymph-node involvement and stage. Fifty-four patients with endometrial carcinoma whowere treated by total abdominal hysterectomy and bilateral salpingo-oophorectomy wereassessed. The immunohistological staining was performed on formalin-fixedparaffin-embedded tissue, and haematoxylin and eosin-stained sections were used toevaluated the conventional prognostic markers. Bcl-2 expression was positive in 63.41% ofendometrioid carcinomas and in 53.84% of non-endometrioid carcinoma (p = 0.5374 NS).Statistically significant correlation was found between the surgical staging, depth ofmyometrial invasion, lymph node involvement , tumor grade and the bcl-2 expression ( p <0.001, p = 0.0019, p = 0.0138 and p = 0.0136 respectively).Key-words: bcl-2, endometrial carcinoma, prognosis
REZUMAT: Protooncogena bcl-2 inhibã moartea celularã programatã (apoptoza), supraexpresia bcl-2putând juca un rol în carcinogeneza ºi evoluþia carcinomului endometrial. Scopul acestuistudiu este de a determina expresia imunohistochimicã a anticorpului bcl-2 la paciente cucarcinom endometrial ºi corelarea acesteia cu diferiþi parametri histologici incluzând tipulhistologic, gradul de diferenþiere, adâncimea invaziei miometriale, statusul limfonodulilor ºistadiul bolii. Au fost luate în studiu cincizeci ºi patru de paciente cu carcinom endometrialtratate prin histerectomie totalã cu anexectomie bilateralã. Imunocolorarea s-a realizat peþesuturi fixate în formaldehidã, incluse la parafinã, iar markerii convenþionali de prognosticau fost evaluaþi pe secþiuni colorate cu hematoxilinã- eozinã. Expresia bcl-2 a fost pozitivã în63.41% din carcinoamele endometrioide ºi în 53.84% din carcinoamele non-endometrioide(p=0.5374 NS). Între expresia bcl-2 ºi stadiul bolii, adâncimea invaziei miometriale,statusul limfonodulilor ºi gradul de diferenþiere al tumorii s-a obþinut o corelaþiesemnificativã statistic ( p < 0.001, respectiv p = 0.0019, p = 0.0138 ºi p = 0.0136 ).Cuvinte-cheie: bcl-2, carcinom endometrial, prognostic
G. Guºet1, S. Costi2, E. Lazãr3,A. Dema3, C. Lãzureanu3, C. Vernic4, L. Pãiuºan5
Received for publication: 04.05.2010
Revised: 12.10.2010
1. - Obstetrics and Gynecology Department, Clinical Hospital, Arad2 - Service of Pathology, Emergency Clinical Hospital, Timisoara3 - Department of Pathology4 - Deparment of Medical Informatics and Biostatistics, „Victor Babes” University of Medicine and Pharmacy, Timisoara5 - Department of Pathology, „Vasile Goldis” Western University, Arad
INTRODUCTION
The bcl-2 gene encodes a protein of 25-26 kDa (Bcl-2),
which is located in the mitochondrial membrane,
endoplasmic reticulum and nuclear membrane.(1)
In the endometrium, bcl-2 expression assessed by
immunohistochemistry varies during the menstrual cycle
and is highly expressed in the proliferative phase, with
downregulation during the secretory phase (2). Many
studies support the concept that bcl-2 protein expression
persists at high levels in simple hyperplasia but
progressively diminishes in atypical hyperplasia and with
deacreasing differentiation in invazive endometrial
adenocarcinoma (3,4,5,6,7,8,9).
The aim of this study was to determine bcl-2
immunohistochemical expression in patients who have
been surgically treated for endometrial carcinoma, and to
correlate it with conventional histological markers.
Conventional histological and prognostic markers used to
determine the clinical course of endometrial carcinoma
include histological type, tumor grade, depth of
myometrial invasion, lymph-node involvement and stage.
MATERIALS AND METHODS
In order to investigate bcl-2 expression in endometrial
neoplasia, a total of fifty-four endometrial carcinoma
cases surgically resected at Obstetrics and Gynecology
Department of Clinical Hospital Arad were examened.
The mean age of patients was 57 years with a minimum
of 38 and maximum of 81 years. All patients had been
treated surgically with total abdominal hysterectomy and
bilateral salpingo-oophorectomy. Oh these, 25 patients
were stage I, and 29 patients were stage II and III. N
staging was based on pre-operative lymphangiography
or pelvic and abdominal tomography (CT) scan. The
cases investigated comprised 24 grade 1 (G1), 21 grade
2 (G2), and 9 grade 3 (G3) endometrial carcinomas
(Table I). Histologic typing of the endometrial tumours,
tumor grade and depth of myometrial invasion (< ½ vs
> ½ ) were evaluated based on the criteria of the World
Health Organization.
Tissue samples were fixed in 10% formalin and
embedded in paraffin wax for routine histopathology.
Immunohistochemical Analysis: The deparaffinized
tissue sections were submitted to routine
immunohistochemical analysis using as positive controls
for bcl-2 expression lymph nodes. The antibody used was
mouse monoclonal anti-human bcl-2 antibody (clone
124, Dako) through LSAB 2 detection system. A variable
intensity of bcl-2 immunoreactivity was observed with
cytoplasmic brown staining; the visualization system
used diaminobenzidine tetrahydrochloride (DAB, Dako).
Statistical Analysis: The correlation between bcl-2
expression and histopathologic markers were analyzed
using Chi-square test. A p value less than 0.05 was
considered significant.
RESULTS
On the basis of the percentages of bcl-2
immunopositive cells in the endometrial carcinomas, the
lesion were included into four categories as follows:
n 0 = negative: no or fewer than 5% positive cells;
n 1+ = positive immunoreaction in 5-20% of tumor
cells;
n 2+ = positive immunoreaction in 30-50% of tumor
cells;
n 3+ = positive immunoreaction in more than 50% of
tumor cells;
A variable intensity of a bcl-2 immunoreactivity (weak,
moderate or strong) and a heterogenous distribution of
cytoplasmic staining were observed.
The correlations of bcl-2 expression with histological
parameters are listed in Table II. In our study , we
detected cytoplasmic bcl-2 expression in 26
endometrioid carcinomas (63.41%) and 7 non-
endometrioid carcinomas (53.84%); differences were not
statistically significant (p = 0.537467 NS). Statistically
significant correlation was found between the tumor
differentiation grade and bcl-2 expression: 21 (87.50%) of
G1 endometrial carcinoma were bcl-2 positive, while
bcl-2 expression was positive in only 12 (57.14 %) of G2
and G3 cases (p = 0.013676 S). Statistically significant
correlation was found between depth of myometrial
invasion and bcl-2 expression (p = 0.001916) and
between surgical staging and bcl-2 expression (p <
0.001 ES). By comparing bcl-2 expression and the status
of limph nodes we obtained positive bcl-2 reactions in
67.34% of cases without metastasis while the lymph
nodes with metastasis were not positive (p = 0.013852
S).
DISCUSSION
Several studies are focused on the genetic and
molecular changes that are observed in endometrial
carcinomas.
The fact that bcl-2 expression was correlated with
favorable clinicopathological markers in our study is in
line with other studies (Saegusa et al, Saegusa et
Okayasu, Erlich et al, Creasman et al, Sivridis et al) that
demonstrated a close association between bcl-2 and
252
progesterone receptor immunoreactivity, since it is
widely accepted that the later is also linked to a favorable
outcome (10,11,12,13,14). In many studies (Geisler et al,
Taskin et al, Saegusa et al, Coppola et al, Yamauchi et al))
bcl-2 positivity has been directly correlated with a
favorable clinical outcome and good histopathologic
prognostic factors i.e. well-differentiated endometrioid
tumors, superficial myometrial invasion and early staging
(5, 9, 11,15,16). Similar results have been observed for
other tumors, including breast, lung and thyroid
carcinomas (17,18,19).
253
CharacteristicsNumber of
patients (%)Bcl-2 positive (%) Bcl-2 negative (%)
Histological type
Endometrioid
Non-endometrioid
54 (100)
41 (75.92)
13 (24.08)
33 (61.11)
26 (63.41)
7 (53.84)
21 (38.89)
15 (36.59)
6 (46.16)
Tumor grade
G1
G2
G3
24 (44.45)
21 (38.88)
9 (16.67)
21 (87.50)
12 (57.14)
0 (0.0)
3 (12.50)
9 (42.86)
9 (100)
Table 2. Correlation between bcl-2 expression and the histopathological prognostic markers of patients with endometrialcarcinoma.
Markers Number of patients %
Histological type
Endometrioid
Non-endometrioid
41
13
75.92
24.08
Tumor grade
G1
G2
G3
24
21
9
44.45
38.88
16.67
Table 1. Histopathological markers of endometrial carcinomas.
Several other studies do not reveal any correlation
between bcl-2 expression and known prognostic factors.
Giatromanolaki et al (20) performed a study on 133
patients with endometrial carcinoma and did not fiind any
relationship between bcl-2 and tumor grade, depth of
myometrial invasion and lymphovascular invasion.
Sakuragi et al (8) did not demonstrate any significant
differences in bcl-2 expression when lymph node
involvement and tumor grade were analyzed, but this
expression was lincked inversely proportional to
myometrial invasion (p=0.025). Kounelis et al (21)
performed a study on 61 patients and did not obtained
any significant difference between bcl-2 expression and
histopathological type, tumor grade and staging. Appel et
al (22) studied 48 Brazilian patients with a histological
diagnosis of endometrial carcinoma and did not
demonstrate any correlation between bcl-2 expression
and age, histological type,tumor grade, depth of
myometrial invasion and survival.
CONCLUSIONS
In conclusion, the present study provided strong
evidence that, in endometrial carcinoma, bcl-2
expression is associated with favorable prognostic
factors and may play important roles in tumor
progression from early to advanced stages.
254
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