- Email: [email protected]
Cyclin E and p27: their putative role as prognostic markers
Current Diagnostic Pathology (2002) 8, 289^296
c 2002 Elsevier Science Ltd. doi:10.1054/cdip.2002.0130, available online at http://www.idealibrary.com on
MINI-SYMPOSIUM: MOLECULAR MARKERS IN PATHOLOGY
Cyclin E and p27: their putative role as prognostic markers R. Chetty Department of Pathology, Nelson R Mandela School of Medicine, Private Bag 7, Congella 4013, Durban, South Africa
KEYWORDS cell cycle proteins, proliferation, prognosis, biological markers, cyclins, cyclin-dependent kinase inhibitors, cyclin E, p27
Summary Abnormalities or derangements ofthe orderly proliferation and cycling of cells is the quintessential de¢nition of a cancer or malignant cell.The complex nature of the interaction of several interdependent cell cycle proteins has and continues to be unravelled.Key functions have been ascribed to many of the proteins and the delicate balance that maintains cell normal cell cycling is now understood.Within the cell cycle, the G1proteins have come under intense scrutiny, especially the interaction between cyclin E and p27. Essentially, cyclin E drives the cell cycle forward towards mitosis, while p27 acts as a brake preventing cell cycle progression.The levels of these two proteins, independently and together, have been analysed in many studies in several tumour types. A pattern or trend has emerged: high cyclin E with low p27 is an adverse prognostic indicator in the majority of commonly encountered malignant tumours. Furthermore, in several instances, there is a stepwise increase of cyclin E and decrease of p27 that matches the progression from dysplastic, pre-invasive lesions to full-blown invasive malignanttumours. As a cautionary note, there are exceptions to this tenet as exempli¢ed by bladder and oesophageal cancers, where the relationship between cyclin E and p27 is not straightforward. The body of evidence in the literature points to both cyclin E and p27 as being useful adjuncts to prognostication indices, but not unreservedly as indec 2002 Elsevier Science Ltd. pendent portenders of outcome.
Everything should be made as simple as possible, but not simpler. Albert Einstein
INTRODUCTION With advances in biomedical research exploding and producing new knowledge seemingly e¡ortlessly, a sea of information now surrounds the diagnostic pathologist. Much research is of the translational variety and as medical doctors, let alone pathologists, we need to know how research and its by-products impact on patient management and outcome. Clinicians are constantly on the lookout for ancillary information that may in£uence patient management and enhance care. Pathologists are Correspondence to: RC.Tel.: +27-31-260 - 4483; Fax: +27-31-2052711; E-mail: [email protected]
often asked questions about a variety of molecules. Indeed, pathologists are asking themselves searching questions about the plethora of putative markers that abound in the literature. At this juncture, one must address a vital question. Should diagnostic pathologists even know about molecular aberrations and markers, let alone allow them to pervade the ordered sanctity of morphological analysis? Should pathologists apply Occam’s razor to this glut of information and not increase beyond what is absolutely necessary the number of entities required to explain anythingF‘the principle of parsimony’? The tide of new information is unstoppable and the concept of unnecessary plurality has been submerged. Molecular medicine harnesses the genetic and biomedical determinants that govern the orderly progression of cellular physiology from cell birth to cell death.1 It, therefore, provides the basis for modern prevention, diagnosis and treatment. There are several modes of oncogenesis and each of
290
CURRENT DIAGNOSTIC PATHOLOGY
these pathways has provided fertile ground for potential interventional strategies. The cell cycle is one such pathway that has been targeted for extensive study. The search for biological markers in tumour pathology continues unabated. Application of research to the diagnostic setting is increasing, and the availability of easy-touse, reproducible tests, such as immunohistochemistry, will play an increasing role in patient management.
The cell cycle The molecular regulation of the cell cycle (See Fig. 1) maintains homeostatic balance, cell growth, di¡erentiation, survival and ultimately death.1 The tight equilibrium is due to an inter-play of positive regulators (the cyclins and the cyclin-dependent kinases) and negative regulators, constituted by tumour suppressor proteins (mainly p53 and retinoblastoma) and the cyclin-dependent kinase inhibitors. When activated, the cyclins and cyclindependent kinases drive the cell through the various phases of the cell cycle, whilst the negative regulators serve as the brake. Aberrations of the G1 cyclins are important in the transformation and progression of many di¡erent malignancies.2^5 Key proteins that are active in the cell cycle, p53 and bcl-2, have been the subject of several publications. In an article assessing the value of immunohistochemistry for p53 and bcl-2 proteins in the routine diagnostic laboratory, Pezzella and Gatter raised the image of these two proteins being balanced on a seesaw.6 This inverse relationship was re-emphasized in a subsequent review and possible practical applications of p53 and bcl-2 immunohistochemistry in the diagnostic realm have been sug-
p53
p21
CDK2
CDK2
Cyclin E
Cyclin A
S
p27
G1
E2F
pRB-E2F
CDK1
p15
Cyclin B
gested.7 The purpose of this homily is to highlight the role of two cell cycle proteins, cyclin E and p27, in tumour pathology and their possible roles as prognostic markers that may be used in diagnostic pathology.
Cyclin E Cyclin E, located on chromosome 19q12-13, produces a 395 amino acid protein that contributes to normal cell proliferation and development.5 Overexpression of cyclin E protein accelerates the G1 phase of the cell cycle, a process that is accompanied by phosphorylation of the product of the retinoblastoma gene.5,8 The ability of cyclin E to phosphorylate retinoblastoma protein is dependent on a group of molecules termed the cyclindependent kinase inhibitors (CKIs). The CKIs suppress the activity of cyclin E. Overexpression and hence accumulation of cyclin E protein in the majority of cases is as a result of ampli¢cation of the gene.9^12 Cyclin E expression in the absence of gene abnormalities may also be due to post-transcriptional mechanisms.5 Immunolabelling of cyclin E is mainly nuclear; however, cytoplasmic staining has been observed in many studies. The signi¢cance of this is at present not clear. The protein is synthesized and degraded within the cytoplasm whence it is transferred rapidly to the nucleus, where it is functional.Cytoplasmic cyclin E may in essence be due to one or more of several possibilities: increased synthesis, decreased degradation or lack of nuclear transfer. At this point, cytoplasmic staining in the absence of accompanying nuclear localization is regarded as negative. In attempting to understand the role of cyclin E in tumourigenesis, two questions arise. Is cyclin E part of a myriad of events that result in cell proliferation or is it a primary driving force? In some tumours, cyclin E gene and protein accumulation occur late,11 whilst in other neoplasms it appears to be an early event.13,14 When examining something as complex as the cell cycle with the intricate networking that is operational, looking at the role of one protein at a time is not advisable. It is better to look at them in concert, and since cyclin E has an intimate association with p27, these two proteins should be examined in tandem.
pRB p21
CDK4,6
G2
Cyclin D1,2,3
CDK1
M
Cyclin A,B
Figure 1 Schematic representation of the cell cycle highlighting the G1 proteins.It is important to note that both cyclin E and p27 interact with a variety of other proteins, especially retinoblastoma in this phase of the cell cycle.
p27 The CKIs can be categorized into two groups: the Kip/ Cip proteins (p21, p27 and p57) and the INK4 proteins (p15, p16, p18 and p19). The Kip/Cip family of CKIs is capable of interacting with (inhibiting) all the cyclins, but especially with cyclin E. Overexpression of Kip/Cip proteins leads to cell cycle arrest.The p27 gene is located on chromosome 12p13, at the junction of 12p12 and 12p13.1.15 Several functions have been ascribed to p27, but loss of p27 expression is thought to be tumourigenic and may
CYCLIN E AND p27:THEIR PUTATIVE ROLE AS PROGNOSTIC MARKERS lead to tumour progression.15 Other functions include promotion of apoptosis, regulation of drug resistance in solid tumours and a protective role in in£ammatory injury.15 Loss of expression of p27 protein is not thought to occur because of mutations in the gene.16 ^19 However, given the potentially critical role that Kip/Cip proteins play in controlling cell cycle checkpoints, it is perhaps surprising that their deletion did not give rise to tumours in mice and for that matter, mutations in p21, p27 and p57 are not frequently encountered in human tumours.15 Despite this, several studies have characterized p27 as an independent prognostic factor in a variety of human malignancies, including breast, colon and prostate cancers.15
291
Perusal of these papers shows compelling and convincing data, which indicate that both ¢t the bill as markers.This is aided and abetted by the strides that new monoclonal antibody generation with antigen retrieval has made. Immunohistochemistry and its application beyond the diagnostic realm is close at hand. This necessitates knowledge of what is available and the likely implications of their use. The purpose of the remainder of this review is to look at the body of evidence that appears in the literature regarding cyclin E and p27 in speci¢c tumour entities in the di¡erent organs.
BREAST GENERAL CONSIDERATIONS Both cyclin E and p27 have been examined in many malignancies to ascertain whether they have any prognostic signi¢cance, either alone or in concert. Cyclin E immunoexpression has been explored in several malignancies and it is generally felt that overexpression of cyclin E is associated with an adverse prognosis.5 Similarly, the prognostic signi¢cance of p27 has also been examined in a variety of tumours and most studies show that decreased expression of p27 is encountered with more aggressive tumours.20 The cell cycle is an intricate process with extensive interaction and networking between the various cell cycle regulators; thus, isolating any one protein and analysing its e¡ects may or may not reveal any meaningful information. It is therefore, better to examine the cell cycle regulatory proteins in concert.5 For instance, high levels of cyclin E are functionally inactivated by large numbers of cyclin kinase-dependent inhibitors, such as p21. This has been o¡ered as the explanation for the association of high levels of cyclin E with a good prognosis in uterine cervical adenocarcinomas.5,21 Thus, one can see that a straightforward application of up- and downregulation does not apply in a uniform fashion in tumour biology. For a new prognostic marker to be accepted for routine clinical use, at least three criteria have to be satis¢ed.22 Firstly, the marker must provide information independent of and better than conventional pathological criteria; secondly, the marker must provide information that can impact on treatment decisions and protocols; and thirdly, studies with the particular marker must be reproducible. These are stringent criteria and if applied absolutely to the latter, it will be di⁄cult for either cyclin E or p27 to ful¢l all criteria. However, both these markers come very close and warrant consideration as potential markers in the investigative armamentarium that diagnostic pathologists are likely to have at their disposal. As mentioned previously, the literature abounds with papers highlighting the putative roles of cyclin E and p27 as prognostic and/or diagnostic markers.
Cyclin E expression has been explored in both in situ and invasive breast cancers, and immunodetection has been correlated with outcome and survival.23 In fact, cyclin E has been suggested to be a better prognostic marker for breast cancer than cyclin D1.24 Overexpression of cyclin E has been shown to correlate with proliferation markers such as proliferating cell nuclear antigen (PCNA).25 In one study, positive cyclin E immunostaining correlated with negative oestrogen receptor status and high-grade tumours.26 Cyclin E staining is probably most important as a prognostic marker in the setting of lymph node negative breast cancers, where it can be used to re¢ne prognosis.23,26 It is important to note that cyclin E alone is not an independent prognostic factor in lymph node positive cases, but is in the lymph node negative cases.26 Several studies have demonstrated that decreased p27 is associated with both tumour progression and a poor prognosis.23,27,28 However, one study on 512 cases of breast carcinoma with a median follow-up period of 9 years, did not ¢nd p27 immunohistochemistry alone to be of predictive value.29 Contrary to most other studies, this showed high p27 immunoexpression as a marker of poor prognosis.This appears to be the only study that is at odds with the general trend that low p27 is attended by a poor prognosis. The combined immunopro¢le of high cyclin E and low p27 is a marker of aggressive disease, progression and a poor prognosis in breast cancer.
OESOPHAGUS In squamous carcinoma of the oesophagus, the role of p27 is controversial. Some reports state that p27 is not a signi¢cant prognostic factor,30 whilst others have correlated increased p27 with tumour invasion, lymph node spread and poor prognosis.31 Yet another study has shown that low p27 labelling had a worse prognosis than those with high levels of p27 protein expression.32 Thus, there is a lack of consistency (and no small amount of confusion) with regard to the role of p27 in oesophageal squamous carcinomas.This ¢eld awaits a de¢nitive study
292
that will answer the question about the use of p27 immunohistochemistry. The picture is a little clearer with regard to cyclin E immunoexpression in squamous carcinoma of the oesophagus. A study by Ohbu and colleagues demonstrated stepwise increasing cyclin E expression from normal appearing oesophageal mucosa through low- and high-grade dysplasias and ¢nally, invasive cancers.33 Thus, in keeping with most malignancies, increased cyclin E is seen as a marker of tumour progression and poor prognosis in squamous carcinoma of the oesophagus. In Barrett’s associated adenocarcinoma, the usual scenario of low p27 and high cyclin E conferring an adverse prognosis, applies.34 However, cyclin E on its own is not a useful predictor in Barrett’s oesophagus because expression is seen in metaplastic, dysplastic and invasive lesions.35
STOMACH The cyclin E gene is ampli¢ed in 15% of gastric cancers. However, overexpression of cyclin E protein and mRNA is more frequent.11,36,37 Several studies have identi¢ed cyclin E overexpression as a poor prognostic marker in gastric cancers of all histological types.11,36,38 Concomitant loss of p27 is accompanied by a poor prognosis,39 and a co-operative role for cyclin E and p27 has been advanced in gastric cancer.40 These latter investigators concluded that decreased p27 expression is a negative prognostic marker in patients with cyclin E positive tumours.40
COLON AND RECTUM Cyclin E gene ampli¢cation has been detected in about 10% of colorectal carcinomas.5 With regard to immunohistochemical protein expression of cyclin E, there is a stepwise increase in expression as seen in the oesophagus. Increased expression is seen from normal through the grades of dysplasia to in¢ltrating adenocarcinoma.41,42 The reciprocal role of p27 loss in colorectal cancer has been shown to identify those cancers that develop metachronous metastases and hence those showing tumour progression.43
LUNG Neoplastic bronchial epithelial cells have higher levels of functional cyclin E and cyclin-dependent kinase 2 complexes. High cyclin E and low p27 are poor prognostic markers for lung adenocarcinomas.44 Cyclin E overexpression is more frequently observed in squamous carcinomas than adenocarcinomas, and in poorly-di¡erentiated compared to well-di¡erentiated tumours.45 This latter staining property is independent of the histological type of tumour. Finally, p27 is regarded as a prognostic
CURRENT DIAGNOSTIC PATHOLOGY
factor that correlates with survival in non-small cell carcinomas as a group.46
KIDNEY Cyclin E overexpression in renal cell carcinomas was found to be rare in one study.47 This study, however, con¢rmed the association of low p27 expression with poor prognosis and outcome. Another con¢rmed that low p27 protein levels, especially when taken in conjunction with p53 overexpression, were a predictor of poor outcome in clear cell renal cancers.48
URINARY BLADDER In contrast to the usual inverse relationship between cyclin E and p27, decreasing or low levels of both p27 and cyclin E were associated with progression from super¢cial into deeply invasive bladder cancers.49,50 However, another study provides contradictory evidence regarding the role of cyclin E in transitional carcinomas of the renal pelvis and ureters.51 This paper showed that cyclin E immunopositivity correlated with high tumour grade and poor prognosis.
PROSTATE Cyclin E is thought to act as a co-activator or increase the transactivation activity of the human androgen receptor.52 The aberrant expression of cyclin E induces persistent activation of the androgen receptor, thus impacting on prostatic carcinogenesis. Loss of p27 protein is associated with high-grade tumours, predicts treatment failure, is an adverse prognostic factor and correlates with lymph node spread of prostate cancer.53^56 Interestingly, both p27 protein and mRNA are markedly decreased in both epithelium and stroma in benign prostatic hyperplasia.57
UTERINE CERVIX Cyclin E appears to be an important early factor in the pathogenesis of squamous carcinomas through its putative link with the transforming genotypes of HPV.58,59 However, the prognostic signi¢cance of upregulated cyclin E in this particular tumour has been questioned in one study.60 When both cyclin E and p27 expression were compared in normal cervical squamous epithelium, intra-epithelial neoplasia and invasive cancers, p27 loss was noted in the progression through the stages of evolution of the disease. Furthermore, there was a reciprocal upregulation in cyclin E levels.61 Thus, the evidence points towards p27 loss and increased cyclin E expression as being of prognostic value in squamous
CYCLIN E AND p27:THEIR PUTATIVE ROLE AS PROGNOSTIC MARKERS
carcinomas of the uterine cervix. Very little appears to have been done with adenocarcinomas at this site.
ENDOMETRIUM Upregulation of cyclin E is seen in the majority of endometrial cancers.62 As in breast cancer, an inverse correlation between oestrogen receptor status and cyclin E immunostaining exists.63 It is worth remembering that cyclin E is also expressed by proliferative phase endometrium, which of itself is unsurprising since the cells are proliferating.64 The levels are lower than the marked upregulation that is encountered in endometrial carcinoma. From a morphological point of view, distinction of atypical endometrial hyperplasia and frank adenocarcinoma from proliferative phase endometrium, is rarely a problem. Clear cell carcinomas of the endometrium also tend to display strong immunopositivity for cyclin E.65 As regards p27, one study did not ¢nd any association with stage of tumour, age of patient, histological appearance or prognosis.66 To confound matters further, this study found that increased levels of p27 were associated with higher-grade advanced tumours.When comparing cyclin E and p27, increasing cyclin E expression was seen from normal to hyperplastic to malignant endometrial tissue.67 Thus, the jury is still out with regard to p27 in endometrial cancer.
293
mas.74 The role of diminished levels of p27 was con¢rmed in another study, which showed that low p27 expression is seen in intermediate, and high-grade nonHodgkin’s lymphomas and correlates with poor prognosis.75 As a cautionary note, it must be remembered that not all non-Hodgkin’s lymphomas follow this paradigm, and overexpression of p27 has been correlated with shortened survival in one study.76 The general trend that higher-grade lymphomas and those with a blastic component show higher levels of cyclin and low levels of p27, is true.
ENDOCRINE In general, low p27 has been found to be associated with high-grade endocrine tumours.77 This is especially so in thyroid and parathyroid carcinomas.78,79 When compared against each other as prognostic markers, p27 was found to be more useful than cyclin E in thyroid tumours.80 In addition, p27 seemed to be of value in separating the follicular variant of papillary thyroid cancer from follicular adenoma, with lower levels of p27 seen in the cancer.80 Thus, p27 immunohistochemistry may have a diagnostic role to play in follicular thyroid lesions, which often pose vexing problems for surgical pathologists.
SARCOMAS OVARY A correlation with the serous histological subtype, grade and stage of ovarian cancer has been suggested, although the usefulness and value of cyclin E as a prognostic marker is yet to be con¢rmed.5 The immunopro¢le of low p27 and high cyclin E is seen in malignant rather than benign or borderline ovarian tumours68 and decreased p27 is associated with decreased survival in some primary epithelial ovarian cancers.69
HAEMATOLOGICALTUMOURS Cyclin E has been shown to be markedly increased in relapse specimens of adult acute lymphoblastic leukaemia compared to the staining seen in pre-treatment samples.70 However, others have failed to demonstrate any di¡erence in duration of relapse-free intervals or frequency of recurrence in childhood acute lymphoblastic leukaemias.71 In acute myeloid leukaemia, the rates of complete remission and of disease-free survival were low in patients who overexpressed cyclin E.72 Cyclin E overexpression has also been encountered in chronic lymphocytic leukaemia, Hodgkin’s disease and nonHodgkin’s lymphoma.73 A study by Erlanson and colleagues con¢rmed the prognostic value of the low p27/ high cyclin E pattern of expression in malignant lympho-
Low p27 expression is an independent predictor of decreased survival and metastasis-free period and overall survival in myxoid and round cell liposarcomas.81 A similar picture was seen in one study on synovial sarcomas.82 Also in synovial sarcomas, increased cyclin E immunoexpression correlated with decreased survival but did not emerge as an independent prognostic factor.83 Cyclin E is markedly upregulated in leiomyosarcomas compared to leiomyomas and predicts poor overall survival.84,85 In Kaposi’s sarcoma, decreased p27 correlated with higher stage of disease and extra-cutaneous involvement.86
CONCLUDING REMARKS The variation in ¢ndings is not totally unexpected given the complexity of the cell cycle and the intricate interrelationship between the key proteins. It would be too simplistic to isolate just two proteins from the entire myriad of cell cycle proteins and expect a consistent, hard and fast pattern to emerge across all tumours. The problems of inter-laboratory reproducibility, subjective interpretation and other technical considerations all need to be factored into the equation. A possible way around this would be to apply identical conditions to several laboratories analysing the same material, allowing for meaningful comparisons and information to emerge.
294
CURRENT DIAGNOSTIC PATHOLOGY
This too may be too idealistic, but perhaps the time has come to get co-ordination in this potential mine¢eld of misinformation. Despite these cautionary notes, the cell cycle aberrations that result in low p27/high cyclin E appear to be operative in the vast majority of tumours. Several good studies have con¢rmed the prognostic utility of the pattern of immunoexpression. The addition of immunohistochemistry into the prognostic algorithm is a positive step, but one that has to be re¢ned, monitored and carefully evaluated. Already there is good evidence justifying the examination of the p27 and cyclin E protein content of many tumours. The impact of immunohistochemistry alone on treatment protocols is yet to be established. However, when taken in conjunction with traditional markers of prognosis (stage, grade of tumour, etc.), there is persuasive evidence that immunohistochemical markers of the cell cycle have a role to play.
PRACTICE POINTS K
K
K
K
K
Cyclin E and p27 immunohistochemistry is a useful adjunct to the traditionally accepted prognostic markers The immunopro¢le of high cyclin E and low p27 confers an adverse prognosis on the vast majority of malignanttumours Neither cyclin E nor p27 have been shown unequivocally to be independent prognostic markers The use of immunohistochemistry in biopsy specimens may assist with treatment regimens Assiduous performance and interpretation of the immunohistochemical staining is mandatory
RESEARCH DIRECTIONS K
K K
Re¢nement of staining protocols to achieve consistency and reproducibility Production of better monoclonal antibodies Multi-centre trials involving the same material and the generation of a universally accepted and applicable scoring system of staining obtained
REFERENCES 1. Karp J E, Broder S. Molecular foundations of cancer: new targets for intervention. Nat Med 1995; 1: 309–319. 2. Motokura T, Arnold A. Cyclin D and oncogenesis. Curr Opin Genet Dev 1993; 3: 5–10. 3. Sherr C J. Mammalian G1 cyclins and cell cycle progression. Proc Assoc Am Physicians 1995; 107: 181–186. 4. Donnellan R, Chetty R. Cyclin D1 and human neoplasia. J Clin Pathol (Mol Pathol) 1998; 51: 1–7.
5. Donnellan R, Chetty R. Cyclin E in human cancers. FASEB J 1999; 13: 773–780. 6. Pezzella F, Gatter K. What is the value of bcl-2 protein for histopathologists? Histopathology 1995; 26: 89–93. 7. Chetty R, Dada M A, Gatter K C. bcl-2: longevity personified! Adv Anat Pathol 1997; 4: 134–138. 8. Wimmel A, Lucibello F C, Sewing A, Adolph S, Muller R. Inducible acceleration of G1 progression through tetracyclineregulated expression of human cyclin E. Oncogene 1994; 9: 995–997. 9. Courjal F, Louason G, Speiser P, Katsaros D, Zeillinger R, Theillet C. Cyclin gene amplification and overexpression in breast and ovarian cancers: evidence for the selection of cyclin D1 in breast and cyclin E in ovarian tumors. Int J Cancer 1996; 69: 247–253. 10. Kitahara K, Yasui W, Kuniyasu H, Yokozaki H, Akama Y, Yunotani S, Hisatsugu T et al. Concurrent amplification of cyclin E and CDK2 genes in colorectal carcinomas. Int J Cancer 1995; 62: 25–28. 11. Akama Y, Yasui W, Yokozaki H, Kuniyasu H, Kitahara K, Ishikawa K, Tahara E. Frequent amplification of the cyclin E gene in human gastric carcinomas. Jpn J Cancer Res 1995; 86: 617–621. 12. Marone M, Scambia G, Giannitelli C, Ferrandina G, Masciullo V, Bellacosa A, Benedetti-Panici P et al. Analysis of cyclin E and CDK2 in ovarian cancer: give amplification and RNA overexpression. Int J Cancer 1998; 75: 34–39. 13. Bito T, Ueda M, Ito A, Ichihashi M. Less expression of cyclin E in cutaneous squamous cell carcinomas than in benign and premalignant keratinocytic lesions. J Cutan Pathol 1997; 24: 305–308. 14. Stanta G, Bonin S, Losi L, Eusebi V. Molecular characterization of intraductal breast carcinomas. Virchows Arch 1998; 432: 107–111. 15. Ponce-Castaneda M V, Lee M-H, Latres E, Polyak K, Lacombe L, Montgomery K, Mathew S, et al. p27 kip1 chromosomal mapping to 12p 12-12p 13.1 and absence of mutations in human tumors. Cancer Res 1995; 55: 1211–1214. 16. Morosetti R, Kawamata N, Gombart A F, Miller C W, Hatta Y, Hirama T, Said J et al. Alterations of the p27/Kip 1 gene in nonHodgkin’s lymphomas and adult T-cell leukemia/lymphoma. Blood 1995; 86: 1924–1930. 17. Spirin K S, Simpson J F, Takenchi S, Kawamata N, Miller C W, Koeffler H P. p27/Kip 1 mutation found in breast cancer. Cancer Res 1996; 56: 2400–2404. 18. St Croix B, Florenes V A, Rak J W, Flanagan M, Bhattacharya N, Slingerland J M, Kerbel R S. Impact of the cyclin-dependent kinase inhibitor p27kip 1 on resistance of tumor cells to anti-cancer agents. Nat Med 1996; 2: 1204–1210. 19. Tanaka C, Yoshimoto K, Yang P, Kimura T, Yamada S, Moritani M, Saro T et al. Infrequent mutations of p27kip1 gene and trisomy 12 in a subset of human pituitary adenomas. J Clin Endocrinol Metab 1997; 82: 3141–3147. 20. Lloyd R V, Erickson L A, Jin L, Kulig E, Qian X, Cheville J C, Scheithauer B W. p27kip 1: A multifunctional cyclin-dependent kinase inhibitor with prognostic significance in human cancers. Am J Pathol 1999; 154: 313–323. 21. Lu X, Toki T, Konishi J, Nikaido T, Fujii S. Expression of p21 WAF1/CIP 1 in adenocarcinoma of the uterine cervix: a possible immunohistochemical marker of a favourable prognosis. Cancer 1998; 82: 2409–2417. 22. Steeg P S, Abram J S. Cancer prognostics: past, present and p 27. Nat Med 1997; 3: 152–154. 23. Porter P L, Malone K E, Heagerty P J, Alexander G M, Gatti L A, Firpo E J, Daling J R et al. Expression of cell cycle regulators p27kip 1 and cyclin E, alone and in combination, correlate with survival in young breast cancer patients. Nat Med 1997; 3: 222–225. 24. Dou Q, Pardee A, Keyomarsi K. Cyclin EFa better prognostic marker for breast cancer than cyclin D? Nat Med 1996; 2: 254.
CYCLIN E AND p27:THEIR PUTATIVE ROLE AS PROGNOSTIC MARKERS
25. Keyomarsi K, O’Leary N, Molnar G, Lees E, Fingert H J, Pardee A B. Cyclin EFa potential prognostic marker for breast cancer. Cancer Res 1994; 54: 380–385. 26. Donnellan R, Kleinschmidt I, Chetty R. Cyclin E immunoexpression in breast ductal carcinoma: pathological correlations and prognostic implications. Hum Pathol 2001; 32: 89–94. 27. Catzavelos C, Bhatlacharya N, Ung Y C, Wilson J A, Roncari L, Sandhu C, Shaw P et al. Decreased levels of the cell cycle inhibitor p27 kip 1 protein: prognostic implications in primary breast cancer. Nat Med 1997; 3: 227–230. 28. Tan P, Cady B, Wanner M, Worland P, Cukor B, Magi-Galluzi C, Lavin P et al. The cell cycle inhibitor p27 is an independent prognostic marker in small (T1a,b) invasive breast carcinoma. Cancer Res 1997; 57: 1259–1263. 29. Barbareschi M, van Tinteren H, Mauri F A, Veronese F, Peterse H, Maisonneuve P, Scaioli M et al. p27 (kip 1) expression in breast carcinomas: an immunohistochemical study on 512 patients with long-term follow-up. Int J Cancer 2000; 89: 236–241. 30. Itami A, Shimada Y, Watanabe G, Imamura M. Prognostic value of p27 (Kip 1) and cyclin D1 expression in esophageal cancer. Oncology 1999; 57: 311–317. 31. Kagawa Y, Yoshida K, Hirai T, Toge T. Significance of the expression of p27 Kip 1 in esophageal squamous cell carcinomas. Dis Esophagus 2000; 13: 179–184. 32. Ohashi Y, Sasano H, Yamaki H, Shizawa S, Shineha R, Akaishi T, Santomi S et al. Cell cycle inhibitory protein p27 in esophageal squamous cell carcinoma. Anticancer Res 1999; 19: 1843–1848. 33. Ohbu M, Kobayashi N, Okayasu I. Expression of cell cycle regulatory proteins in the multistep process of oesophageal carcinogenesis: stepwise over-expression of cyclin E and p53, reduction of p21 (WAP1/CIP1) and dysregulation of cyclin D1 and p27 (KIP 1). Histopathology 2001; 39: 589–596. 34. Singh S P, Lipman J, Goldman H, Ellis Jr F H, Aizenman L, Cangi M G, Signoretti S et al. Loss or altered subcellular localization of p27 in Barrett’s associated adenocarcinoma. Cancer Res 1998; 58: 1730–1735. 35. Sarbia M, Bektas N, Muller W, Heep H, Borchard F, Gabbert H E. Expression of cyclin E in dysplasia, carcinoma and non-malignant lesions of Barrett esophagus. Cancer 1999; 86: 2597–2601. 36. Nakamura M, Katano M, Fujimoto K, Morisaki T. A new prognostic strategy for gastric carcinoma: mRNA expression of tumor growth-related factors in endoscopic biopsy specimens. Ann Surg 1997; 226: 35–42. 37. Sasaki H, Ishizuka T, Igaki H, Terada M. Mutation frequency of the p16/CDKN2 gene and amplification of the cyclin E gene in human primary gastric carcinomas. Jpn J Clin Med 1996; 54: 1049–1053. 38. Sakaguchi T, Watanabe A, Sawada H, Yamada Y, Yamashita J, Matsuda M, Nakajima M et al. Prognostic value of cyclin E and p53 expression in gastric carcinoma. Cancer 1998; 82: 1238–1243. 39. Mori M, Mimori K, Shiraishi T, Tanaka S, Ueo H, Susimachi K, Akiyoshi T. p27 expression and gastric carcinoma. Nat Med 1997; 3: 593. 40. Xiangming C, Natsugoe S, Takao S, Hokita S, Tanabe G, Baba M, Kuroshima K et al. The cooperative role of p27 with cyclin E in the prognosis of advanced gastric carcinoma. Cancer 2000; 89: 1214–1219. 41. Wang A, Yoshima N, Suzuki M, Yamauchi A, Tarao M, Mori H. Different expression patterns of cyclins A, D1 and E in human colorectal cancer. J Cancer Res Clin Oncol 1996; 122: 122–126. 42. Yasui W, Kuniyasu H, Yokozaki H, Semba S, Shimamoto F, Tahara E. Expression of cyclin E in colorectal adenomas and adenocarcinomas: correlation with expression of Ki-67 antigen and p53 protein. Virchows Arch 1996; 429: 13–19. 43. Thomas G V, Szigeti K, Murphy M, Draetta G, Pagano M, Loda M. Down-regulation of p27 is associated with development of
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
295
colorectal adenocarcinoma metastasis. Am J Pathol 1998; 153: 681–687. Hayashi H, Ogawa N, Ishiwa N, Yazawa T, Inayama Y, Ito T, Kitamura H. High cyclin E and low p27/Kip 1 expressions are potentially poor prognostic factors in lung adenocarcinoma patients. Lung Cancer 2001; 34: 59–65. Yamanouchi H, Furihata M, Fujita J, Murakami H, Yoshinouchi T, Takahara J, Ohtsuki Y. Expression of cyclin E and cyclin D1 in nonsmall cell lung cancers. Lung Cancer 2001; 31: 3–8. Esposito V, Baldi A, DeLuca A, Groger A M, Loda M, Giordano G G, Caputi M et al. Prognostic role of the cyclin-dependent kinase inhibitor p27 in non-small cell lung cancer. Cancer Res 1997; 57: 3381–3385. Migita T, Oda Y, Naito S, Tsuneyoshi M. Low expression of p27 (Kip 1) is associated with tumor size and poor prognosis in patients with renal cell carcinoma. Cancer 2002; 94: 973–979. Haitel A, Wiener H G, Neudert B, Marberger M, Susani M. Expression of the cell cycle proteins p21, p27 and pRb in clear cell renal cell carcinoma and their prognostic significance. Urology 2001; 58: 477–481. Kamai T, Takagi K, Asomi H, Ito Y, Oshima H, Yoshida K I. Decreasing of p27 (Kip 1) and cyclin E protein levels is associated with progression from superficial into invasive bladder cancer. Br J Cancer 2001; 84: 1242–1251. Del Pizzo J J, Borkowski A, Jacobs S C, Kyprianou N. Loss of cell cycle regulators p27 (Kip 1) and cyclin E in transitional cell carcinoma of the bladder correlates with tumor grade and patient survival. Am J Pathol 1999, 155: 1129–1136. Furihata M, Ohtsuki Y, Sonobe H, Shuin T, Yamamoto A, Terao N, Kuwahara M. Prognostic significance of cyclin E and p53 protein overexpression in carcinoma of the renal pelvis and ureter. Br J Cancer 1998; 77: 783–788. Yamamoto A, Hashimoto Y, Kohri K, Ogata E, Kato S, Ikeda K, Nakanishi M. Cyclin E as a coactivator of the androgen receptor. J Cell Biol 2000; 150: 873–880. Guo Y, Sklar G N, Borkowski A, Kyprianou N. Loss of the cell cyclin-dependent kinase inhibitor p27 (Kip 1) protein in human prostate cancer correlates with tumor grade. Clin Cancer Res 1997; 12: 2269–2274. Tsihlias J, Kapusta L R, De Buer G, Morava-Protzner I, Zbieranowski I, Bhattacharya N, Catzavelos G C et al. Loss of cyclin-dependent kinase inhibitor p27kip 1 is a novel prognostic factor in localized human prostatic adenocarcinoma. Cancer Res 1998; 58: 542–548. Yang R M, Naitoh H J, Murphy M, Wang H-J, Phillipson J, DeKernion J B, Loda M et al. Low p27 expression predicts poor disease-free survival in patients with prostate cancer. J Urol 1998; 159: 941–945. Cheville J C, Lloyd R V, Sebo T J, Cheng L, Erickson L, Bostwick D G, Lohse C M et al. Expression of p27Kip 1 in prostate adenocarcinoma. Med Pathol 1998; 11: 324–328. Cordon-Cardo C, Koff A, Drobnjak M, Capodieci P, Osman I, Millard S S, Gaudin P B et al. Distinct altered patterns of p27 Kip 1 gene expression in benign prostatic hyperplasia and prostatic carcinoma. J Natl Cancer Inst 1998; 17: 1284–1291. Cho N H, Kim Y T, Kim J W. Correlation between G1 cyclins and HPV in the uterine cervix. Int J Gynecol Pathol 1997; 16: 339–347. Quade B, Park J, Crum C, Sun D, Dutta A. In vivo cyclin E expression as a marker for early cervical neoplasia. Mod Pathol 1998; 11: 1238–1246. Kanai M, Shiozawa T, Xin L, Nikaido T, Fujii S. Immunohistochemical detection of sex steroid receptors, cyclins and cyclindependent kinases in the normal and neoplastic squamous epithelia of the cervix. Cancer 1998; 82: 1709–1719.
296
61. Tae K Y, Kyoung C E, Hoon C N, Hung K J, Ick Y W, Wook K J. Expression of cyclin E and p27 (KIP 1) in cervical carcinoma. Cancer Lett 2000; 153: 41–50. 62. Ito K, Sasano H, Yoshida Y, Sato S, Yajima A. Immunohistochemical study of cyclins D and E and cyclin-dependent kinase (cdk) 2 and 4 in human endometrial carcinoma. Anticancer Res 1998; 18: 1661–1664. 63. Li S F, Shiozawa T, Nakayama K, Nikaido T, Fujii S. Stepwise abnormality of sex steroid hormone receptors, tumor suppressor gene products (p53 and Rb), and cyclin E in uterine endometrioid carcinoma. Cancer 1996; 77: 321–329. 64. Shiozawa T, Li S F, Nakayama K, Nikaido T, Fujii S. Relationship between the expression of cyclins/cyclin-dependent kinases and sex steroid receptors/Ki-67 in human endometrial glands and stroma during the menstrual cycle. Mol Hum Reprod 1996; 2: 745–752. 65. Session D R, Lee G S, Choi J, Wolgemuth D J. Expression of cyclin E in gynecologic malignancies. Gynecol Oncol 1999; 72: 32–37. 66. Nycum L R, Smith L M, Farley J H, Kost E R, Method M W, Birrer M J. The role of p27 in endometrial carcinoma. Gynecol Oncol 2001; 81: 242–246. 67. Ahn H, Kwon K, Choi Y, Cho N. Expression of cyclin E and cyclindependent kinase inhibitor, p27 in uterine endometrial carcinoma: relationship with p53 status. Int J Surg Pathol 1998; 6: 205–212. 68. Sui L, Dong Y, Ohno M, Sugimoto K, Tai Y, Hando T, Tokuda M. Implication of malignancy and prognosis of p27 (Kip 1), cyclin E and cdk2 expression in epithelial ovarian tumors. Gynecol Oncol 2001; 83: 56–63. 69. Hurteau J A, Allison B M, Brutkiewicz S A, Goebl M G, Heilman D K, Bigsby R M, Harrington M A. Expression and subcellular localization of the cyclin-dependent kinase inhibitor p27 (Kip 1) in epithelial ovarian cancer. Gynecol Oncol 2001; 83: 292–298. 70. Scuderi R, Palucka K A, Pokrovskaja K, Bjorkholm M, Wiman K G, Pisa P. Cyclin E overexpression in relapsed adult acute lymphoblastic leukaemias of B-cell lineage. Blood 1996; 87: 3360–3367. 71. Volm M, Koomagi R, Stammler G, Rittgen W, Zintl F, Sauerbrey A. Prognostic implications of cyclins (D1, E, A) cyclin-dependent kinases (CDK2, CDK4) and tumor suppressor genes (pRb, p16INK4A) in childhood acute lymphoblastic leukaemia. Int J Cancer 1997; 74: 508–512. 72. Iida H, Towatari M, Tanimoto M, Morishita Y, Kodera Y, Saito H. Overexpression of cyclin E in acute myelogenous leukaemia. Blood 1997; 90: 3707–3713. 73. Wolowiec D, Benchaib M, Pernas P, Deviller P, Souchier C, Rimokh R, Felman P et al. Expression of cell cycle regulator proteins in chronic lymphocytic leukaemias. Comparison with
CURRENT DIAGNOSTIC PATHOLOGY
74.
75.
76. 77. 78.
79.
80.
81.
82.
83.
84.
85.
86.
non-Hodkgin’s lymphomas and non-neoplastic lymphoid tissue. Leukaemia 1995; 9: 1382–1388. Erlanson M, Portin C, Linderholm B, Lindh J, Roos G, Landberg G. Expression of cyclin E and the cyclin-dependent kinase inhibitor p 27 in malignant lymphomasFprognostic implications. Blood 1998; 92: 770–777. Kudoh S, Kumaravel T S, Kuramavel B, Eguchi M, Asaoku H, Dohy H, Fujiwara M et al. Protein expression of cell cycle regulators p27kip1, correlates with histopathological grade of non-Hodgkin’s lymphoma. Jpn J Cancer Res 1999; 90: 1262–1269. Moller M B. p27 in cell cycle control and cancer. Leuk Lymphoma 2000; 39: 19–27. Lloyd R V, Jin L, Qian X, Kulig E. Aberrant p27Kip 1 expression in endocrine and other tumors. Am J Pathol 1997; 150: 401–407. Erickson L A, Jin L, Wollan P C, Thompson G B, van Heerden J, Lloyd R V. Expression of p27Kip 1 and Ki-67 in benign and malignant thyroid tumors. Mod Pathol 1998; 11: 169–174. Erickson L A, Jin L, Wollan P C, Thompson G B, van Heerden J A, Lloyd R V. Parathyroid hyperplasia, adenomas and carcinomas: differential expression of p27Kip 1 protein. Am J Surg Pathol 1999; 23: 288–295. Wang S, Wuu J, Savas L, Patwardhan, Khan A. The role of cell cycle regulatory proteins, cyclin D1, cyclin E, and p 27 in thyroid carcinogenesis. Hum Pathol 1998; 29: 1304–1309. Oliveira A M, Nascimento A G, Okuno S H, Lloyd R V. P27 (Kip 1) protein expression correlates with survival in myxoid and round cell liposarcoma. J Clin Oncol 2000; 18: 2888–2893. Kawauchi S, Goto Y, Liu X P, Furuya T, Oga A, Oda Y, Tsuneyoshi M et al. Low expression of p27 (Kip 1), a cyclin-dependent kinase inhibitor, is a marker of poor prognosis in synovial sarcoma. Cancer 2001; 91: 1005–1012. Antonescu C R, Leung J R, Dudas M, Ladanyi M, Brennan M, Woodruff, J M, Cordon-Cardo C. Alterations of cell cycle regulators in localized synovial sarcoma: a multifactorial study with prognostic implications. Am J Pathol 2000; 156: 977–983. Noguchi T, Dobashi Y, Minehara H, Itoman M, Kameya T. Involvement of cyclins in cell proliferation and their clinical implications in soft tissue smooth muscle tumors. Am J Pathol 2000; 156: 2135–2147. Zhai Y L, Nikaido T, Shiozawa T, Orii A, Fujii S. Expression of cyclins and cyclin-dependent kinases in smooth muscle tumors of the uterus. Int J Cancer 1999; 84: 244–250. Fernandez-Figueras M T, Puig L, Penin R M, Mate J L, Bigata X, Ariza A. Decreased immunoreactivity for cell cycle regulator p27 Kip 1 in Kaposi’s sarcoma correlates with higher stage and extracutaneous involvement. J Pathol 2000; 191: 387–393.
c 2002 Elsevier Science Ltd. doi:10.1054/cdip.2002.0130, available online at http://www.idealibrary.com on
MINI-SYMPOSIUM: MOLECULAR MARKERS IN PATHOLOGY
Cyclin E and p27: their putative role as prognostic markers R. Chetty Department of Pathology, Nelson R Mandela School of Medicine, Private Bag 7, Congella 4013, Durban, South Africa
KEYWORDS cell cycle proteins, proliferation, prognosis, biological markers, cyclins, cyclin-dependent kinase inhibitors, cyclin E, p27
Summary Abnormalities or derangements ofthe orderly proliferation and cycling of cells is the quintessential de¢nition of a cancer or malignant cell.The complex nature of the interaction of several interdependent cell cycle proteins has and continues to be unravelled.Key functions have been ascribed to many of the proteins and the delicate balance that maintains cell normal cell cycling is now understood.Within the cell cycle, the G1proteins have come under intense scrutiny, especially the interaction between cyclin E and p27. Essentially, cyclin E drives the cell cycle forward towards mitosis, while p27 acts as a brake preventing cell cycle progression.The levels of these two proteins, independently and together, have been analysed in many studies in several tumour types. A pattern or trend has emerged: high cyclin E with low p27 is an adverse prognostic indicator in the majority of commonly encountered malignant tumours. Furthermore, in several instances, there is a stepwise increase of cyclin E and decrease of p27 that matches the progression from dysplastic, pre-invasive lesions to full-blown invasive malignanttumours. As a cautionary note, there are exceptions to this tenet as exempli¢ed by bladder and oesophageal cancers, where the relationship between cyclin E and p27 is not straightforward. The body of evidence in the literature points to both cyclin E and p27 as being useful adjuncts to prognostication indices, but not unreservedly as indec 2002 Elsevier Science Ltd. pendent portenders of outcome.
Everything should be made as simple as possible, but not simpler. Albert Einstein
INTRODUCTION With advances in biomedical research exploding and producing new knowledge seemingly e¡ortlessly, a sea of information now surrounds the diagnostic pathologist. Much research is of the translational variety and as medical doctors, let alone pathologists, we need to know how research and its by-products impact on patient management and outcome. Clinicians are constantly on the lookout for ancillary information that may in£uence patient management and enhance care. Pathologists are Correspondence to: RC.Tel.: +27-31-260 - 4483; Fax: +27-31-2052711; E-mail: [email protected]
often asked questions about a variety of molecules. Indeed, pathologists are asking themselves searching questions about the plethora of putative markers that abound in the literature. At this juncture, one must address a vital question. Should diagnostic pathologists even know about molecular aberrations and markers, let alone allow them to pervade the ordered sanctity of morphological analysis? Should pathologists apply Occam’s razor to this glut of information and not increase beyond what is absolutely necessary the number of entities required to explain anythingF‘the principle of parsimony’? The tide of new information is unstoppable and the concept of unnecessary plurality has been submerged. Molecular medicine harnesses the genetic and biomedical determinants that govern the orderly progression of cellular physiology from cell birth to cell death.1 It, therefore, provides the basis for modern prevention, diagnosis and treatment. There are several modes of oncogenesis and each of
290
CURRENT DIAGNOSTIC PATHOLOGY
these pathways has provided fertile ground for potential interventional strategies. The cell cycle is one such pathway that has been targeted for extensive study. The search for biological markers in tumour pathology continues unabated. Application of research to the diagnostic setting is increasing, and the availability of easy-touse, reproducible tests, such as immunohistochemistry, will play an increasing role in patient management.
The cell cycle The molecular regulation of the cell cycle (See Fig. 1) maintains homeostatic balance, cell growth, di¡erentiation, survival and ultimately death.1 The tight equilibrium is due to an inter-play of positive regulators (the cyclins and the cyclin-dependent kinases) and negative regulators, constituted by tumour suppressor proteins (mainly p53 and retinoblastoma) and the cyclin-dependent kinase inhibitors. When activated, the cyclins and cyclindependent kinases drive the cell through the various phases of the cell cycle, whilst the negative regulators serve as the brake. Aberrations of the G1 cyclins are important in the transformation and progression of many di¡erent malignancies.2^5 Key proteins that are active in the cell cycle, p53 and bcl-2, have been the subject of several publications. In an article assessing the value of immunohistochemistry for p53 and bcl-2 proteins in the routine diagnostic laboratory, Pezzella and Gatter raised the image of these two proteins being balanced on a seesaw.6 This inverse relationship was re-emphasized in a subsequent review and possible practical applications of p53 and bcl-2 immunohistochemistry in the diagnostic realm have been sug-
p53
p21
CDK2
CDK2
Cyclin E
Cyclin A
S
p27
G1
E2F
pRB-E2F
CDK1
p15
Cyclin B
gested.7 The purpose of this homily is to highlight the role of two cell cycle proteins, cyclin E and p27, in tumour pathology and their possible roles as prognostic markers that may be used in diagnostic pathology.
Cyclin E Cyclin E, located on chromosome 19q12-13, produces a 395 amino acid protein that contributes to normal cell proliferation and development.5 Overexpression of cyclin E protein accelerates the G1 phase of the cell cycle, a process that is accompanied by phosphorylation of the product of the retinoblastoma gene.5,8 The ability of cyclin E to phosphorylate retinoblastoma protein is dependent on a group of molecules termed the cyclindependent kinase inhibitors (CKIs). The CKIs suppress the activity of cyclin E. Overexpression and hence accumulation of cyclin E protein in the majority of cases is as a result of ampli¢cation of the gene.9^12 Cyclin E expression in the absence of gene abnormalities may also be due to post-transcriptional mechanisms.5 Immunolabelling of cyclin E is mainly nuclear; however, cytoplasmic staining has been observed in many studies. The signi¢cance of this is at present not clear. The protein is synthesized and degraded within the cytoplasm whence it is transferred rapidly to the nucleus, where it is functional.Cytoplasmic cyclin E may in essence be due to one or more of several possibilities: increased synthesis, decreased degradation or lack of nuclear transfer. At this point, cytoplasmic staining in the absence of accompanying nuclear localization is regarded as negative. In attempting to understand the role of cyclin E in tumourigenesis, two questions arise. Is cyclin E part of a myriad of events that result in cell proliferation or is it a primary driving force? In some tumours, cyclin E gene and protein accumulation occur late,11 whilst in other neoplasms it appears to be an early event.13,14 When examining something as complex as the cell cycle with the intricate networking that is operational, looking at the role of one protein at a time is not advisable. It is better to look at them in concert, and since cyclin E has an intimate association with p27, these two proteins should be examined in tandem.
pRB p21
CDK4,6
G2
Cyclin D1,2,3
CDK1
M
Cyclin A,B
Figure 1 Schematic representation of the cell cycle highlighting the G1 proteins.It is important to note that both cyclin E and p27 interact with a variety of other proteins, especially retinoblastoma in this phase of the cell cycle.
p27 The CKIs can be categorized into two groups: the Kip/ Cip proteins (p21, p27 and p57) and the INK4 proteins (p15, p16, p18 and p19). The Kip/Cip family of CKIs is capable of interacting with (inhibiting) all the cyclins, but especially with cyclin E. Overexpression of Kip/Cip proteins leads to cell cycle arrest.The p27 gene is located on chromosome 12p13, at the junction of 12p12 and 12p13.1.15 Several functions have been ascribed to p27, but loss of p27 expression is thought to be tumourigenic and may
CYCLIN E AND p27:THEIR PUTATIVE ROLE AS PROGNOSTIC MARKERS lead to tumour progression.15 Other functions include promotion of apoptosis, regulation of drug resistance in solid tumours and a protective role in in£ammatory injury.15 Loss of expression of p27 protein is not thought to occur because of mutations in the gene.16 ^19 However, given the potentially critical role that Kip/Cip proteins play in controlling cell cycle checkpoints, it is perhaps surprising that their deletion did not give rise to tumours in mice and for that matter, mutations in p21, p27 and p57 are not frequently encountered in human tumours.15 Despite this, several studies have characterized p27 as an independent prognostic factor in a variety of human malignancies, including breast, colon and prostate cancers.15
291
Perusal of these papers shows compelling and convincing data, which indicate that both ¢t the bill as markers.This is aided and abetted by the strides that new monoclonal antibody generation with antigen retrieval has made. Immunohistochemistry and its application beyond the diagnostic realm is close at hand. This necessitates knowledge of what is available and the likely implications of their use. The purpose of the remainder of this review is to look at the body of evidence that appears in the literature regarding cyclin E and p27 in speci¢c tumour entities in the di¡erent organs.
BREAST GENERAL CONSIDERATIONS Both cyclin E and p27 have been examined in many malignancies to ascertain whether they have any prognostic signi¢cance, either alone or in concert. Cyclin E immunoexpression has been explored in several malignancies and it is generally felt that overexpression of cyclin E is associated with an adverse prognosis.5 Similarly, the prognostic signi¢cance of p27 has also been examined in a variety of tumours and most studies show that decreased expression of p27 is encountered with more aggressive tumours.20 The cell cycle is an intricate process with extensive interaction and networking between the various cell cycle regulators; thus, isolating any one protein and analysing its e¡ects may or may not reveal any meaningful information. It is therefore, better to examine the cell cycle regulatory proteins in concert.5 For instance, high levels of cyclin E are functionally inactivated by large numbers of cyclin kinase-dependent inhibitors, such as p21. This has been o¡ered as the explanation for the association of high levels of cyclin E with a good prognosis in uterine cervical adenocarcinomas.5,21 Thus, one can see that a straightforward application of up- and downregulation does not apply in a uniform fashion in tumour biology. For a new prognostic marker to be accepted for routine clinical use, at least three criteria have to be satis¢ed.22 Firstly, the marker must provide information independent of and better than conventional pathological criteria; secondly, the marker must provide information that can impact on treatment decisions and protocols; and thirdly, studies with the particular marker must be reproducible. These are stringent criteria and if applied absolutely to the latter, it will be di⁄cult for either cyclin E or p27 to ful¢l all criteria. However, both these markers come very close and warrant consideration as potential markers in the investigative armamentarium that diagnostic pathologists are likely to have at their disposal. As mentioned previously, the literature abounds with papers highlighting the putative roles of cyclin E and p27 as prognostic and/or diagnostic markers.
Cyclin E expression has been explored in both in situ and invasive breast cancers, and immunodetection has been correlated with outcome and survival.23 In fact, cyclin E has been suggested to be a better prognostic marker for breast cancer than cyclin D1.24 Overexpression of cyclin E has been shown to correlate with proliferation markers such as proliferating cell nuclear antigen (PCNA).25 In one study, positive cyclin E immunostaining correlated with negative oestrogen receptor status and high-grade tumours.26 Cyclin E staining is probably most important as a prognostic marker in the setting of lymph node negative breast cancers, where it can be used to re¢ne prognosis.23,26 It is important to note that cyclin E alone is not an independent prognostic factor in lymph node positive cases, but is in the lymph node negative cases.26 Several studies have demonstrated that decreased p27 is associated with both tumour progression and a poor prognosis.23,27,28 However, one study on 512 cases of breast carcinoma with a median follow-up period of 9 years, did not ¢nd p27 immunohistochemistry alone to be of predictive value.29 Contrary to most other studies, this showed high p27 immunoexpression as a marker of poor prognosis.This appears to be the only study that is at odds with the general trend that low p27 is attended by a poor prognosis. The combined immunopro¢le of high cyclin E and low p27 is a marker of aggressive disease, progression and a poor prognosis in breast cancer.
OESOPHAGUS In squamous carcinoma of the oesophagus, the role of p27 is controversial. Some reports state that p27 is not a signi¢cant prognostic factor,30 whilst others have correlated increased p27 with tumour invasion, lymph node spread and poor prognosis.31 Yet another study has shown that low p27 labelling had a worse prognosis than those with high levels of p27 protein expression.32 Thus, there is a lack of consistency (and no small amount of confusion) with regard to the role of p27 in oesophageal squamous carcinomas.This ¢eld awaits a de¢nitive study
292
that will answer the question about the use of p27 immunohistochemistry. The picture is a little clearer with regard to cyclin E immunoexpression in squamous carcinoma of the oesophagus. A study by Ohbu and colleagues demonstrated stepwise increasing cyclin E expression from normal appearing oesophageal mucosa through low- and high-grade dysplasias and ¢nally, invasive cancers.33 Thus, in keeping with most malignancies, increased cyclin E is seen as a marker of tumour progression and poor prognosis in squamous carcinoma of the oesophagus. In Barrett’s associated adenocarcinoma, the usual scenario of low p27 and high cyclin E conferring an adverse prognosis, applies.34 However, cyclin E on its own is not a useful predictor in Barrett’s oesophagus because expression is seen in metaplastic, dysplastic and invasive lesions.35
STOMACH The cyclin E gene is ampli¢ed in 15% of gastric cancers. However, overexpression of cyclin E protein and mRNA is more frequent.11,36,37 Several studies have identi¢ed cyclin E overexpression as a poor prognostic marker in gastric cancers of all histological types.11,36,38 Concomitant loss of p27 is accompanied by a poor prognosis,39 and a co-operative role for cyclin E and p27 has been advanced in gastric cancer.40 These latter investigators concluded that decreased p27 expression is a negative prognostic marker in patients with cyclin E positive tumours.40
COLON AND RECTUM Cyclin E gene ampli¢cation has been detected in about 10% of colorectal carcinomas.5 With regard to immunohistochemical protein expression of cyclin E, there is a stepwise increase in expression as seen in the oesophagus. Increased expression is seen from normal through the grades of dysplasia to in¢ltrating adenocarcinoma.41,42 The reciprocal role of p27 loss in colorectal cancer has been shown to identify those cancers that develop metachronous metastases and hence those showing tumour progression.43
LUNG Neoplastic bronchial epithelial cells have higher levels of functional cyclin E and cyclin-dependent kinase 2 complexes. High cyclin E and low p27 are poor prognostic markers for lung adenocarcinomas.44 Cyclin E overexpression is more frequently observed in squamous carcinomas than adenocarcinomas, and in poorly-di¡erentiated compared to well-di¡erentiated tumours.45 This latter staining property is independent of the histological type of tumour. Finally, p27 is regarded as a prognostic
CURRENT DIAGNOSTIC PATHOLOGY
factor that correlates with survival in non-small cell carcinomas as a group.46
KIDNEY Cyclin E overexpression in renal cell carcinomas was found to be rare in one study.47 This study, however, con¢rmed the association of low p27 expression with poor prognosis and outcome. Another con¢rmed that low p27 protein levels, especially when taken in conjunction with p53 overexpression, were a predictor of poor outcome in clear cell renal cancers.48
URINARY BLADDER In contrast to the usual inverse relationship between cyclin E and p27, decreasing or low levels of both p27 and cyclin E were associated with progression from super¢cial into deeply invasive bladder cancers.49,50 However, another study provides contradictory evidence regarding the role of cyclin E in transitional carcinomas of the renal pelvis and ureters.51 This paper showed that cyclin E immunopositivity correlated with high tumour grade and poor prognosis.
PROSTATE Cyclin E is thought to act as a co-activator or increase the transactivation activity of the human androgen receptor.52 The aberrant expression of cyclin E induces persistent activation of the androgen receptor, thus impacting on prostatic carcinogenesis. Loss of p27 protein is associated with high-grade tumours, predicts treatment failure, is an adverse prognostic factor and correlates with lymph node spread of prostate cancer.53^56 Interestingly, both p27 protein and mRNA are markedly decreased in both epithelium and stroma in benign prostatic hyperplasia.57
UTERINE CERVIX Cyclin E appears to be an important early factor in the pathogenesis of squamous carcinomas through its putative link with the transforming genotypes of HPV.58,59 However, the prognostic signi¢cance of upregulated cyclin E in this particular tumour has been questioned in one study.60 When both cyclin E and p27 expression were compared in normal cervical squamous epithelium, intra-epithelial neoplasia and invasive cancers, p27 loss was noted in the progression through the stages of evolution of the disease. Furthermore, there was a reciprocal upregulation in cyclin E levels.61 Thus, the evidence points towards p27 loss and increased cyclin E expression as being of prognostic value in squamous
CYCLIN E AND p27:THEIR PUTATIVE ROLE AS PROGNOSTIC MARKERS
carcinomas of the uterine cervix. Very little appears to have been done with adenocarcinomas at this site.
ENDOMETRIUM Upregulation of cyclin E is seen in the majority of endometrial cancers.62 As in breast cancer, an inverse correlation between oestrogen receptor status and cyclin E immunostaining exists.63 It is worth remembering that cyclin E is also expressed by proliferative phase endometrium, which of itself is unsurprising since the cells are proliferating.64 The levels are lower than the marked upregulation that is encountered in endometrial carcinoma. From a morphological point of view, distinction of atypical endometrial hyperplasia and frank adenocarcinoma from proliferative phase endometrium, is rarely a problem. Clear cell carcinomas of the endometrium also tend to display strong immunopositivity for cyclin E.65 As regards p27, one study did not ¢nd any association with stage of tumour, age of patient, histological appearance or prognosis.66 To confound matters further, this study found that increased levels of p27 were associated with higher-grade advanced tumours.When comparing cyclin E and p27, increasing cyclin E expression was seen from normal to hyperplastic to malignant endometrial tissue.67 Thus, the jury is still out with regard to p27 in endometrial cancer.
293
mas.74 The role of diminished levels of p27 was con¢rmed in another study, which showed that low p27 expression is seen in intermediate, and high-grade nonHodgkin’s lymphomas and correlates with poor prognosis.75 As a cautionary note, it must be remembered that not all non-Hodgkin’s lymphomas follow this paradigm, and overexpression of p27 has been correlated with shortened survival in one study.76 The general trend that higher-grade lymphomas and those with a blastic component show higher levels of cyclin and low levels of p27, is true.
ENDOCRINE In general, low p27 has been found to be associated with high-grade endocrine tumours.77 This is especially so in thyroid and parathyroid carcinomas.78,79 When compared against each other as prognostic markers, p27 was found to be more useful than cyclin E in thyroid tumours.80 In addition, p27 seemed to be of value in separating the follicular variant of papillary thyroid cancer from follicular adenoma, with lower levels of p27 seen in the cancer.80 Thus, p27 immunohistochemistry may have a diagnostic role to play in follicular thyroid lesions, which often pose vexing problems for surgical pathologists.
SARCOMAS OVARY A correlation with the serous histological subtype, grade and stage of ovarian cancer has been suggested, although the usefulness and value of cyclin E as a prognostic marker is yet to be con¢rmed.5 The immunopro¢le of low p27 and high cyclin E is seen in malignant rather than benign or borderline ovarian tumours68 and decreased p27 is associated with decreased survival in some primary epithelial ovarian cancers.69
HAEMATOLOGICALTUMOURS Cyclin E has been shown to be markedly increased in relapse specimens of adult acute lymphoblastic leukaemia compared to the staining seen in pre-treatment samples.70 However, others have failed to demonstrate any di¡erence in duration of relapse-free intervals or frequency of recurrence in childhood acute lymphoblastic leukaemias.71 In acute myeloid leukaemia, the rates of complete remission and of disease-free survival were low in patients who overexpressed cyclin E.72 Cyclin E overexpression has also been encountered in chronic lymphocytic leukaemia, Hodgkin’s disease and nonHodgkin’s lymphoma.73 A study by Erlanson and colleagues con¢rmed the prognostic value of the low p27/ high cyclin E pattern of expression in malignant lympho-
Low p27 expression is an independent predictor of decreased survival and metastasis-free period and overall survival in myxoid and round cell liposarcomas.81 A similar picture was seen in one study on synovial sarcomas.82 Also in synovial sarcomas, increased cyclin E immunoexpression correlated with decreased survival but did not emerge as an independent prognostic factor.83 Cyclin E is markedly upregulated in leiomyosarcomas compared to leiomyomas and predicts poor overall survival.84,85 In Kaposi’s sarcoma, decreased p27 correlated with higher stage of disease and extra-cutaneous involvement.86
CONCLUDING REMARKS The variation in ¢ndings is not totally unexpected given the complexity of the cell cycle and the intricate interrelationship between the key proteins. It would be too simplistic to isolate just two proteins from the entire myriad of cell cycle proteins and expect a consistent, hard and fast pattern to emerge across all tumours. The problems of inter-laboratory reproducibility, subjective interpretation and other technical considerations all need to be factored into the equation. A possible way around this would be to apply identical conditions to several laboratories analysing the same material, allowing for meaningful comparisons and information to emerge.
294
CURRENT DIAGNOSTIC PATHOLOGY
This too may be too idealistic, but perhaps the time has come to get co-ordination in this potential mine¢eld of misinformation. Despite these cautionary notes, the cell cycle aberrations that result in low p27/high cyclin E appear to be operative in the vast majority of tumours. Several good studies have con¢rmed the prognostic utility of the pattern of immunoexpression. The addition of immunohistochemistry into the prognostic algorithm is a positive step, but one that has to be re¢ned, monitored and carefully evaluated. Already there is good evidence justifying the examination of the p27 and cyclin E protein content of many tumours. The impact of immunohistochemistry alone on treatment protocols is yet to be established. However, when taken in conjunction with traditional markers of prognosis (stage, grade of tumour, etc.), there is persuasive evidence that immunohistochemical markers of the cell cycle have a role to play.
PRACTICE POINTS K
K
K
K
K
Cyclin E and p27 immunohistochemistry is a useful adjunct to the traditionally accepted prognostic markers The immunopro¢le of high cyclin E and low p27 confers an adverse prognosis on the vast majority of malignanttumours Neither cyclin E nor p27 have been shown unequivocally to be independent prognostic markers The use of immunohistochemistry in biopsy specimens may assist with treatment regimens Assiduous performance and interpretation of the immunohistochemical staining is mandatory
RESEARCH DIRECTIONS K
K K
Re¢nement of staining protocols to achieve consistency and reproducibility Production of better monoclonal antibodies Multi-centre trials involving the same material and the generation of a universally accepted and applicable scoring system of staining obtained
REFERENCES 1. Karp J E, Broder S. Molecular foundations of cancer: new targets for intervention. Nat Med 1995; 1: 309–319. 2. Motokura T, Arnold A. Cyclin D and oncogenesis. Curr Opin Genet Dev 1993; 3: 5–10. 3. Sherr C J. Mammalian G1 cyclins and cell cycle progression. Proc Assoc Am Physicians 1995; 107: 181–186. 4. Donnellan R, Chetty R. Cyclin D1 and human neoplasia. J Clin Pathol (Mol Pathol) 1998; 51: 1–7.
5. Donnellan R, Chetty R. Cyclin E in human cancers. FASEB J 1999; 13: 773–780. 6. Pezzella F, Gatter K. What is the value of bcl-2 protein for histopathologists? Histopathology 1995; 26: 89–93. 7. Chetty R, Dada M A, Gatter K C. bcl-2: longevity personified! Adv Anat Pathol 1997; 4: 134–138. 8. Wimmel A, Lucibello F C, Sewing A, Adolph S, Muller R. Inducible acceleration of G1 progression through tetracyclineregulated expression of human cyclin E. Oncogene 1994; 9: 995–997. 9. Courjal F, Louason G, Speiser P, Katsaros D, Zeillinger R, Theillet C. Cyclin gene amplification and overexpression in breast and ovarian cancers: evidence for the selection of cyclin D1 in breast and cyclin E in ovarian tumors. Int J Cancer 1996; 69: 247–253. 10. Kitahara K, Yasui W, Kuniyasu H, Yokozaki H, Akama Y, Yunotani S, Hisatsugu T et al. Concurrent amplification of cyclin E and CDK2 genes in colorectal carcinomas. Int J Cancer 1995; 62: 25–28. 11. Akama Y, Yasui W, Yokozaki H, Kuniyasu H, Kitahara K, Ishikawa K, Tahara E. Frequent amplification of the cyclin E gene in human gastric carcinomas. Jpn J Cancer Res 1995; 86: 617–621. 12. Marone M, Scambia G, Giannitelli C, Ferrandina G, Masciullo V, Bellacosa A, Benedetti-Panici P et al. Analysis of cyclin E and CDK2 in ovarian cancer: give amplification and RNA overexpression. Int J Cancer 1998; 75: 34–39. 13. Bito T, Ueda M, Ito A, Ichihashi M. Less expression of cyclin E in cutaneous squamous cell carcinomas than in benign and premalignant keratinocytic lesions. J Cutan Pathol 1997; 24: 305–308. 14. Stanta G, Bonin S, Losi L, Eusebi V. Molecular characterization of intraductal breast carcinomas. Virchows Arch 1998; 432: 107–111. 15. Ponce-Castaneda M V, Lee M-H, Latres E, Polyak K, Lacombe L, Montgomery K, Mathew S, et al. p27 kip1 chromosomal mapping to 12p 12-12p 13.1 and absence of mutations in human tumors. Cancer Res 1995; 55: 1211–1214. 16. Morosetti R, Kawamata N, Gombart A F, Miller C W, Hatta Y, Hirama T, Said J et al. Alterations of the p27/Kip 1 gene in nonHodgkin’s lymphomas and adult T-cell leukemia/lymphoma. Blood 1995; 86: 1924–1930. 17. Spirin K S, Simpson J F, Takenchi S, Kawamata N, Miller C W, Koeffler H P. p27/Kip 1 mutation found in breast cancer. Cancer Res 1996; 56: 2400–2404. 18. St Croix B, Florenes V A, Rak J W, Flanagan M, Bhattacharya N, Slingerland J M, Kerbel R S. Impact of the cyclin-dependent kinase inhibitor p27kip 1 on resistance of tumor cells to anti-cancer agents. Nat Med 1996; 2: 1204–1210. 19. Tanaka C, Yoshimoto K, Yang P, Kimura T, Yamada S, Moritani M, Saro T et al. Infrequent mutations of p27kip1 gene and trisomy 12 in a subset of human pituitary adenomas. J Clin Endocrinol Metab 1997; 82: 3141–3147. 20. Lloyd R V, Erickson L A, Jin L, Kulig E, Qian X, Cheville J C, Scheithauer B W. p27kip 1: A multifunctional cyclin-dependent kinase inhibitor with prognostic significance in human cancers. Am J Pathol 1999; 154: 313–323. 21. Lu X, Toki T, Konishi J, Nikaido T, Fujii S. Expression of p21 WAF1/CIP 1 in adenocarcinoma of the uterine cervix: a possible immunohistochemical marker of a favourable prognosis. Cancer 1998; 82: 2409–2417. 22. Steeg P S, Abram J S. Cancer prognostics: past, present and p 27. Nat Med 1997; 3: 152–154. 23. Porter P L, Malone K E, Heagerty P J, Alexander G M, Gatti L A, Firpo E J, Daling J R et al. Expression of cell cycle regulators p27kip 1 and cyclin E, alone and in combination, correlate with survival in young breast cancer patients. Nat Med 1997; 3: 222–225. 24. Dou Q, Pardee A, Keyomarsi K. Cyclin EFa better prognostic marker for breast cancer than cyclin D? Nat Med 1996; 2: 254.
CYCLIN E AND p27:THEIR PUTATIVE ROLE AS PROGNOSTIC MARKERS
25. Keyomarsi K, O’Leary N, Molnar G, Lees E, Fingert H J, Pardee A B. Cyclin EFa potential prognostic marker for breast cancer. Cancer Res 1994; 54: 380–385. 26. Donnellan R, Kleinschmidt I, Chetty R. Cyclin E immunoexpression in breast ductal carcinoma: pathological correlations and prognostic implications. Hum Pathol 2001; 32: 89–94. 27. Catzavelos C, Bhatlacharya N, Ung Y C, Wilson J A, Roncari L, Sandhu C, Shaw P et al. Decreased levels of the cell cycle inhibitor p27 kip 1 protein: prognostic implications in primary breast cancer. Nat Med 1997; 3: 227–230. 28. Tan P, Cady B, Wanner M, Worland P, Cukor B, Magi-Galluzi C, Lavin P et al. The cell cycle inhibitor p27 is an independent prognostic marker in small (T1a,b) invasive breast carcinoma. Cancer Res 1997; 57: 1259–1263. 29. Barbareschi M, van Tinteren H, Mauri F A, Veronese F, Peterse H, Maisonneuve P, Scaioli M et al. p27 (kip 1) expression in breast carcinomas: an immunohistochemical study on 512 patients with long-term follow-up. Int J Cancer 2000; 89: 236–241. 30. Itami A, Shimada Y, Watanabe G, Imamura M. Prognostic value of p27 (Kip 1) and cyclin D1 expression in esophageal cancer. Oncology 1999; 57: 311–317. 31. Kagawa Y, Yoshida K, Hirai T, Toge T. Significance of the expression of p27 Kip 1 in esophageal squamous cell carcinomas. Dis Esophagus 2000; 13: 179–184. 32. Ohashi Y, Sasano H, Yamaki H, Shizawa S, Shineha R, Akaishi T, Santomi S et al. Cell cycle inhibitory protein p27 in esophageal squamous cell carcinoma. Anticancer Res 1999; 19: 1843–1848. 33. Ohbu M, Kobayashi N, Okayasu I. Expression of cell cycle regulatory proteins in the multistep process of oesophageal carcinogenesis: stepwise over-expression of cyclin E and p53, reduction of p21 (WAP1/CIP1) and dysregulation of cyclin D1 and p27 (KIP 1). Histopathology 2001; 39: 589–596. 34. Singh S P, Lipman J, Goldman H, Ellis Jr F H, Aizenman L, Cangi M G, Signoretti S et al. Loss or altered subcellular localization of p27 in Barrett’s associated adenocarcinoma. Cancer Res 1998; 58: 1730–1735. 35. Sarbia M, Bektas N, Muller W, Heep H, Borchard F, Gabbert H E. Expression of cyclin E in dysplasia, carcinoma and non-malignant lesions of Barrett esophagus. Cancer 1999; 86: 2597–2601. 36. Nakamura M, Katano M, Fujimoto K, Morisaki T. A new prognostic strategy for gastric carcinoma: mRNA expression of tumor growth-related factors in endoscopic biopsy specimens. Ann Surg 1997; 226: 35–42. 37. Sasaki H, Ishizuka T, Igaki H, Terada M. Mutation frequency of the p16/CDKN2 gene and amplification of the cyclin E gene in human primary gastric carcinomas. Jpn J Clin Med 1996; 54: 1049–1053. 38. Sakaguchi T, Watanabe A, Sawada H, Yamada Y, Yamashita J, Matsuda M, Nakajima M et al. Prognostic value of cyclin E and p53 expression in gastric carcinoma. Cancer 1998; 82: 1238–1243. 39. Mori M, Mimori K, Shiraishi T, Tanaka S, Ueo H, Susimachi K, Akiyoshi T. p27 expression and gastric carcinoma. Nat Med 1997; 3: 593. 40. Xiangming C, Natsugoe S, Takao S, Hokita S, Tanabe G, Baba M, Kuroshima K et al. The cooperative role of p27 with cyclin E in the prognosis of advanced gastric carcinoma. Cancer 2000; 89: 1214–1219. 41. Wang A, Yoshima N, Suzuki M, Yamauchi A, Tarao M, Mori H. Different expression patterns of cyclins A, D1 and E in human colorectal cancer. J Cancer Res Clin Oncol 1996; 122: 122–126. 42. Yasui W, Kuniyasu H, Yokozaki H, Semba S, Shimamoto F, Tahara E. Expression of cyclin E in colorectal adenomas and adenocarcinomas: correlation with expression of Ki-67 antigen and p53 protein. Virchows Arch 1996; 429: 13–19. 43. Thomas G V, Szigeti K, Murphy M, Draetta G, Pagano M, Loda M. Down-regulation of p27 is associated with development of
44.
45.
46.
47.
48.
49.
50.
51.
52.
53.
54.
55.
56.
57.
58.
59.
60.
295
colorectal adenocarcinoma metastasis. Am J Pathol 1998; 153: 681–687. Hayashi H, Ogawa N, Ishiwa N, Yazawa T, Inayama Y, Ito T, Kitamura H. High cyclin E and low p27/Kip 1 expressions are potentially poor prognostic factors in lung adenocarcinoma patients. Lung Cancer 2001; 34: 59–65. Yamanouchi H, Furihata M, Fujita J, Murakami H, Yoshinouchi T, Takahara J, Ohtsuki Y. Expression of cyclin E and cyclin D1 in nonsmall cell lung cancers. Lung Cancer 2001; 31: 3–8. Esposito V, Baldi A, DeLuca A, Groger A M, Loda M, Giordano G G, Caputi M et al. Prognostic role of the cyclin-dependent kinase inhibitor p27 in non-small cell lung cancer. Cancer Res 1997; 57: 3381–3385. Migita T, Oda Y, Naito S, Tsuneyoshi M. Low expression of p27 (Kip 1) is associated with tumor size and poor prognosis in patients with renal cell carcinoma. Cancer 2002; 94: 973–979. Haitel A, Wiener H G, Neudert B, Marberger M, Susani M. Expression of the cell cycle proteins p21, p27 and pRb in clear cell renal cell carcinoma and their prognostic significance. Urology 2001; 58: 477–481. Kamai T, Takagi K, Asomi H, Ito Y, Oshima H, Yoshida K I. Decreasing of p27 (Kip 1) and cyclin E protein levels is associated with progression from superficial into invasive bladder cancer. Br J Cancer 2001; 84: 1242–1251. Del Pizzo J J, Borkowski A, Jacobs S C, Kyprianou N. Loss of cell cycle regulators p27 (Kip 1) and cyclin E in transitional cell carcinoma of the bladder correlates with tumor grade and patient survival. Am J Pathol 1999, 155: 1129–1136. Furihata M, Ohtsuki Y, Sonobe H, Shuin T, Yamamoto A, Terao N, Kuwahara M. Prognostic significance of cyclin E and p53 protein overexpression in carcinoma of the renal pelvis and ureter. Br J Cancer 1998; 77: 783–788. Yamamoto A, Hashimoto Y, Kohri K, Ogata E, Kato S, Ikeda K, Nakanishi M. Cyclin E as a coactivator of the androgen receptor. J Cell Biol 2000; 150: 873–880. Guo Y, Sklar G N, Borkowski A, Kyprianou N. Loss of the cell cyclin-dependent kinase inhibitor p27 (Kip 1) protein in human prostate cancer correlates with tumor grade. Clin Cancer Res 1997; 12: 2269–2274. Tsihlias J, Kapusta L R, De Buer G, Morava-Protzner I, Zbieranowski I, Bhattacharya N, Catzavelos G C et al. Loss of cyclin-dependent kinase inhibitor p27kip 1 is a novel prognostic factor in localized human prostatic adenocarcinoma. Cancer Res 1998; 58: 542–548. Yang R M, Naitoh H J, Murphy M, Wang H-J, Phillipson J, DeKernion J B, Loda M et al. Low p27 expression predicts poor disease-free survival in patients with prostate cancer. J Urol 1998; 159: 941–945. Cheville J C, Lloyd R V, Sebo T J, Cheng L, Erickson L, Bostwick D G, Lohse C M et al. Expression of p27Kip 1 in prostate adenocarcinoma. Med Pathol 1998; 11: 324–328. Cordon-Cardo C, Koff A, Drobnjak M, Capodieci P, Osman I, Millard S S, Gaudin P B et al. Distinct altered patterns of p27 Kip 1 gene expression in benign prostatic hyperplasia and prostatic carcinoma. J Natl Cancer Inst 1998; 17: 1284–1291. Cho N H, Kim Y T, Kim J W. Correlation between G1 cyclins and HPV in the uterine cervix. Int J Gynecol Pathol 1997; 16: 339–347. Quade B, Park J, Crum C, Sun D, Dutta A. In vivo cyclin E expression as a marker for early cervical neoplasia. Mod Pathol 1998; 11: 1238–1246. Kanai M, Shiozawa T, Xin L, Nikaido T, Fujii S. Immunohistochemical detection of sex steroid receptors, cyclins and cyclindependent kinases in the normal and neoplastic squamous epithelia of the cervix. Cancer 1998; 82: 1709–1719.
296
61. Tae K Y, Kyoung C E, Hoon C N, Hung K J, Ick Y W, Wook K J. Expression of cyclin E and p27 (KIP 1) in cervical carcinoma. Cancer Lett 2000; 153: 41–50. 62. Ito K, Sasano H, Yoshida Y, Sato S, Yajima A. Immunohistochemical study of cyclins D and E and cyclin-dependent kinase (cdk) 2 and 4 in human endometrial carcinoma. Anticancer Res 1998; 18: 1661–1664. 63. Li S F, Shiozawa T, Nakayama K, Nikaido T, Fujii S. Stepwise abnormality of sex steroid hormone receptors, tumor suppressor gene products (p53 and Rb), and cyclin E in uterine endometrioid carcinoma. Cancer 1996; 77: 321–329. 64. Shiozawa T, Li S F, Nakayama K, Nikaido T, Fujii S. Relationship between the expression of cyclins/cyclin-dependent kinases and sex steroid receptors/Ki-67 in human endometrial glands and stroma during the menstrual cycle. Mol Hum Reprod 1996; 2: 745–752. 65. Session D R, Lee G S, Choi J, Wolgemuth D J. Expression of cyclin E in gynecologic malignancies. Gynecol Oncol 1999; 72: 32–37. 66. Nycum L R, Smith L M, Farley J H, Kost E R, Method M W, Birrer M J. The role of p27 in endometrial carcinoma. Gynecol Oncol 2001; 81: 242–246. 67. Ahn H, Kwon K, Choi Y, Cho N. Expression of cyclin E and cyclindependent kinase inhibitor, p27 in uterine endometrial carcinoma: relationship with p53 status. Int J Surg Pathol 1998; 6: 205–212. 68. Sui L, Dong Y, Ohno M, Sugimoto K, Tai Y, Hando T, Tokuda M. Implication of malignancy and prognosis of p27 (Kip 1), cyclin E and cdk2 expression in epithelial ovarian tumors. Gynecol Oncol 2001; 83: 56–63. 69. Hurteau J A, Allison B M, Brutkiewicz S A, Goebl M G, Heilman D K, Bigsby R M, Harrington M A. Expression and subcellular localization of the cyclin-dependent kinase inhibitor p27 (Kip 1) in epithelial ovarian cancer. Gynecol Oncol 2001; 83: 292–298. 70. Scuderi R, Palucka K A, Pokrovskaja K, Bjorkholm M, Wiman K G, Pisa P. Cyclin E overexpression in relapsed adult acute lymphoblastic leukaemias of B-cell lineage. Blood 1996; 87: 3360–3367. 71. Volm M, Koomagi R, Stammler G, Rittgen W, Zintl F, Sauerbrey A. Prognostic implications of cyclins (D1, E, A) cyclin-dependent kinases (CDK2, CDK4) and tumor suppressor genes (pRb, p16INK4A) in childhood acute lymphoblastic leukaemia. Int J Cancer 1997; 74: 508–512. 72. Iida H, Towatari M, Tanimoto M, Morishita Y, Kodera Y, Saito H. Overexpression of cyclin E in acute myelogenous leukaemia. Blood 1997; 90: 3707–3713. 73. Wolowiec D, Benchaib M, Pernas P, Deviller P, Souchier C, Rimokh R, Felman P et al. Expression of cell cycle regulator proteins in chronic lymphocytic leukaemias. Comparison with
CURRENT DIAGNOSTIC PATHOLOGY
74.
75.
76. 77. 78.
79.
80.
81.
82.
83.
84.
85.
86.
non-Hodkgin’s lymphomas and non-neoplastic lymphoid tissue. Leukaemia 1995; 9: 1382–1388. Erlanson M, Portin C, Linderholm B, Lindh J, Roos G, Landberg G. Expression of cyclin E and the cyclin-dependent kinase inhibitor p 27 in malignant lymphomasFprognostic implications. Blood 1998; 92: 770–777. Kudoh S, Kumaravel T S, Kuramavel B, Eguchi M, Asaoku H, Dohy H, Fujiwara M et al. Protein expression of cell cycle regulators p27kip1, correlates with histopathological grade of non-Hodgkin’s lymphoma. Jpn J Cancer Res 1999; 90: 1262–1269. Moller M B. p27 in cell cycle control and cancer. Leuk Lymphoma 2000; 39: 19–27. Lloyd R V, Jin L, Qian X, Kulig E. Aberrant p27Kip 1 expression in endocrine and other tumors. Am J Pathol 1997; 150: 401–407. Erickson L A, Jin L, Wollan P C, Thompson G B, van Heerden J, Lloyd R V. Expression of p27Kip 1 and Ki-67 in benign and malignant thyroid tumors. Mod Pathol 1998; 11: 169–174. Erickson L A, Jin L, Wollan P C, Thompson G B, van Heerden J A, Lloyd R V. Parathyroid hyperplasia, adenomas and carcinomas: differential expression of p27Kip 1 protein. Am J Surg Pathol 1999; 23: 288–295. Wang S, Wuu J, Savas L, Patwardhan, Khan A. The role of cell cycle regulatory proteins, cyclin D1, cyclin E, and p 27 in thyroid carcinogenesis. Hum Pathol 1998; 29: 1304–1309. Oliveira A M, Nascimento A G, Okuno S H, Lloyd R V. P27 (Kip 1) protein expression correlates with survival in myxoid and round cell liposarcoma. J Clin Oncol 2000; 18: 2888–2893. Kawauchi S, Goto Y, Liu X P, Furuya T, Oga A, Oda Y, Tsuneyoshi M et al. Low expression of p27 (Kip 1), a cyclin-dependent kinase inhibitor, is a marker of poor prognosis in synovial sarcoma. Cancer 2001; 91: 1005–1012. Antonescu C R, Leung J R, Dudas M, Ladanyi M, Brennan M, Woodruff, J M, Cordon-Cardo C. Alterations of cell cycle regulators in localized synovial sarcoma: a multifactorial study with prognostic implications. Am J Pathol 2000; 156: 977–983. Noguchi T, Dobashi Y, Minehara H, Itoman M, Kameya T. Involvement of cyclins in cell proliferation and their clinical implications in soft tissue smooth muscle tumors. Am J Pathol 2000; 156: 2135–2147. Zhai Y L, Nikaido T, Shiozawa T, Orii A, Fujii S. Expression of cyclins and cyclin-dependent kinases in smooth muscle tumors of the uterus. Int J Cancer 1999; 84: 244–250. Fernandez-Figueras M T, Puig L, Penin R M, Mate J L, Bigata X, Ariza A. Decreased immunoreactivity for cell cycle regulator p27 Kip 1 in Kaposi’s sarcoma correlates with higher stage and extracutaneous involvement. J Pathol 2000; 191: 387–393.