Predictive value of the cancer stem cell related marker NANOG in ovarian serous carcinoma

Izhodišče Patogeneza raka jajčnikov še vedno ni jasna. Novejše raziskave kažejo, da bi bile lahko za nastanek, razvoj in ponovitev tumorja po zdravljenju odgovorne rakave matične celice. Te tako kot embrionalne matične celice izražajo označevalce pluripotentnosti. NANOG je ključni transkripcijski dejavnik za uravnavanje samoobnavljanja in pluripotentnosti v embrionalnih matičnih celicah, izraža pa se tudi v različnih tumorjih, vključno z epitelijskim rakom jajčnikov. Namen naše raziskave je bil ovrednotiti izražanje označevalca NANOG pri bolnicah s seroznimi tumorji jajčnikov in pri seroznih karcinomih jajčnikov ter le-to primerjati s patohistološkimi in kliničnimi napovednimi kazalci. Preiskovanke in metode Prvi del raziskave je potekal retrospektivno, del prospektivno. V retrospektivnem delu raziskave smo izražanje označevalca NANOG določali z imunohistokemično metodo na tkivni mreži, zgrajeni iz arhiviranega tkiva jajčnikov. V raziskavo smo vključili 20 bolnic s seroznim benignim tumorjem jajčnikov, 30 bolnic s seroznim atipično proliferativnim (angl. borderline) tumorjem jajčnikov in 109 bolnic s seroznim karcinomom jajčnikov. Imunohistokemično reakcijo smo točkovali na osnovi intenzivnosti ter deleža obarvanega tumorja in na osnovi seštevka tumorje razdelili v štiri skupine: NANOG negativno (0), NANOG blago pozitivno (+1), NANOG zmerno pozitivno (+2) in NANOG močno pozitivno (+3) skupino. Za bolnice s karcinomom jajčnikov smo pridobili tudi klinične podatke in jih primerjali med omenjenimi skupinami. 20 tkivnih vzorcev seroznega karcinoma jajčnikov smo dodatno IHK barvali še na označevalca pluripotentnosti SOX2 in SSEA-4 ter označevalec za mezenhimske celice vimentin. V prospektivnem delu raziskave smo izražanje označevalca NANOG določali v 17 intraoperativno pridobljenih vzorcih seroznega tumorja jajčnikov. Poleg imunohistokemične metode smo pri tem uporabili tudi metodo prenosa western. Za analizo primerjave rezultatov obeh metod smo izračunali korelacijski koeficient. Rezultati V skupini arhiviranih vzorcev 159 seroznih tumorjev jajčnikov je bilo imunohistokemično NANOG pozitivnih 78 (49,1 %) tumorjev. Vsi NANOG pozitivni tumorji so bili patohistološko karcinomi visoke stopnje malignosti (p < 0,001). Vsi karcinomi nizke stopnje malignosti, vsi atipični proliferativni tumorji ter vsi benigni tumorji so bili NANOG negativni. Med karcinomi visoke stopnje malignosti je bilo NANOG pozitivnih 78 (73,6 %) tumorjev, od tega 24 (22,6 %) blago, 29 (27,4 %) zmerno in 25 (23,6 %) močno pozitivnih. Izražanje označevalca NANOG med seroznimi tumorji jajčnikov je bilo statistično značilno povezano z neugodnimi patohistološkimi napovednimi kazalci, to je stopnjo malignosti. Statistično značilne povezave s kliničnimi napovednimi kazalci, to je s starostjo bolnic, stadijem bolezni, ostankom tumorja po citoreduktivni operaciji, odzivom bolezni na kemoterapijo in preživetjem, pa nismo našli. Za neodvisna napovedna kazalca preživetja smo potrdili le stadij bolezni (p = 0,023) in ostanek tumorja po radikalni operaciji (p < 0,001). Rezultati prospektivnega dela raziskave so pokazali, da je imunohistokemično barvanja na NANOG pri bolnicah s seroznim tumorjem jajčnikov v statistično značilni korelaciji z rezultati metode prenosa western (p < 0,001). Dodatno smo s svetlobnim mikroskopom v povrhnjem epiteliju seroznega karcinoma jajčnikov zaznali spremembe, podobne epitelijsko-mezenhimski tranziciji, pri kateri se matičnim celicam podobne celice, pozitivne na označevalce pluripotentnosti, spreminjajo v rakavim matičnim celicam podobne celice, ki so poleg na označevalce pluripotentnosti pozitivne tudi na vimentin. Zaključek Imunohistokemična metoda je primerna diagnostična metoda določanja označevalca NANOG v tumorskih celicah bolnic s seroznimi tumorji jajčnikov. Imunohistokemično izražanje označevalca NANOG v tumorskih celicah pri bolnicah s seroznimi tumorji jajčnikov je bilo statistično značilno povezano s karcinomi visoke stopnje malignosti. Statistično značilne povezave med izražanjem označevalca NANOG in kliničnimi napovednimi kazalci nismo potrdili. S svetlobnim mikroskopom zaznane spremembe podobne epitelijsko-mezenhimski tranziciji, ter nastanek celic podobnih rakavim matičnim celicam, odpirajo novo področje za nadaljnje raziskave.Background The ovarian cancer pathogenesis is still unknown. According to recent data, it is possible that cancer stem cells are responsible for formation, progression and tumor repetition after the treatment has been completed. Same as embryonic stem cells, cancer stem cells express markers of pluripotency. NANOG is a key transcription factor that regulates self-renewal and differentiation in embryonic stem cellsits expression was also detected in different tumors, one of them being ovarian carcinoma. The purpose of our study was to assess NANOG expression in different ovarian serous tumors, and in case of ovarian serous carcinoma to evaluate its significance for prognosis of disease. Patients and methods The first part of the study was retrospective, and the second part was prospective. In the retrospective part NANOG expression was immunohistochemically analyzed in the ovarian tissue microarrays. The microarrays were constructed from archived ovarian tissue of 109 ovarian serous carcinoma patients, 30 borderline ovarian serous tumor patients, and 20 benign ovarian serous tumor patients. Immunohistochemical reaction in tumor tissue samples was scored based on percentage of positive cells and signal intensity of tumor cells. According to acquired scores we classified tumor samples into four groups: NANOG – negative group (0), NANOG - slightly positive group (+1), NANOG - moderately positive group (+2) and NANOG - strongly positive group (+3). For ovarian serous carcinoma patients clinical data was acquired, and correlation between NANOG expression and clinical parameters was analyzed. 20 tissue samples of ovarian serous carcinoma were further immunohistochemically stained for markers of pluripotency SOX2, SSEA-4 and marker of mesenchymally-derived cells vimentin. In prospective part of our study Western blot and immunohistochemistry were performed for assessment of NANOG expression in 17 intraoperatively obtained tissue samples of ovarian serous tumors and the correlation between the results were analyzed. Results Out of 159 ovarian serous tumors, NANOG was positive in 78 (49.1%) cases. All NANOG positive tumors were high grade carcinomas (p < 0.001). All low grade carcinomas, all borderline tumors and all benign tumors were NANOG negative. In terms of high grade carcinoma group 78 (73.6%) were NANOG positive: 24 (22.6%) slightly positive, 29 (27.4%) moderately positive and 25 (23.6%) strongly positive. All cases, where NANOG was positively expressed presented high grade morphology. NANOG expression showed no significant correlation with clinical parameters such as age of patients, stage of disease, tumor residue after radical surgery, chemotherapy efficiency and survival. The only independent prognostic factors were stage of disease (p = 0.023) and tumor residue (p < 0.001). We proved immunohistochemistry to be reliable method for NANOG assessment in case of ovarian serous tumors as significant correlation (p < 0.001) between the results of Western blot and immunohistochemistry were confirmed. Using light microscope, changes similar to epithelial-mesenchymal transition were observed in ovarian surface epithelium of patients suffering from ovarian serous carcinoma. These changes might generate putative cancer stem cells positive for markers of pluripotency and vimentin. Conclusions Immunohistochemistry was proved to be an adequate method for NANOG expression assessment. NANOG expression in ovarian serous tumor cells statistically significantly correlated with high grade ovarian serous carcinoma. Our results showed no statistically significant correlation between NANOG expression and clinical parameters. Changes similar to epithelial-mesenchymal transition and generation of putative cancer stem cells observed by light microscope need further research and clarification

Office hysteroscopy in removing retained products of conception – a highly successful approach with minimal complications

Data of 101 patients with retained products of conception (RPOC), treated with office hysteroscopy (OH) from 2012 to 2015 at the University Medical Centre Ljubljana were analysed. Patients with >30 mm RPOC thickness or strong vascularisation on ultrasound (US) were excluded. Procedures were successfully completed in 94/101 (93%). Mean duration was 18 min (4–60), patient pain estimation with VAS was 2.3 (0–8). No intraoperative complications > Grade II according to Clavien-Dindo classification occurred. Uncompleted cases were safely referred to procedures in general anaesthesia. Follow-up after one month was performed in 78/101 (77%) patients with OH (69) or US (9). Only three patients reported endometritis, three cases of intrauterine adhesions were related to curettage or pre-existing adhesions. We compared preoperative findings of completed and uncompleted cases. Larger size of RPOC and the presence of irregular tissue-myometrial border on US was statistically significantly higher in uncompleted OH (p<.05); mild vascularisation and β-hCG levels up to 80 U/L did not affect the outcome.Impact statement What is already known on this subject? In the last three decades research has focussed on comparing hysteroscopic resection (HR) to traditional dilation and curettage in removing retained products of conception (RPOC). Office hysteroscopy (OH) without hospitalisation or general anaesthesia enables women to return to their daily routine immediately (especially desired by breastfeeding mothers) and is used where available, yet there is little published data to evaluate its role in the management of RPOC. What do the results of this study add? To the best of our knowledge, this article is unique in addressing success, safety and possible limiting factors of OH in removing placental polyps. According to our findings, OH is highly successful (93%), safe, and well tolerated in removing RPOC up to 30 mm in thickness and with no or minimal vascularisation on ultrasound. Thorough follow-up (68% with OH, 9% with US after 1 month) adds to strength of data. What are the implications of these findings for clinical practice and/or further research? Removing large and vascularised RPOC can be a very demanding procedure, yet a majority of patients might benefit from an outpatient approach. Prospective studies on limiting factors and more data on long term reproductive outcomes are needed to fully compare OH to other methods of removal

AKR1C3 is associated with better survival of patients with endometrial carcinomas

The aldo-keto reductase (AKR) superfamily is gaining attention in cancer research. AKRs are involved in important biochemical processes and have crucial roles in carcinogenesis and chemoresistance. The enzyme AKR1C3 has many functions, which include production of prostaglandins, androgens and estrogens, and metabolism of different chemotherapeuticsAKR1C3 is thus implicated in the pathophysiology of different cancers. Endometrial and ovarian cancers represent the majority of gynecological malignancies in developed countries. Personalized treatments for these cancers depend on identification of prognostic and predictive biomarkers that allow stratification of patients. In this study, we evaluated the immunohistochemical (IHC) staining of AKR1C3 in 123 paraffin-embedded samples of endometrial cancer and 99 samples of ovarian cancer, and examined possible correlations between expression of AKR1C3 and other clinicopathological data. The IHC expression of AKR1C3 was higher in endometrial cancer compared to ovarian cancer. In endometrioid endometrial carcinoma, high AKR1C3 IHC expression correlated with better overall survival (hazard ratio, 0.1995% confidence interval, 0.06−0.65, p = 0.008) and with disease-free survival (hazard ratio, 0.32895% confidence interval, 0.12–0.88, p = 0.027). In patients with ovarian cancer, there was no correlation between AKR1C3 IHC expression and overall and disease-free survival or response to chemotherapy. These results demonstrate that AKR1C3 is a potential prognostic biomarker for endometrioid endometrial cancer

AKR1C3 Is Associated with Better Survival of Patients with Endometrial Carcinomas

The aldo-keto reductase (AKR) superfamily is gaining attention in cancer research. AKRs are involved in important biochemical processes and have crucial roles in carcinogenesis and chemoresistance. The enzyme AKR1C3 has many functions, which include production of prostaglandins, androgens and estrogens, and metabolism of different chemotherapeutics; AKR1C3 is thus implicated in the pathophysiology of different cancers. Endometrial and ovarian cancers represent the majority of gynecological malignancies in developed countries. Personalized treatments for these cancers depend on identification of prognostic and predictive biomarkers that allow stratification of patients. In this study, we evaluated the immunohistochemical (IHC) staining of AKR1C3 in 123 paraffin-embedded samples of endometrial cancer and 99 samples of ovarian cancer, and examined possible correlations between expression of AKR1C3 and other clinicopathological data. The IHC expression of AKR1C3 was higher in endometrial cancer compared to ovarian cancer. In endometrioid endometrial carcinoma, high AKR1C3 IHC expression correlated with better overall survival (hazard ratio, 0.19; 95% confidence interval, 0.06&minus;0.65, p = 0.008) and with disease-free survival (hazard ratio, 0.328; 95% confidence interval, 0.12&ndash;0.88, p = 0.027). In patients with ovarian cancer, there was no correlation between AKR1C3 IHC expression and overall and disease-free survival or response to chemotherapy. These results demonstrate that AKR1C3 is a potential prognostic biomarker for endometrioid endometrial cancer

AKR1B1 as a prognostic biomarker of high-grade serous ovarian cancer

Although aldo-keto reductases (AKRs) have been widely studied in cancer, no study to date has examined the roles of AKR family 1 members B1 (AKR1B1) and B10 (AKR1B10) in a large group of ovarian cancer patients. AKR1B1 and AKR1B10 play a significant role in inflammation and the metabolism of different chemotherapeutics as well as cell differentiation, proliferation, and apoptosis. Due to these functions, we examined the potential of AKR1B1 and AKR1B10 as tissue biomarkers. We assessed the immunohistochemical levels of AKR1B1 and AKR1B10 in tissue paraffin sections from 99 patients with high-grade serous ovarian cancer (HGSC) and compared these levels with clinicopathological characteristics, survival, and response to chemotherapy. A higher immunohistochemical AKR1B1 expression correlated with a better overall and disease-free survival of HGSC patients whereas AKR1B10 expression did not show any significant differences. A multivariant Cox analysis demonstrated that a high AKR1B1 expression was an important prognostic factor for both overall and disease-free survival. However, AKR1B1 and AKR1B10 were not associated with different responses to chemotherapy. Our data suggest that AKR1B1 is involved in the pathogenesis of HGSC and is a potential prognostic biomarker for this cancer