Histopathology 2015, 67, 206–215. DOI: 10.1111/his.12633
Lipocalin-2 and matrix metalloproteinase-9 expression in high-grade endometrial cancer and their prognostic value Sanja Srdelic Mihalj,1 Ivana Kuzmic-Prusac,2 Sandra Zekic-Tomas,2 Ivana Samija-Proji c3 & 4 Vesna Capkun 1
Department of Gynecology, Split University Hospital Center, Split, Croatia, 2Department of Pathology, Split University Hospital Center, Split, Croatia, 3Department of Pathology and Cytology, University Hospital Center Zagreb, Zagreb, Croatia, and 4Department of Nuclear Medicine, Split University Hospital Center, Split, Croatia
Date of submission 9 September 2014 Accepted for publication 12 December 2014 Published online Article Accepted 17 December 2014
Srdelic Mihalj S, Kuzmic-Prusac I, Zekic-Tomas S, Samija-Proji c I, Capkun V (2015) Histopathology 67, 206–215. DOI: 10.1111/his.12633
Lipocalin-2 and matrix metalloproteinase-9 expression in high-grade endometrial cancer and their prognostic value Aims: To demonstrate lipocalin-2 (LCN-2) immunohistochemical expression together with matrix metalloproteinase-9 (MMP-9) protein in high-grade endometrial cancer and determine their correlations with FIGO (International Federation of Gynecology and Obstetrics) stage, histological subtype, presence of vascular invasion, patient age and overall and disease-free survival. Methods and results: Immunohistochemical staining was performed using LCN-2 and MMP-9 antibodies on high-grade endometrial cancer (n = 85) diagnosed at Split University Hospital Centre during 1998–2010. Immunohistochemical expression was determined on archived paraffin-embedded samples and scored semiquantitatively. Survival time was analysed using the Kaplan–Meier method, and the log-rank test was used
to assess between-group differences. The Cox proportional hazard regression model was used on multivariate survival analysis. Patients were followed from the time of primary surgery until death or last follow-up until December 2012. LCN-2 and MMP-9 were highly expressed in high-grade endometrial cancer. Univariate analysis showed positive immunohistochemical staining for LCN-2 and MMP-9 to be associated with shorter survival in patients with high-grade endometrial cancer. Multivariate analysis showed LCN-2 overexpression to be associated with shorter overall and disease-free survival in high-grade endometrial cancer. Conclusions: Our findings suggest that LCN-2 expression may be an important independent indicator of shorter survival in patients with high-grade endometrial cancer.
Keywords: endometrial cancer, lipocalin-2, matrix metalloproteinase-9, survival
Introduction Endometrial cancer is the most common malignant tumour in gynaecology in developed countries.1,2 Approximately 75% of cases are diagnosed at an early stage, with the tumour limited to the uterus. The cornerstone of therapy is surgery alone, and the majority of patients will be cured only via surgery. In Address for correspondence: S Srdelic Mihalj, Department of Gynecology, Split University Hospital Center, Spinciceva 1, HR-21000 Split, Croatia. e-mail: [email protected] © 2014 John Wiley & Sons Ltd.
15–20% of patients with no signs of locally advanced or metastatic disease at diagnosis the disease will return, with a limited response to systemic therapy. Although belonging to different pathogenetic types, uterine serous carcinoma, clear cell carcinoma and grade 3 endometrioid carcinoma have been identified as high-risk endometrial cancers and account for the majority of uterine cancer relapses and deaths. Recurrence will occur in approximately 40–50% of high-risk endometrial cancer cases.3–5 The objective of this trial was to determine the expression and prognostic significance of lipocalin-2 (LCN-2) and
LCN-2/MMP-9 coexpression in high-grade endometrial cancer
matrix metalloproteinase-9 (MMP-9) in high-grade endometrial cancer. Although the primary function of lipocalins is thought to be in the transport of small ligands, they have also been implicated in a variety of different physiological functions.6 They are also involved in several processes related to malignant tumours, such as cell proliferation, apoptosis and inflammation.6–9 Lipocalin-2 was first described 20 years ago, when Kjeldsen et al. found this protein to be associated with MMP-9 in exocytosed material from phorbol myristate acetate-stimulated neutrophils;10,11 its role in innate immunity was its first described function. Further, LCN-2 was found to be expressed in numerous cell types, including epithelial cells undergoing inflammatory reactions.12,13 Physiological functions of LCN-2 have been shown to involve modulation of immune response, regulation of cell growth and metabolism, fatty acid and iron transportation and prostaglandin synthesis.14 In human cancer tissues, elevated levels of LCN-2 expression have been detected in breast,15,16 ovarian,17 endometrial,18 intestinal,19 lung,20 pancreatic,21 oesophageal22 and gastric23 cancers. In most of the cancers, LCN-2 has been shown to exert a protumoral activity.15–19,22,23 The prognostic significance of LCN-2 overexpression in humans has been shown in breast,15 gastric22 and oesophageal cancer,23 where the impact on survival has been described. The formation of complexes with MMP-9 defines their pro-neoplastic potential (breast, stomach, oesophagus, brain, thyroid cancer); conversely, inhibition of the hypoxia-inducible factor 1-alpha (HIF-1a) factor and focal adhesion (FA)-kinase phosphorylation and arrest of vascular endothelial growth factor (VEGF) synthesis demonstrate their anti-tumoral and anti-metastatic action (colon, ovary, pancreatic cancer).24–26 Lipocalin-2 was also detected in blood and urine in different cancer patients. In some of these patients, LCN2 was found in complex with MMP-9.27–29 The amount of the complex was correlated positively with the disease status. These biomarkers decrease with treatment, and can be tracked from the source tissue to urine.28 Matrix metalloproteinase-9 belongs to the family of matrix metalloproteinases, which includes at least 23 zinc-dependent endopeptidases divided into eight distinct structural subclasses that are capable of virtually cleaving all components of the extracellular matrix. MMPs participate in a number of remodelling processes in normal and pathological conditions, including carcinogenesis.30,31 Some MMPs have been linked to key events in cancer development, including © 2014 John Wiley & Sons Ltd, Histopathology, 67, 206–215.
207
neoplastic cell growth, apoptosis, angiogenesis and metastasis.30 It has been noted that overexpression of MMP-9 exists in endometrial cancer,32–34 and correlates with disease progression.35 The most widely used hypothesis in researches on LCN-2 in cancers is that LCN-2 drives induction of the epithelial to mesenchymal transition (EMT) via MMP-9-dependent and -independent mechanisms. The aim of this study was to determine the LCN-2/ MMP-9 coexpression by immunohistochemistry in high-grade endometrial cancer and examine their relationship with clinicopathological parameters and patient survival.
Materials and methods PATIENTS
This retrospective study included archived paraffinembedded specimens of 85 patients diagnosed with high-grade endometrial cancer at the Department of Pathology, Split University Hospital Centre, Split, Croatia, from January 1998 to December 2010. Clinical data were collected from the Department of Oncology, Split University Hospital Centre. The study inclusion criteria were: patients with high-grade endometrial cancer having undergone surgery and treated postoperatively and monitored at Split University Hospital Centre, whose tissue samples were stored at the Department of Pathology, Split University Hospital Centre. Surgical procedures included hysterectomy, bilateral adnexectomy, omentectomy, and lymphadenectomy in 47% of the patients. The included patients received oncological treatment conducted by the Department of Oncology clinical practice checklist (external pelvic radiotherapy and/or vaginal brachytherapy and/or chemotherapy). The study exclusion criteria were: pre-operative oncological treatment including pelvic radiation and/ or chemotherapy and/or hormonal therapy; residual disease after surgery; FIGO (International Federation of Gynecology and Obstetrics) stage IV; and inadequate tumour tissue samples. After completing surgical and oncological treatment, patients were monitored at the Clinical Department of Oncology, Split University Hospital Centre. For the first 2 years after treatment, follow-up check-ups were performed every 3 months, and then every 6 months. Control surveys included gynaecological examination, laboratory tests (blood count, basic liver and renal tests), abdominal ultrasound twice a year, computed tomography of the abdomen and pelvis once a year, and other medical tests if needed.
208
S Srdelic Mihalj et al.
All carcinomas were classified according to the 2009 FIGO staging system.36 Time to recurrence (disease-free survival: DFS) was marked in months after the date of surgery until the diagnosis of recurrence. Survival time of patients was calculated as the interval from the date of diagnosis to the date of the last clinical follow-up or death from endometrial cancerrelated causes until 31 December 2012. The median follow-up of survivors was 55 months. The study was approved by the Split University Hospital Centre Ethics Committee (500-03/13-01/ 20). Written informed consent for participation in the study was obtained from all study patients. IMMUNOHISTOCHEMICAL ANALYSIS
Immunohistochemical staining was performed on 4lm-thick sections of the most representative paraffin block from each tumour specimen. Paraffin sections were mounted on super frost plus slides (Thermo Scientific, Schwerte, Germany). After cooling to room temperature, slides were washed in distilled water and phosphate-buffered saline (PBS) solution. Further processing was carried out in an automatic stainer (Dako, Glostrup, Denmark). Endogenous peroxidase was blocked using 3% H2O2 for 10 min. After washing in distilled water, primary antibodies were used. Primary rat monoclonal antibody Ngala (R&D Systems, Minneapolis, MN, USA), diluted previously at 1:50, was applied overnight. Primary polyclonal rabbit antibody against MMP-9 (Dako) was diluted at 1:75 and applied for 1 h. After washing in PBS solution, labelled streptavidin–biotin (LSAB) (LINK, biotinylated secondary antibodies; Dako) was used as secondary antibody for 30 min, followed by rinsing with PBS. Diaminobenzidine hydrogen (DAB; Dako) was applied as chromogen for 10 min and then washed in distilled water. The sections were counterstained in haematoxylin, dehydrated, cleared and mounted on silanized slides. Specimens of acute appendicitis and colon cancer served as positive controls for LNC2 and MMP-9, respectively. For negative control, primary antibodies were omitted. Lipocalin-2 and MMP-9 were determined on the same tumour paraffin block on adjacent sections. Preparations were analysed on an Olympus BX41 microscope (Olympus Inc., Melville, NY, USA). EVALUATION OF STAINING
All sections were evaluated independently by two gynaecological pathologists with no previous knowledge of the patient’s clinical information. The slides
with discrepant findings were additionally examined by a third, randomly chosen pathologist specialized in gynecologic oncology, and this finding was decisive in determining the final result of immunohistochemical staining. The LCN-2 and MMP-9 positive samples were defined as those showing brown signals in the cytoplasm. When 5% of the cells in a given specimen stained positive, it was defined as a positive stain. Cytoplasmic staining intensity in tumour cells (grades 0–3) and staining area (0 = no tumour cells positive; 1 = 5–10% cells positive; 2 = 10–50% cells positive; 3 = >50% cells positive) were recorded. Staining index (SI) was calculated as a product of staining intensity and positive area giving a staining index of 0–9.18 On statistical analysis, final staining scores of 1 and 2, 3 and 4 and 6 and 9 were considered as low, medium and high expression, respectively. STATISTICAL ANALYSIS
A statistically significant association between two qualitative variables was carried out by v2 test and logistic regression (odds ratio). Logistic regression analysis was used to establish the correlation of LCN2 and MMP-9 expression with recurrence and clinicopathological variables. The Kaplan–Meier method was used to estimate survival as a function of time, and survival differences were analysed with the log-rank test. The Cox proportional hazard regression model was used to examine simultaneously all factors found to be prognostic of survival in univariate analysis. In the analysis of DFS and overall survival (OS), a multifactorial Cox regression analysis was also used. In all statistical procedures, the level of significance was set at P < 0.05. Analyses were performed using SPSS version 9 software.
Results LCN-2/MMP-9 EXPRESSION
Relationship with clinicopathological characteristics From 1998 to 2010, 110 patients with high-grade endometrial cancer were diagnosed. According to inclusion and exclusion criteria or insufficient tissue quality, 85 patients were included in the study, including 40 (47%), nine (10%) and 36 (43%) with serous, clear cell and endometrioid grade 3 histology, respectively. All patients underwent simple hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Systematic pelvic with or without para-aortic lymphadenectomy was performed in 40 (47.5%) cases. During the study © 2014 John Wiley & Sons Ltd, Histopathology, 67, 206–215.
LCN-2/MMP-9 coexpression in high-grade endometrial cancer
A
209
B
Figure 1. Lipocalin-2 (LCN-2) and matrix metalloproteinase-9 (MMP-9) immunohistochemical expression in high-grade endometrial cancer. A, LCN-2 immunohistochemical expression; B, MMP-9 immunohistochemical expression.
period, recurrence of disease occurred in 38 (44%) patients, 31 of whom (36%) died from endometrial cancer. Another 11 patients died from causes unrelated to
carcinoma. Regarding immunohistochemistry, 59 (69.5%) endometrial cancers were positive and 26 (30.6%) negative for LCN-2.
Table 1. Association of lipocalin-2 (LCN-2) and matrix metalloproteinase-9 (MMP-9) expression and clinicopathological variables in 85 patients with high-grade endometrial cancer No. (%) of patients with MMP-9 expression
No. (%) of patients with LCN-2 expression Variable
Negative
Positive
P*
Negative
Positive
P*
Histological type ECG3†
13 (50)
23 (39)
Lipocalin-2 and matrix metalloproteinase-9 expression in high-grade endometrial cancer and their prognostic value Sanja Srdelic Mihalj,1 Ivana Kuzmic-Prusac,2 Sandra Zekic-Tomas,2 Ivana Samija-Proji c3 & 4 Vesna Capkun 1
Department of Gynecology, Split University Hospital Center, Split, Croatia, 2Department of Pathology, Split University Hospital Center, Split, Croatia, 3Department of Pathology and Cytology, University Hospital Center Zagreb, Zagreb, Croatia, and 4Department of Nuclear Medicine, Split University Hospital Center, Split, Croatia
Date of submission 9 September 2014 Accepted for publication 12 December 2014 Published online Article Accepted 17 December 2014
Srdelic Mihalj S, Kuzmic-Prusac I, Zekic-Tomas S, Samija-Proji c I, Capkun V (2015) Histopathology 67, 206–215. DOI: 10.1111/his.12633
Lipocalin-2 and matrix metalloproteinase-9 expression in high-grade endometrial cancer and their prognostic value Aims: To demonstrate lipocalin-2 (LCN-2) immunohistochemical expression together with matrix metalloproteinase-9 (MMP-9) protein in high-grade endometrial cancer and determine their correlations with FIGO (International Federation of Gynecology and Obstetrics) stage, histological subtype, presence of vascular invasion, patient age and overall and disease-free survival. Methods and results: Immunohistochemical staining was performed using LCN-2 and MMP-9 antibodies on high-grade endometrial cancer (n = 85) diagnosed at Split University Hospital Centre during 1998–2010. Immunohistochemical expression was determined on archived paraffin-embedded samples and scored semiquantitatively. Survival time was analysed using the Kaplan–Meier method, and the log-rank test was used
to assess between-group differences. The Cox proportional hazard regression model was used on multivariate survival analysis. Patients were followed from the time of primary surgery until death or last follow-up until December 2012. LCN-2 and MMP-9 were highly expressed in high-grade endometrial cancer. Univariate analysis showed positive immunohistochemical staining for LCN-2 and MMP-9 to be associated with shorter survival in patients with high-grade endometrial cancer. Multivariate analysis showed LCN-2 overexpression to be associated with shorter overall and disease-free survival in high-grade endometrial cancer. Conclusions: Our findings suggest that LCN-2 expression may be an important independent indicator of shorter survival in patients with high-grade endometrial cancer.
Keywords: endometrial cancer, lipocalin-2, matrix metalloproteinase-9, survival
Introduction Endometrial cancer is the most common malignant tumour in gynaecology in developed countries.1,2 Approximately 75% of cases are diagnosed at an early stage, with the tumour limited to the uterus. The cornerstone of therapy is surgery alone, and the majority of patients will be cured only via surgery. In Address for correspondence: S Srdelic Mihalj, Department of Gynecology, Split University Hospital Center, Spinciceva 1, HR-21000 Split, Croatia. e-mail: [email protected] © 2014 John Wiley & Sons Ltd.
15–20% of patients with no signs of locally advanced or metastatic disease at diagnosis the disease will return, with a limited response to systemic therapy. Although belonging to different pathogenetic types, uterine serous carcinoma, clear cell carcinoma and grade 3 endometrioid carcinoma have been identified as high-risk endometrial cancers and account for the majority of uterine cancer relapses and deaths. Recurrence will occur in approximately 40–50% of high-risk endometrial cancer cases.3–5 The objective of this trial was to determine the expression and prognostic significance of lipocalin-2 (LCN-2) and
LCN-2/MMP-9 coexpression in high-grade endometrial cancer
matrix metalloproteinase-9 (MMP-9) in high-grade endometrial cancer. Although the primary function of lipocalins is thought to be in the transport of small ligands, they have also been implicated in a variety of different physiological functions.6 They are also involved in several processes related to malignant tumours, such as cell proliferation, apoptosis and inflammation.6–9 Lipocalin-2 was first described 20 years ago, when Kjeldsen et al. found this protein to be associated with MMP-9 in exocytosed material from phorbol myristate acetate-stimulated neutrophils;10,11 its role in innate immunity was its first described function. Further, LCN-2 was found to be expressed in numerous cell types, including epithelial cells undergoing inflammatory reactions.12,13 Physiological functions of LCN-2 have been shown to involve modulation of immune response, regulation of cell growth and metabolism, fatty acid and iron transportation and prostaglandin synthesis.14 In human cancer tissues, elevated levels of LCN-2 expression have been detected in breast,15,16 ovarian,17 endometrial,18 intestinal,19 lung,20 pancreatic,21 oesophageal22 and gastric23 cancers. In most of the cancers, LCN-2 has been shown to exert a protumoral activity.15–19,22,23 The prognostic significance of LCN-2 overexpression in humans has been shown in breast,15 gastric22 and oesophageal cancer,23 where the impact on survival has been described. The formation of complexes with MMP-9 defines their pro-neoplastic potential (breast, stomach, oesophagus, brain, thyroid cancer); conversely, inhibition of the hypoxia-inducible factor 1-alpha (HIF-1a) factor and focal adhesion (FA)-kinase phosphorylation and arrest of vascular endothelial growth factor (VEGF) synthesis demonstrate their anti-tumoral and anti-metastatic action (colon, ovary, pancreatic cancer).24–26 Lipocalin-2 was also detected in blood and urine in different cancer patients. In some of these patients, LCN2 was found in complex with MMP-9.27–29 The amount of the complex was correlated positively with the disease status. These biomarkers decrease with treatment, and can be tracked from the source tissue to urine.28 Matrix metalloproteinase-9 belongs to the family of matrix metalloproteinases, which includes at least 23 zinc-dependent endopeptidases divided into eight distinct structural subclasses that are capable of virtually cleaving all components of the extracellular matrix. MMPs participate in a number of remodelling processes in normal and pathological conditions, including carcinogenesis.30,31 Some MMPs have been linked to key events in cancer development, including © 2014 John Wiley & Sons Ltd, Histopathology, 67, 206–215.
207
neoplastic cell growth, apoptosis, angiogenesis and metastasis.30 It has been noted that overexpression of MMP-9 exists in endometrial cancer,32–34 and correlates with disease progression.35 The most widely used hypothesis in researches on LCN-2 in cancers is that LCN-2 drives induction of the epithelial to mesenchymal transition (EMT) via MMP-9-dependent and -independent mechanisms. The aim of this study was to determine the LCN-2/ MMP-9 coexpression by immunohistochemistry in high-grade endometrial cancer and examine their relationship with clinicopathological parameters and patient survival.
Materials and methods PATIENTS
This retrospective study included archived paraffinembedded specimens of 85 patients diagnosed with high-grade endometrial cancer at the Department of Pathology, Split University Hospital Centre, Split, Croatia, from January 1998 to December 2010. Clinical data were collected from the Department of Oncology, Split University Hospital Centre. The study inclusion criteria were: patients with high-grade endometrial cancer having undergone surgery and treated postoperatively and monitored at Split University Hospital Centre, whose tissue samples were stored at the Department of Pathology, Split University Hospital Centre. Surgical procedures included hysterectomy, bilateral adnexectomy, omentectomy, and lymphadenectomy in 47% of the patients. The included patients received oncological treatment conducted by the Department of Oncology clinical practice checklist (external pelvic radiotherapy and/or vaginal brachytherapy and/or chemotherapy). The study exclusion criteria were: pre-operative oncological treatment including pelvic radiation and/ or chemotherapy and/or hormonal therapy; residual disease after surgery; FIGO (International Federation of Gynecology and Obstetrics) stage IV; and inadequate tumour tissue samples. After completing surgical and oncological treatment, patients were monitored at the Clinical Department of Oncology, Split University Hospital Centre. For the first 2 years after treatment, follow-up check-ups were performed every 3 months, and then every 6 months. Control surveys included gynaecological examination, laboratory tests (blood count, basic liver and renal tests), abdominal ultrasound twice a year, computed tomography of the abdomen and pelvis once a year, and other medical tests if needed.
208
S Srdelic Mihalj et al.
All carcinomas were classified according to the 2009 FIGO staging system.36 Time to recurrence (disease-free survival: DFS) was marked in months after the date of surgery until the diagnosis of recurrence. Survival time of patients was calculated as the interval from the date of diagnosis to the date of the last clinical follow-up or death from endometrial cancerrelated causes until 31 December 2012. The median follow-up of survivors was 55 months. The study was approved by the Split University Hospital Centre Ethics Committee (500-03/13-01/ 20). Written informed consent for participation in the study was obtained from all study patients. IMMUNOHISTOCHEMICAL ANALYSIS
Immunohistochemical staining was performed on 4lm-thick sections of the most representative paraffin block from each tumour specimen. Paraffin sections were mounted on super frost plus slides (Thermo Scientific, Schwerte, Germany). After cooling to room temperature, slides were washed in distilled water and phosphate-buffered saline (PBS) solution. Further processing was carried out in an automatic stainer (Dako, Glostrup, Denmark). Endogenous peroxidase was blocked using 3% H2O2 for 10 min. After washing in distilled water, primary antibodies were used. Primary rat monoclonal antibody Ngala (R&D Systems, Minneapolis, MN, USA), diluted previously at 1:50, was applied overnight. Primary polyclonal rabbit antibody against MMP-9 (Dako) was diluted at 1:75 and applied for 1 h. After washing in PBS solution, labelled streptavidin–biotin (LSAB) (LINK, biotinylated secondary antibodies; Dako) was used as secondary antibody for 30 min, followed by rinsing with PBS. Diaminobenzidine hydrogen (DAB; Dako) was applied as chromogen for 10 min and then washed in distilled water. The sections were counterstained in haematoxylin, dehydrated, cleared and mounted on silanized slides. Specimens of acute appendicitis and colon cancer served as positive controls for LNC2 and MMP-9, respectively. For negative control, primary antibodies were omitted. Lipocalin-2 and MMP-9 were determined on the same tumour paraffin block on adjacent sections. Preparations were analysed on an Olympus BX41 microscope (Olympus Inc., Melville, NY, USA). EVALUATION OF STAINING
All sections were evaluated independently by two gynaecological pathologists with no previous knowledge of the patient’s clinical information. The slides
with discrepant findings were additionally examined by a third, randomly chosen pathologist specialized in gynecologic oncology, and this finding was decisive in determining the final result of immunohistochemical staining. The LCN-2 and MMP-9 positive samples were defined as those showing brown signals in the cytoplasm. When 5% of the cells in a given specimen stained positive, it was defined as a positive stain. Cytoplasmic staining intensity in tumour cells (grades 0–3) and staining area (0 = no tumour cells positive; 1 = 5–10% cells positive; 2 = 10–50% cells positive; 3 = >50% cells positive) were recorded. Staining index (SI) was calculated as a product of staining intensity and positive area giving a staining index of 0–9.18 On statistical analysis, final staining scores of 1 and 2, 3 and 4 and 6 and 9 were considered as low, medium and high expression, respectively. STATISTICAL ANALYSIS
A statistically significant association between two qualitative variables was carried out by v2 test and logistic regression (odds ratio). Logistic regression analysis was used to establish the correlation of LCN2 and MMP-9 expression with recurrence and clinicopathological variables. The Kaplan–Meier method was used to estimate survival as a function of time, and survival differences were analysed with the log-rank test. The Cox proportional hazard regression model was used to examine simultaneously all factors found to be prognostic of survival in univariate analysis. In the analysis of DFS and overall survival (OS), a multifactorial Cox regression analysis was also used. In all statistical procedures, the level of significance was set at P < 0.05. Analyses were performed using SPSS version 9 software.
Results LCN-2/MMP-9 EXPRESSION
Relationship with clinicopathological characteristics From 1998 to 2010, 110 patients with high-grade endometrial cancer were diagnosed. According to inclusion and exclusion criteria or insufficient tissue quality, 85 patients were included in the study, including 40 (47%), nine (10%) and 36 (43%) with serous, clear cell and endometrioid grade 3 histology, respectively. All patients underwent simple hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Systematic pelvic with or without para-aortic lymphadenectomy was performed in 40 (47.5%) cases. During the study © 2014 John Wiley & Sons Ltd, Histopathology, 67, 206–215.
LCN-2/MMP-9 coexpression in high-grade endometrial cancer
A
209
B
Figure 1. Lipocalin-2 (LCN-2) and matrix metalloproteinase-9 (MMP-9) immunohistochemical expression in high-grade endometrial cancer. A, LCN-2 immunohistochemical expression; B, MMP-9 immunohistochemical expression.
period, recurrence of disease occurred in 38 (44%) patients, 31 of whom (36%) died from endometrial cancer. Another 11 patients died from causes unrelated to
carcinoma. Regarding immunohistochemistry, 59 (69.5%) endometrial cancers were positive and 26 (30.6%) negative for LCN-2.
Table 1. Association of lipocalin-2 (LCN-2) and matrix metalloproteinase-9 (MMP-9) expression and clinicopathological variables in 85 patients with high-grade endometrial cancer No. (%) of patients with MMP-9 expression
No. (%) of patients with LCN-2 expression Variable
Negative
Positive
P*
Negative
Positive
P*
Histological type ECG3†
13 (50)
23 (39)
