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Analysis of differential diagnostic gene expression profiles in uterine leiomyoma and leiomyosarcoma
Abstracts
Methods: A retrospective case series of women who had frozen section at the time of their endometrial cancer hysterectomy was performed. All hysterectomies from January 2010 to December 2010 were identified using the Pathology database. Early grade (FIGO grade 1 or 2) endometrial cancer cases were identified from the frozen pathology diagnosis. Intra-operative frozen sections of the uterus were compared with the final pathology for FIGO grade and depth of invasion. Chi-squared analysis for categorical variables and t-tests for continuously measured variables were used for statistical analysis. Results: A total of 546 frozen sections at the time of hysterectomy were reviewed. A total of 117 FIGO grade 1 and 2 cases were identified. The mean age of the sample population was 60.15 years, and the mean BMI was 31.92. 22 of 117 cases (18.83%) were discordant for grade and 5 of 117 (4.27%) were discordant for depth of invasion. At the time of frozen section, 104/117 (88.89%) cases were identified at FIGO grade 1. Of the intra-operative FIGO grade 1 predictions, 12 of 104 (10.52%) were FIGO grade 2 at final pathology, and 7 of 104 (6.73%) were FIGO grade 3 at final pathology. There were 13/117 FIGO grade 2 cases identified at the time of frozen section (11.11%). Of these cases, 1 of 13 (7.69%) was found to be FIGO grade 1 at final pathology and 2 of 13 (15.38%) were FIGO grade 3 at final pathology. There were a total of 5 (4.27%) cases with discordant depth. 4 cases of discordant depth were read as <50% invasion at time of frozen section and were >50% invasion on final pathology and 1 case was diagnosed as >50% at time of frozen section and was <50% invasion on final pathology. Conclusion: Intra operative frozen sections are useful to assess the need for further surgical staging in early endometrial cancer. In this series, potentially 11% of cases could have been “under-staged”. However, in clinical practice this percentage is reduced by cases where lymph node dissection would be omitted due to medical co-morbidities.
doi:10.1016/j.ygyno.2011.07.079
Analysis of differential diagnostic gene expression profiles in uterine leiomyoma and leiomyosarcoma I.K. Dimitrova, P. Ramanathan, M.C. Neville, A.P. Bradford University of Colorado Anschutz Medical Campus, Aurora, CO, USA Objective: Smooth muscle tumors are the most frequent mesenchymal tumors of the uterus, the majority of which are readily classifiable as benign or malignant. However, when unusual features are seen in some leiomyoma (fibroid) variants, the differential diagnosis with a leiomyosarcoma may become challenging. Moreover, diagnostic criteria for the different subtypes of leiomyosarcoma are not uniform. Correct diagnosis has important prognostic and therapeutic implications. We examined the transcriptomes of normal myometrium, benign uterine fibroids and uterine leiomyosarcoma in search of a molecular signature that would aid in differentiating between benign and malignant lesions of the myometrium. Methods: We collected, with IRB approval, normal myometrium and fibroid tissue from 3 patients undergoing hysterectomies for symptomatic uterine leiomyoma. Leiomyosarcomas were obtained from 3 patients undergoing primary or secondary surgery. RNA was isolated and purified according to QIAGEN protocol. Samples were hybridized to Affimetrix Human Gene 1.0 ST microarray platforms. Data were normalized and quality control and statistical analysis performed using Genespring 10 protocols. Results: We identified statistically significant differences in mRNA levels of 777 genes relative to normal myometrium. We focused on those genes that exhibited differential expression between benign and malignant tumors, namely 242 genes were down-regulated in fibroids and simultaneously up-regulated in sarcomas compared to normal myometrium and conversely, 49 genes were up-regulated in fibroids and down-
445
regulated in sarcomas. Further review of those genes identified 60 that have been previously implicated in processes relevant to carcinogenesis. Examples include genes involved in cell cycle regulation (CDC20, cyclin B1, cyclin B2, CDC7, cyclin A2, CDK-1 and CDK-2), antiapoptotic genes (CHI3L1, MLLT11, MELK), proproliferative (PLK1, EZH2, STIL), genes involved in resistance to chemotherapeutic agents (CHI3L1, TOP2A, RPN2), and genes involved in angiogenesis, migration and metastasis. Expression profiles were generally consistent with the benign versus malignant, invasive phenotypes of leiomyoma and leiomyosarcoma, respectively. We propose that these distinctive and characteristic changes in myometrial gene expression will permit development of a diagnostic transcriptional profile to facilitate identification and treatment of early stage uterine leiomyosarcoma. Conclusion: The oncogenic mechanisms underlying the development of malignant mesenchymal uterine tumors remain elusive. Our gene expression profiling of normal myometrium, benign fibroids and malignant sarcomas has identified a potential molecular signature that will help differentiate between uterine fibroids and sarcomas. It has been demonstrated in prior studies that gene expression profiles can be used to classify different types of tumors and improve on the histology-based classification method. Pathway analysis of the gene expression profiles of sarcomas may provide insight into their etiology and pathophysiology, thereby yielding clues about oncogenic pathways underlying the development and progression of these tumors and identifying novel potential therapeutic targets.
doi:10.1016/j.ygyno.2011.07.080
Predictive value of carcinoembryonic antigen and cancer antigen 125 in identifying mucinous ovarian tumors D.B. Manders, S.C. Purinton, J.S. Lea, D.L. Richardson, D.S. Miller, S.M. Kehoe University of Texas Southwestern Medical Center, Dallas, TX, USA Objective: Mucinous ovarian neoplasms are uncommon. The usual CA125 marker may not be elevated in these tumors. We sought to determine if preoperative CEA and CA125 can predict borderline and malignant mucinous ovarian tumors and potentially be used as treatment response markers. Methods: A retrospective chart review of all patients operated on at a single institution from January 1, 1998 through August 30, 2010 with a diagnosis of a primary ovarian mucinous tumor was performed. Medical records were reviewed to obtain pathologic and laboratory data. Results: 72 patients were identified as having primary mucinous ovarian tumors. 26 patients (36%) had benign pathology while 46 patients (64%) had non-benign tumors, either borderline or malignant neoplasm. 63 patients (88%) had at least one preoperative tumor marker drawn, most commonly a CA125. Of malignancies, there were 13 stage I, 3 stage III and 1 stage IV cases. Using the CA125 as an isolated marker (N = 63), an abnormal result correctly indentified 14 of 39 non-benign tumors (sensitivity 36%) while a normal result identified 19 of 24 benign masses (specificity 79%). Similarly, an isolated CEA (N = 22) correctly identified 8 of 18 non-benign cases (sensitivity 44%) and 4 of 4 benign cases (specificity 100%). Considering only malignant pathology (not borderline tumors), the CA125 identified 4 of 12 cancers (sensitivity 33%), and the CEA correctly predicted 4 of 7 malignancies (sensitivity 57%). The sensitivity of CEA increased with advancing stage: 20% for stage I/II disease vs. 100% for stage III/IV. The sensitivity of CA125 was constant across all stages. When both markers were drawn (N=20), an abnormality in at least one correctly predicted non-benign pathology in 9 of 16 cases (sensitivity 56%) while identifying 3 of 4 benign cases correctly (specificity 75%).
Methods: A retrospective case series of women who had frozen section at the time of their endometrial cancer hysterectomy was performed. All hysterectomies from January 2010 to December 2010 were identified using the Pathology database. Early grade (FIGO grade 1 or 2) endometrial cancer cases were identified from the frozen pathology diagnosis. Intra-operative frozen sections of the uterus were compared with the final pathology for FIGO grade and depth of invasion. Chi-squared analysis for categorical variables and t-tests for continuously measured variables were used for statistical analysis. Results: A total of 546 frozen sections at the time of hysterectomy were reviewed. A total of 117 FIGO grade 1 and 2 cases were identified. The mean age of the sample population was 60.15 years, and the mean BMI was 31.92. 22 of 117 cases (18.83%) were discordant for grade and 5 of 117 (4.27%) were discordant for depth of invasion. At the time of frozen section, 104/117 (88.89%) cases were identified at FIGO grade 1. Of the intra-operative FIGO grade 1 predictions, 12 of 104 (10.52%) were FIGO grade 2 at final pathology, and 7 of 104 (6.73%) were FIGO grade 3 at final pathology. There were 13/117 FIGO grade 2 cases identified at the time of frozen section (11.11%). Of these cases, 1 of 13 (7.69%) was found to be FIGO grade 1 at final pathology and 2 of 13 (15.38%) were FIGO grade 3 at final pathology. There were a total of 5 (4.27%) cases with discordant depth. 4 cases of discordant depth were read as <50% invasion at time of frozen section and were >50% invasion on final pathology and 1 case was diagnosed as >50% at time of frozen section and was <50% invasion on final pathology. Conclusion: Intra operative frozen sections are useful to assess the need for further surgical staging in early endometrial cancer. In this series, potentially 11% of cases could have been “under-staged”. However, in clinical practice this percentage is reduced by cases where lymph node dissection would be omitted due to medical co-morbidities.
doi:10.1016/j.ygyno.2011.07.079
Analysis of differential diagnostic gene expression profiles in uterine leiomyoma and leiomyosarcoma I.K. Dimitrova, P. Ramanathan, M.C. Neville, A.P. Bradford University of Colorado Anschutz Medical Campus, Aurora, CO, USA Objective: Smooth muscle tumors are the most frequent mesenchymal tumors of the uterus, the majority of which are readily classifiable as benign or malignant. However, when unusual features are seen in some leiomyoma (fibroid) variants, the differential diagnosis with a leiomyosarcoma may become challenging. Moreover, diagnostic criteria for the different subtypes of leiomyosarcoma are not uniform. Correct diagnosis has important prognostic and therapeutic implications. We examined the transcriptomes of normal myometrium, benign uterine fibroids and uterine leiomyosarcoma in search of a molecular signature that would aid in differentiating between benign and malignant lesions of the myometrium. Methods: We collected, with IRB approval, normal myometrium and fibroid tissue from 3 patients undergoing hysterectomies for symptomatic uterine leiomyoma. Leiomyosarcomas were obtained from 3 patients undergoing primary or secondary surgery. RNA was isolated and purified according to QIAGEN protocol. Samples were hybridized to Affimetrix Human Gene 1.0 ST microarray platforms. Data were normalized and quality control and statistical analysis performed using Genespring 10 protocols. Results: We identified statistically significant differences in mRNA levels of 777 genes relative to normal myometrium. We focused on those genes that exhibited differential expression between benign and malignant tumors, namely 242 genes were down-regulated in fibroids and simultaneously up-regulated in sarcomas compared to normal myometrium and conversely, 49 genes were up-regulated in fibroids and down-
445
regulated in sarcomas. Further review of those genes identified 60 that have been previously implicated in processes relevant to carcinogenesis. Examples include genes involved in cell cycle regulation (CDC20, cyclin B1, cyclin B2, CDC7, cyclin A2, CDK-1 and CDK-2), antiapoptotic genes (CHI3L1, MLLT11, MELK), proproliferative (PLK1, EZH2, STIL), genes involved in resistance to chemotherapeutic agents (CHI3L1, TOP2A, RPN2), and genes involved in angiogenesis, migration and metastasis. Expression profiles were generally consistent with the benign versus malignant, invasive phenotypes of leiomyoma and leiomyosarcoma, respectively. We propose that these distinctive and characteristic changes in myometrial gene expression will permit development of a diagnostic transcriptional profile to facilitate identification and treatment of early stage uterine leiomyosarcoma. Conclusion: The oncogenic mechanisms underlying the development of malignant mesenchymal uterine tumors remain elusive. Our gene expression profiling of normal myometrium, benign fibroids and malignant sarcomas has identified a potential molecular signature that will help differentiate between uterine fibroids and sarcomas. It has been demonstrated in prior studies that gene expression profiles can be used to classify different types of tumors and improve on the histology-based classification method. Pathway analysis of the gene expression profiles of sarcomas may provide insight into their etiology and pathophysiology, thereby yielding clues about oncogenic pathways underlying the development and progression of these tumors and identifying novel potential therapeutic targets.
doi:10.1016/j.ygyno.2011.07.080
Predictive value of carcinoembryonic antigen and cancer antigen 125 in identifying mucinous ovarian tumors D.B. Manders, S.C. Purinton, J.S. Lea, D.L. Richardson, D.S. Miller, S.M. Kehoe University of Texas Southwestern Medical Center, Dallas, TX, USA Objective: Mucinous ovarian neoplasms are uncommon. The usual CA125 marker may not be elevated in these tumors. We sought to determine if preoperative CEA and CA125 can predict borderline and malignant mucinous ovarian tumors and potentially be used as treatment response markers. Methods: A retrospective chart review of all patients operated on at a single institution from January 1, 1998 through August 30, 2010 with a diagnosis of a primary ovarian mucinous tumor was performed. Medical records were reviewed to obtain pathologic and laboratory data. Results: 72 patients were identified as having primary mucinous ovarian tumors. 26 patients (36%) had benign pathology while 46 patients (64%) had non-benign tumors, either borderline or malignant neoplasm. 63 patients (88%) had at least one preoperative tumor marker drawn, most commonly a CA125. Of malignancies, there were 13 stage I, 3 stage III and 1 stage IV cases. Using the CA125 as an isolated marker (N = 63), an abnormal result correctly indentified 14 of 39 non-benign tumors (sensitivity 36%) while a normal result identified 19 of 24 benign masses (specificity 79%). Similarly, an isolated CEA (N = 22) correctly identified 8 of 18 non-benign cases (sensitivity 44%) and 4 of 4 benign cases (specificity 100%). Considering only malignant pathology (not borderline tumors), the CA125 identified 4 of 12 cancers (sensitivity 33%), and the CEA correctly predicted 4 of 7 malignancies (sensitivity 57%). The sensitivity of CEA increased with advancing stage: 20% for stage I/II disease vs. 100% for stage III/IV. The sensitivity of CA125 was constant across all stages. When both markers were drawn (N=20), an abnormality in at least one correctly predicted non-benign pathology in 9 of 16 cases (sensitivity 56%) while identifying 3 of 4 benign cases correctly (specificity 75%).