Comparison of Telomerase Expression in Endometrioid Adenocarcinoma with Normal Endometrium

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1 3 Sabar et al Obstet Gynecol Research Report Comparison of Telomerase Expression in Endometrioid Adenocarcinoma with Normal Endometrium Perbandingan Ekspresi Telomerase pada Kanker Endometrium Tipe Endometrioid dengan Endometrium Normal Buha Sabar, Andrijono, Primaria Dewi, Joedo Prihartono 3 Department of Obstetrics and Gynecology of Indonesia University, Jakarta Department of Pathology Anatomy of Indonesia University, Jakarta 3 Public Health Faculty of Indonesia University, Jakarta Abstract Objective: To examine and compare the expression of telomerase in endometrioid adenocarcinoma and normal endometrium using immunohistochemical staining. In the current study using immunohistochemical staining, telomerase expression were significantly different between endometrioid adenocarcinoma and normal endometrium. Method: Eleven samples of endometrioid cancer and ten samples of normal endometrium were obtained from hysterectomy specimens. All block paraffin samples underwent the immunohistochemical staining. Telomerase expression was scored semiquantitatively. Statistical analyses were performed using the Kolmogorov- Smirnov and Fisher test. Result: Telomerase expression in endometrioid adenocarcinoma was higher than in normal endometrium. Weak telomerase expression had. times (.-.36; CI 95%; p =.37), and moderate telomerase expression was 35. times (.7-73.; CI95%; p =.6) higher relation to endometrioid cancer, compared with negative telomerase expression. Conclusion: Telomerase expression has a potential role to be used as a prediction tool whether a normal endometrium cell has a tendency to become endometrioid cancer. [Indones J Obstet Gynecol ; 35-:3-] Keywords: telomerase expression, endometrioid cancer Abstrak Tujuan: Untuk memeriksa dan membandingkan ekspresi telomerase pada kanker endometrium tipe endometrioid dan endometrium normal dengan menggunakan pewarnaan imunohistokimia. Metode: Sebelas sampel kanker endometrium tipe endometrioid dan sampel jaringan endometrium normal diambil dari spesimen histerektomi. Pada semua sampel dilakukan pewarnaan imunohistokimia. Dilakukan penilaian ekspresi telomerase secara semikuantitatif. Analisis statistik menggunakan uji Kolmogorov-Smirnov dan Fisher. Hasil: Ekspresi telomerase pada jaringan kanker endometrium tipe endometrioid lebih tinggi dibandingkan pada jaringan endometrium normal. Ekspresi telomerase lemah, kali (, -,36; CI95%; p =,37), dan ekspresi telomerase sedang sebesar 35, kali (,7-73,; CI95%, p =,6) mempunyai hubungan dengan kanker endometrium tipe endometrioid, dibandingkan ekspresi telomerase negatif. Kesimpulan: Ekspresi telomerase memiliki potensi untuk diteliti sebagai faktor prediksi apakah suatu sel endometrium normal cenderung berubah menjadi kanker endometrium tipe endometrioid. [Maj Obstet Ginekol Indones ; 35-:3-] Kata kunci: ekspresi telomerase, kanker endometrium tipe endometrioid Correspondence: Buha Sabar, Department of Obstetrics and Gynecology of Indonesia University. Phone: , buha_seps@yahoo.com INTRODUCTION Endometrioid cancer takes the second highest place for gynecological cancer after ovarium cancer. Incidence of endometrioid cancer is increasing worldwide, starting from per. in women under y.o. to -5 per. in 6 th, 7 th, 8 th decade each year., In United States, during,.3 new cases had been emerging with 7.9 deaths among them because of endometrioid cancer. In Canada, incidence of this cancer was 9.5 cases per. in 993, with 3.6 deaths cases per.. This cancer is most commonly diagnosed in 6 th decade of life, even -5% cases are found at premenopause. Almost 75% from all cases are found on the first stage. 3, Theories explained the process of carcinogenesis, one of them is roles of expansion survival gene (telomere). 5 Telomere is a repeated DNA sequences at the end of chromosomes. In human chromosomes, they consist of thousands of copies of the nucleotide sequence 5 -TTAGGG-3 ranging from 5 to kb in length. In normal cell, telomere shortening happens everytime a cell divides if telomere is already short, cell will stop to divided undergo growth inhibition, called replicative senescene. In almost all immortal cancer cells senescene does not happen, because they re regulated telomerase which has the role of a telomere stabilisator. 6,7 By activating telomere, few types of cells are going to be immortal. A lot of primodial cancer cells become immortal because telomere activity allows them to divide for a long period of time. At the end of that condition, those immortal cells are becoming cancer. It is said that cell has telomere to eliminate its death process by chromosome instability, losing apoptosisinduced pathway, and mitosis activity-continuing. 6,7 Telomerase is a ribonucleoprotein complex enzyme that catalyzes the addition of DNA specific sequence at the ends of 3 of telomere in chromosomes. The telomerase enzyme is composed of two main parts: the telomerase reverse transcriptase (htert), which is the catalytic protein component, and the telomerase RNA (htr), which provides the template for telomere

2 Vol 35, No October Telomerase expression in endometrioid adenocarcinoma 3 synthesis. 7,8 Telomerase is being activated in every phase of cell cycle with relatively the same degree of activity in every active phase. The activity of telomerase is decreasing on cells that are out from cell cycle and stop temporary on G check point. 9 Telomerase is reported to be expressed in most human tumors and cancer cell lines, yet is not active in most normal diploid human cells. It is required in the advancement of the neoplasma to malignancy. The expression of htert mrna has been reported to parallel the levels of telomerase enzyme activity in hepatocellular carcinoma, endometrial cancer, and colorectal cancer, suggesting that the induction of hte RT-gene expression modulates telomerase activity. Previous studies have shown that htert and telomerase activity can be detected in normal cycling endometrium. These observations potentially limit the utility of telomerase analysis as a diagnostic adjunct in the evaluation of endometrial carcinoma. According to Lehner et al study, there was a linear association between htert mrna and telomerase activity levels. htert mrna levels and telomerase activity levels were significantly higher in endometrioid cancer than in normal endometrium. In normal endometrium, htert mrna and telomerase activity levels were highest in the proliferative phase and were relatively low in secretory. Meanwhile, Brustmann H (5) wrote in his study that htert expression is closely related to proliferation, apoptosis, and high grade in endometrioid carcinomas, reflecting cell cycle deregulation in endometrioid carcinogenesis. From previous explanation, telomerase plays an important role in carcinogenesis process, especially endometrioid cancer. Based on that, an intensive study about telomerase gives a promising tool for early detection whether cells have tendency to be cancer or not based on telomerase activity levels. In Indonesia, there haven t been any study done, both qualitative and quantitative technique, for assessing telomerase activity levels. Because of that, this current study was undergone to find association of telomerase expression between endometrioid cancer and normal endometrium in Indonesia. METHOD This study was performed in Department of Obstetrics Gynecology and Department of Anatomic Pathology Faculty of Medicine University of Indonesia - Dr. Cipto Mangunkusumo Hospital, started from April until May. All samples were taken from block paraffin post hysterectomy specimens with microscopic diagnosis showed endometrioid cancer and non-cancer. These samples were gathered from patients that had been hospitalized in Oncology treatment room, Obstetry- Gynecology Department, since January 6 until December. Histopathological endometrioid cancer datas were taken from Pathology Anatomy Department s archives. The paraffin blocks were being searched and reviewed to found tumor mass in Hematoxylin-Eosin (HE) specimen. If the paraffin blocks were accepted in inclusion criterias, then they would undergo Hematoxylin-Eosine and immunohistochemical staining at Immunohistochemical laboratory of Pathology Anatomy Department. This study samples fulfilled the inclusion criteria. Case group (endometrioid cancer based on microscopic diagnosis) inclusion criteria were:. the oldest specimens existed since January 6;. patients with age 3 years old; 3. patients not having any other organs tumor;. patients who hadn t have any hormonal therapy; 5. patients complete medical record. Control group (normal endometrium based on microscopic diagnosis) inclusion criteria were:. the oldest specimens existed since January 6;. patients with age 3 years old; 3. patients who hadn t have any endometrium abnormality;. patients who hadn t have any hormonal therapy; 5. patients who did not have any other organs tumor; 6. patients medical record. All samples that had been stained were observed under microscope by Pathology Anatomy Specialistic and Obstetry-Gynecology Specialistic, that previously had equalized their perception about the standarization of samples assessment. Observation result datas were recorded and underwent editting and coding process. After that, datas were recorded using micro magnetic computer disc and being validated for clearance. All result datas were filled both in distribution table and cross table that were appropriate with the goal of this study, then were analysed using SPSS ver. with Fisher or Kolmogorov-Smirnov test and p <.5. RESULTS Both groups were being assessed based on sum of cell with positive telomerase expression and intensity of nucleus and cytoplasma telomerase expression. Scoring of telomerase expression was using Remmele score. According to the number of positive cells, the staining was semiquantitatively evaluated as follows: %, ; < %, ; to 5%, ; 5 to 8%, 3; and > 8%,. Intensity of the staining also was also being evaluated as weak, +; moderate, +; and strong, 3+. For each case, the values of the two parameters (percentage of the positive cells and predominant intensity) were multiplied, resulting in possible scores from to. Finally, the cases were classified into four different groups: negative cases, score ; cases with weak, score ; moderate, scores to 6; and strong expression, scores 8 to. In case group was also being assessed about the staging and grading differentiation of cancer. In control group, samples were determined whether in proliferation or secretory phase. We can see different telomerase expression in pictures below. DISCUSSION In the case group, the median age was 5,6 years old, higher than control group,which was 7, years old. This result was appropriate with previous study which showed that incidence of endometrioid cancer increased among samples above 5 years old., Nine of (8.8%) in case group were above age of 5, and 7 (63.6%) among them were in range of age 5-6. As we know that endometrioid cancer were diag-

3 3 Sabar et al Obstet Gynecol nosed the most at 6 th decade. Because few risk factors of endometrioid cancer are found at age of 5 above, such as obesity, post-menopausal, Hormon Replacement Therapy, and anovulation. These risk factors create unopposed estrogen condition. 3, among samples there was presence of variation of expression. Fifteen samples showed positive telomerase expression, which consisted of moderate expression samples and weak expression samples. The rest of 6 samples were negative. From this point forward, we only analysed the nucleus telomerase expression. Firege 3. Moderate Espression. Many eoithelial nuclei showed moderate immunoc limmnocreatovoty (arrow). Figure. Immunohistochemical staining of an endometrioid ade-nocarcinoma with anti htert antibody. Figure. Strong Expression of Immunostaining. Many epithelial nuclei showed strong immunoreactivity (arrow) Figure. Moderate Expression of Immunostaining. Many epithel nuclei showed. The Comparison of Cytoplasm and Nucleus Telomerase Expression Most of samples in both groups showed positive cytoplasm telomerase expression with moderate intensity. Because of that, telomerase expression in both groups seemed constant and could not be compared. Meanwhile, different result showed in case group, that Study of Kyo, et al reported that telomerase had been expressed not only in nucleus, but also in cytoplasm of cancer cell using Western blot methods. The biological functional of cytoplasma telomerase was still speculative. The underlying mechanism of cytoplasm telomerase were thought that cytoplasma telomerase were not being phosphorylated and inactive. The phosphorylation correlated with cytoplasm translocation into nucleus.,3

4 Vol 35, No October Telomerase expression in endometrioid adenocarcinoma 33 The Association between Staging, Grading Differentiation, Phase and Telomerase Expression Eight of case samples (7.7%) were at moderatedifferentiation, while the rest of them were distributed from well- to poor-differentiaton (Table ). Similarly, eight of endometrioid cancer samples (7.7%) found at stadium I, ranged from IA ( samples) until IB ( samples). This result corresponded with the previous study that mentioned about 75% endometrioid cancer was diagnosed at first stadium. 3, Ebina study (999) showed similar result that most of patients with endometrioid cancer detected at stadium I were about 5.7%. All patients showed weak and moderate telomerase expression. Percentage of moderate telomerase expression at stadium II-IV was 66.7%, higher more increased than stadium I that was only 33.3%. This result was consistent with Ebina study that even most of endometrioid cancer was at stage I, but the percentage of strong telomerase expression was about 5%, far below than stage of II-IV that reached 57.9%. In control group, there were 6 samples in proliferation phase and samples in secretory phase. Two (33%) samples in proliferation phase were positive telomerase expression with weak intensity, meanwhile (5%) samples in secretory phase were also showing positive telomerase expression with weak intensity (Table ). This result was different with Maida study (), where in secretory phase had been found about 5% samples with positive telomerase expression. This number were lower compared to the number in proliferative phase which was about 66,6%. 3 The possibility of this result was comparison of total samples in each phase only 6 :. That number was far smaller compared with Maida study that used 5 and samples. Other rational reason, there was a different method in measuring telomerase expression, where in this current study was using htert in immunohistochemical staining, then grouped using Remelle scoring, while in Maida study was using telomeric repeat amplification protocol (TRAP). 5 The Association Of Telomerase Expression in Case Group and Control Group All case group samples showed positive telomerase expression, where (57.%) samples had moderate intensity, and 7 (.86%) samples had weak intensity. In control group, (%) samples had positive telomerase expression and all of them had weak intensity. The rest of 6 samples did not expressed telomerase (Table 3). Table. Distribution of Telomerase Expression in Endometrioid Adenocarcinoma. Classification Grading Differentiation Poor Differentiation Moderate Differentiation Well Differentiation Staging IV III C III C III B III A II I B I A Table. Distribution of Telomerase Expression in Normal Endometrium. Telomerase Expression in Case Group (n=) Strong Moderate Weak Negative Total (9.%) 8 (7.7%) (8.%) (9.%) (9.%) (9.%) (36.%) (36.%) Classification Telomerase Expression (n=) Strong Moderate Weak Negative Total Phase Proliferation 6 (6%) Secretion (%) Table 3. The Odds Ratio and P value of Telomerase expression in Endometrioid adenocarcinoma and normal Endometrium. Group Telomerase Expression Endometrioid Normal Adenocarcinoma Endometrium OR (CI 95%)* p # Strong - - Moderate 35. (.7-73.).6 Weak 7. (.-.36).37 Negative 6 Reff * Odds ratio calculated by adding in every cell, because there are cells with score # p value (p) calculated with Fisher -way test

5 3 Sabar et al Obstet Gynecol In statistic analysis, Odds Ratio (OR) of weak telomerase expression was calculated as. (. -.36; CI95%; p =.37), and moderate telomerase expression was calculated as 35. (.7-73.; CI 95%, p =.6). That means, moderate telomerase expression gave 35 times possibility in progressing into endometrioid cancer, compared with negative telomerase expression. And weak telomerase expression gave. times possibility in progressing into endometrioid cancer compared with the negative one. Both of this OR showed significan difference in statistic. This results were similar with Brustman study (5) that mentioned about 9% of 3 endometrioid cancer samples showed immunologic staining with range from weak to moderate; and only samples showed strong expression. 6 CONCLUSION Telomerase expression in endometrioid adenocarcinoma was higher than in normal endometrium. There was a significant difference in statistic and clinical between moderate telomerase expression compared with negative telomerase expression; and between weak telomerase expression compared with the negative one. The relationship of these differences could be used as the basis that telomerase expression potentially could be used as an early predictor of endometrial malignancy. REFERENCES. Hacker NF, Benedet JL, Ngan HYS. Staging, classification and clinical practice guidelines of gynecologic cancers. Int J Gynecol Obstet ; 7: 7-3. Crowder S, Santoso JT. Epithelial uterine cancer. In: Handbook of gynaecology. International edition. New York: McGraw-Hill, : Hacker NF. Uterine cancer. In: Berek JS, Hacker NF. Practical Gynecologic Oncology, th ed. Philadelphia: Lippincott Williams and Wilkins; 5; Brand A. Diagnosis of endometrial cancer in women with abnormal vaginal bleeding. SOGC Clin Practice Guid, ; 86: De Vita, Hellman and Rosenberg s. Telomerases and telomerase in cancer principles and practice of oncology. 8 th ed. Philadelphia, 8; : David AG, Holt SE, Grant S. Telomeres and telomerase, senescence, genomic instability and tumorogenesis. In: Apoptosis, Senescence and Cancer. nd ed. New Jersey, 7: Kyo S, Kanaya T, Takakura M, Tanaka M. Expression of human telomerase subunit in ovarian malignant, borderline and benign tumors. Int J Cancer 999: Wisman GB, Helder MN, De jong S. Telomerase in ovarian cancer: a possible diagnostic tool and therapeutic target in ovarian cancer. Oxford University, Andrijono. Biologi molekuler, kanker korpus uteri. Dalam: Sinopsis Kanker Ginekologi. Edisi ke-3. Jakarta, 9: 9-6. Pertynski T, Wozniak K, Makowska HR, Czechowska A, Blasiak J. Telomerase expression and activity in endometrial cancer. Experimental Oncology ; : Lehner R, Enomoto T, McGregor JA, Shroyer AL, Haugen BR. Quantitative analysis of telomerase htert mrna and telomerase activity in endometrioid adenocarcinoma and in normal endometrium. Gynecologic Oncology ; 8: -5. Kyo S, Masutomi K, Maida Y. Significance of immunological detection of human telomerase reverse transcriptase. Am J Pathol 3; 63: Liu K, Hodes RJ, Weng NP. Cutting edge: telomerase activation in human T lymphocytes does not require increase in telomerase reverse transcriptase (htert) protein but is associated with htert phosphorylation and nuclear translocation. J Immunol ; 66: Ebina Y, Yamada H, Fujino T, Furuta I, Sakuragi N. Telomerase activity correlates with histopathological factors in uterine endometrial carcinoma. Int J Cancer 999; 8: Maida Y, Kyo S, Kanaya T, Wang Z, Tanaka M. Is the telomerase assay useful for screening of endometrial lesions? Int J Cancer ; : Brustmann H. Immunohistochemical detection of human telomerase reverse transcriptase (htert), topoisomerase IIa expression, and apoptosis in endometrial adenocarcinoma and atypical Hyperplasia. Int J Gynecol Pathol 5; : 8-9