overexpression of cd73 in epithelial ovarian carcinoma is ... · [18]. cd73 is widely expressed on...
TRANSCRIPT
INTRODUCTION
Despitetremendousimprovementsintreatmentstrategiesagainstepithelialovariancancer,epithelialovariancancer
isstill themost lethaltumoramonggynecologicmalignan-cies,andisthefourthmostcommoncauseofcancer-relateddeathsamongwomenworldwide.Althoughovariancancerhasnotbeentraditionallyconsid-
eredtoberesponsivetoimmunotherapy,thereis increasingevidencethat indicatesovariancancersare immunogenic.Thisevidence isderived fromnumerousclinical findingsshowingspontaneousantitumor immuneresponses [1-4],tumor immuneevasionmechanisms [5-7],andclinical re-sponsesto immunotherapy [8-13] inpatientswithovarian
Original Article
Overexpression of CD73 in epithelial ovarian carcinoma is associated with better prognosis, lower stage, better differentiation and lower regulatory T cell infiltrationHoon Kyu Oh1, Jeong-Im Sin2, Junghae Choi3, Sung Hae Park4, Tae Sung Lee4, Youn Seok Choi4
1Department of Pathology, Catholic University of Daegu School of Medicine, Daegu; 2Department of Microbiology, Kangwon National University School of Medicine, Chuncheon; 3Department of Molecular Biology, College of Pharmacy and Life & Nanopharmaceutical Science, Kyung Hee University, Seoul; 4Department of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, Daegu, Korea
Received Apr 3, 2012, Revised Apr 28, 2012, Accepted May 12, 2012
Correspondence to Youn Seok ChoiDepartment of Obstetrics and Gynecology, Catholic University of Daegu School of Medicine, 33 Duryugongwon-ro 17-gil, Nam-gu, Daegu 705-718, Korea. Tel: 82-53-650-4087, Fax: 82-53-650-4078, E-mail: [email protected]
pISSN 2005-0380 eISSN 2005-0399
Copyright © 2012. Asian Society of Gynecologic Oncology, Korean Society of Gynecologic Oncology
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Objective:ThepurposeofthecurrentstudywastoevaluatesurvivaloutcomeaccordingtotheexpressionstatusofCD73inpatientswithepithelialovariancancer.Methods:A totalof167patientswithepithelialovariancancerwereenrolled in thecurrentstudy.Foreachpatient,aretrospectivereviewofmedicalrecordswasconducted. ImmunohistochemicalstainingforCD73,CD8,FoxP3,andCD68wasperformedusingtissuemicroarraymadewithparaffinembeddedtissueblock.Results:Amongtheenrolledpatients,29.9%ofpatients (n=50)showednegativeexpressionforCD73,whereas70.1%ofpatients(n=117)showedpositiveexpressionforCD73.TheCD73positivegroupshowedbetterprognosiscomparedtotheCD73negativegroup(5-yearoverallsurvivalofCD73positivegroup,73.0%;thatofCD73negativegroup,50.1%;p=0.023).CD73wasmorefrequentlyexpressedinmucinousadenocarcinomaandclearcellcarcinomacomparedtoserousorendometrioidadenocarcinoma.Inaddition,CD73overexpressionsweremorefrequentlydetectedinpatientswithknowngoodprognosticfactors, i.e., lowstage,well/moderatedifferentiation,negativeperitonealcytology,nolymphovascular involvement,andnomacroscopicresidualtumorafterdebulkingsurgery.TherewassignificantlymoreinfiltrationofregulatoryTcells intheCD73negativegroupcomparedtotheCD73positivegroup.Conclusion:Goodprognosis inpatientswithoverexpressionofCD73maybeduetothatoverexpressionofCD73wasmorefrequentlyobservedinepithelialovariancancerpatientswithknowngoodprognosticfactors.Therefore,thisresultmeansthatfavorabledifferentiationandstagehavemoreinfluenceonsurvivaloutcomethanadverseeffectofCD73perse.
Keywords:Carcinoma,CD73,Ecto-5’-nucleotidase,Ovarianneoplasms,Survival
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cancer,highlightingthatimmunotherapymaybeapplicabletotreatingovariancancer.Althoughtherehavebeensuccessfulreportsofcancerimmu-
notherapyinanimalstudies,clinicalfindingsaredisappointingwithlittleimprovementofsurvivaloutcomeinpatients.Ithasbeenreportedthatinefficienttumorrejectionisnotonlythepassiveresultofinsufficienteffectorcells[14],butthattumorsalsoactivelyfightbackbyutilizingimmune-suppressivemech-anismsthatprotectthemfromeradication[14,15].CD73,alsoknownasecto-5’-nucleotidase (ecto-5’-NT)or
5' -nucleotidase (5’-NT), isaglycosyl-phosphatidylinositol-linked70-kDacell surfaceenzymethat isencodedby theNT5Egene.Normally,CD73isexpressedonendothelialcellsandsubsetsofhematopoieticcells.CD73wasoriginallyde-finedasalymphocytedifferentiationantigen. It likelyactsasacosignalingmoleculeonTlymphocytes,andisimportantasanadhesionmoleculefor lymphocytebindingtotheendo-thelium[16,17].CD73catalyzesthedephosphorylationofad-enosinemonophosphate(AMP)andothernucleosidemono-phosphates[17].Consequently,adenosineisaccumulatedininterstitialfluidfromthedephosphorylationofAMP.Extracel-lularadenosineinhibitsTlymphocyteactivationandeffectorfunctionbysignalingprimarilythroughA2aandA3adenosinereceptorsonthesurfaceofTcells.A2aadenosinereceptorsignalinghasalsobeenimplicatedintheinhibitionofcyto-kineproductionandcytotoxicactivitybynaturalkillercells[18].CD73iswidelyexpressedonmanytumorcelllinesandisupregulatedincanceroustissuesincludingthoseofthecolon,lung,pancreas,andovary.CD73isalsoassociatedwithdrugresistance,tumorcellsproliferation,tumorneovascularization,invasiveness,andmetastasisofcancercells[19,20].ThesedatasuggestthatCD73expressedontumorcellsmightfunctionasthenegativeregulatoroftumorcontrolimmunologically.Consideringtheabove-mentionedfunctionsofCD73,pa-
tientswithcancercellsexpressingmoreCD73arelikelyhavepoorsurvivaloutcome.However,onlysparse informationisavailableregardingthesurvival influenceofCD73expressionontumorcells inpatientswithmalignancies.Therefore,thepurposeof thecurrentstudywastoevaluatesurvivalout-comeaccordingtotheexpressionstatusofCD73inpatientswithepithelialovariancancer.
MATERIALS AND METHODS
1. Enrolled patientsWesearched forpatientswithepithelialovariancancer
whounderwentstagingoperationswithorwithoutadjuvantchemotherapy inourdepartment inanoncologydatabase
maintainedatourdepartment. Inclusioncriteriawereasfol-lows:1)patientswithepithelialovariancancer(queryterm;serous,mucinous,clear,endometrioid,transitional,malignantBrenner);2)patientswhounderwentprimarytherapyinourdepartment;and3)patientsdiagnosedbetweenJanuary2000andDecember2010.ThisretrospectivestudywasapprovedbytheInstitutionalReviewBoardofDaeguCatholicUniversityMedicalCenter.Applyingtheinclusioncriteria,atotalof167patientswith
epithelialovariancancerwereenrolledinthecurrentstudy.Foreachpatient,aretrospectivereviewofmedical recordswasconducted.Thehistologicslidesofthesurgicallyremovedovariancancertissueswerereviewedagainby1pathologist(HKO),whowasblindedtotheclinicalvariablesofthepatient.
2. Definitions of overall survival and disease-free survivalOverallsurvival(OS)wasdefinedasthetimefromthedate
ofdiagnosistodeathfromepithelialovariancancer.Patientswhosurvivedbeyondthetimeofanalysiswerecensoredatthetimeoftheirlastfollow-update.Disease-freesurvival(DFS)wasdefinedasthetimefromdateofdiagnosistotherecur-renceofcancerinanysites.
3. Construction of tissue microarrays (TMA)Representativeparaffintumorblockswereselectedaccord-
ingtotheprimaryevaluationofH&EstainedslidesofovariancancerbeforetheywerepreparedforTMA.Twotumortissuecores(1mmindiameter)weretakenfromeachofthedonorovariancancer tissueblockswithamanualpuncharrayer(Quick-Ray,Uni-TechScience,Seoul,Korea).Thecoreswereplacedinanewrecipientparaffinblockthatultimatelycon-tained59to91tissuecores.Eacharrayblockcontainedbothtumorandcontroltissue(lung,breast,andprostatecancertis-suesandnormalbreast,colon,endometrium,ovary,andtonsiltissues)samples.Multiplesections(5µminthickness)werecutfromtheTMAblocksandthenmountedontomicroscopeslides.TheTMAH&Estainedsectionswerereviewedunderlightmicroscopytoconfirmthepresenceofrepresentativetumorareas.
4. Immunohistochemical stainingImmunohistochemistrywasconductedon5µmthickTMA
tissuesectionsusingtheBondPolymer IntenseDetectionSystem(LeicaMicrosystems,MountWaverley,VIC,Australia)accordingtothemanufacturer’sinstructionwithminormodi-fications.Briefly,the5-µmthicksectionsofformalinfixedandparaffinembeddedTMAtissuesweredeparaffinizedwithBondDewaxSolution(LeicaMicrosystems),andanantigenre-trievalprocedurewasperformedusingBondERSolution(Leica
Hoon Kyu Oh, et al.
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Microsystems)for30minutesat100oC.Theendogenousper-oxidasewasquenchedfollowing5-minute incubationwithhydrogenperoxide.Sectionswereincubatedfor15minutesatambienttemperaturewithamousemonoclonalanti-CD73antibody (ab91086,1:100;Abcam,Cambridge,MA,USA),amousemonoclonalanti-FOX-P3 (ab20034,1:50;Abcam),amousemonoclonalanti-CD8antibody(m7103,1:200;DAKO,Glostrup,Denmark),andamousemonoclonalanti-CD68an-tibody(M0876,1:200;DAKO),usingabiotin-freepolymerichorseradishperoxidase-linkerantibodyconjugatesysteminaBond-Maxautomaticslidestainer(LeicaMicrosystems).Humantonsil (CD8,CD68,andFOX-P3),andlungcarcinoma(CD73)tissueswereusedaspositivecontrols.
5. Interpretation of immunohistochemical stainCD73expression levelsweregradedonascaleof0 to3
basedoncytoplasmicandmembranestainingintensityandtheproportionofpositivetumorcellsbyanexpertpathologistwhowasblindedtothepatient’sclinicalrecords.Thestainingwasgradedas0ifnocancercellswerereactive,1ifstainingwasweaklypositivein<1/3ofcancercells,2 ifstainingwasweaklypositivein>2/3ofcancercells,orstronglypositivein>1/3ofcancercells,and3ifstainingwasweaklypositiveinmostcancercells,orstronglypositivein>2/3ofcancercells(Fig.1). ImmunohistochemicalstainingforCD73 inovariancancertissuewasclassifiedasnegative(grade0)orpositive(grade1 to3).FOX-P3nuclearexpressionwascountedas
Fig. 1. Representatives of CD73 expression of each grade in immunohistochemical staining (x200). The staining was graded as 0 if no cancer cells were reactive, 1 if staining was weakly positive in <1/3 of cancer cells, 2 if staining was weakly positive in >2/3 of cancer cells, or strongly positive in >1/3 of cancer cells, and 3 if staining was weakly positive in most cancer cells, or strongly positive in >2/3 of cancer cells. Normally, endothelial cells and some of lymphocytes express CD73.
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positivemononuclearcells in3highpowerfields(×400) ineachtumorcore.CD8andCD68cytoplasmicandmembraneexpressionlevelsweregradedonascaleof0to3basedon
theproportionofpositivemononuclearcellsinfiltratedintheintratumoralandperitumoralstromaltissue.Arbitrarycutoffpointsat1%(grade0),5%(grade1),25%(grade2),and50%(grade3) foreachpositivecellper infiltrated immunecellswereused.
6. Statistical analysisComparisonsofvariablesbetweenthegroupswerebased
onthechi-squaretestand independentt-test.TheOSandDFSwereestimatedbythelife-tablemethodofKaplan-Meier.Differencesinsurvivalrateswereassessedbythelog-ranktest.Thep-valuesweretheresultoftwo-sidedtestsandp<0.05wasconsideredstatisticallysignificant.MultivariateanalysiswasperformedbyCoxregressionhazardmodel.StatisticalanalysiswasdoneusingSPSSver.13(SPSSInc.,Chicago, IL,USA).
RESULTS
Characteristicsofenrolledpatientsareshown inTable1.Briefly,meanagewas50.3years,andthemeanofthelargesttumordiameterobtainedfromthe imagingstudy(ultraso-nography,computedtomographyormagnetic resonanceimaging)was11.6cm.ThenumberofpatientsineachFIGOstagewasasfollows;stageIA39,IB4,IC18,IIA2,IIB9,IIC13,IIIA2, IIIB9, IIIC60,and IV11. Intermsofpathologictypes,serousadenocarcinomaaccountfor43.7%,mucinousadeno-carcinoma24.0%,endometrioidadenocarcinoma18.6%,clearcellcarcinoma12.6%,andtransitionalcellcarcinoma1.2%,respectively.TheexpressionstatusofCD73 in immunohistochemical
stainingisshowninTable2.Atotalof29.9%(n=50)patientsshowednegativeexpression,andtheotherpatients(70.1%)showedpositiveexpression(fromgrade1tograde3).SurvivalanalysiswasconductedaccordingtoCD73expressionstatus.
Table 1. Characteristics of the patients enrolled in this study (n=167)
Characteristic Value
Age (yr) 50.3±13.5 (15-77)
Parity 2.4±1.6 (0-8)
Largest tumor diameter (cm) 11.6±6.5 (1-34)
CA-125 649.9±1,075.4 (2.9-5,000)
CA 19-9 122.2±390.8 (0.5-3,238)
Lactate dehydrogenase 512.9±355.7 (150-3,112)
Stage
Stage I 61 (36.5)
IA 39
IB 4
IC 18
Stage II 24 (14.4)
IIA 2
IIB 9
IIC 13
Stage III 71 (42.5)
IIIA 2
IIIB 9
IIIC 60
Stage IV 11 (6.6)
Pathologic type
Serous adenocarcinoma 73 (43.7)
Mucinous adenocarcinoma 40 (24.0)
Endometrioid adenocarcinoma 31 (18.6)
Clear cell carcinoma 21 (12.6)
Transitional cell carcinoma 2 (1.2)
Differentiation
Well differentiated 48 (28.7)
Moderate differentiated 37 (22.2)
Poorly differentiated 82 (49.1)
Cytology
Negative 113 (67.7)
Positive 54 (32.3)
Ascites
Absent 69 (41.3)
Present 98 (58.7)
Lymphovascular involvement
Absent 101 (60.5)
Present 66 (39.5)
Values are presented as mean±SD (range) or number (%).
Table 2. Immunohistochemical (IHC) staining for CD73
Grade of IHC No. of patients (%)
Negative 0 50 (29.9)
Positive +1 72 (43.1)
+2 29 (17.4)
+3 16 (9.6)
The staining was scored as 0 if no cancer cells were reactive, 1 if staining was weakly positive in <1/3 of cancer cells, 2 if staining was weakly positive in >2/3 of cancells, or strongly positive in >1/3 of cancer cells, and 3 if staining was weakly positive in most of cancells, or strongly positive in >2/3 of cancer cells.
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BecauseallpatientswithpositiveCD73expressionshowedsimilarsurvivaloutcome(5-yearOSestimationofgrade1,72.5%;grade2,77.9%;andgrade3,66.7%,respectively;p=0.760),thepatientsweregroupedasCD73positiveandCD73negativegroupsforfurtheranalysis.Contrary toourexpectations, theCD73positivegroup
showedbetterprognosiscomparedto theCD73negativegroup(5-yearOS:CD73positivegroup,73.0%;CD73nega-tivegroup,50.1%;p=0.023;5-yearDFS:CD73positivegroup,53.4%;CD73negativegroup,24.1%;p=0.021)(Fig.2).BecausethereweremorepatientswithmucinousadenocarcinomaintheCD73positivegroup,weconductedasubanalysisforpatientswithnon-mucinousadenocarcinoma.Inasubgroupanalysis forpatientswithnon-mucinousepithelialovariancancer,althoughthedifferencedidnot reachtostatisticalsignificance,theCD73positivegroupshowedatendencytohavebetteroverallsurvivalthantheCD73negativegroup(5-yearOSofthenon-mucinousCD73positive[n=81]andnega-tive[n=46]groupwas69.4%and47.4%,respectively;p=0.052,Logranktest).WecomparedthefrequenciesofCD73overexpression(posi-
tiveexpression, fromgrade1tograde3)accordingtoclini-copathologicvariables.CD73wasmorefrequentlyexpressedinmucinousadenocarcinomaandclearcellcarcinomacom-paredtoserousorendometrioidadenocarcinoma. Inaddi-tion,CD73overexpressionsweremorefrequentlydetectedinpatientswithknowngoodprognosticfactors, i.e., lowstage,well/moderatedifferentiation,negativeperitonealcytology,nolymphovascularinvolvement,andnomacroscopicresidualtumorafterdebulkingsurgery(Table3).ToevaluatetheassociationofCD73expressionwithimmune
celldeposition,wecomparedthedifferencesinthedegreesornumbersof immunecelldepositionsaccordingtoCD73expressionstatus.TherewerenodifferencesinthedepositionsofcytotoxicTlymphocyte(CD8positivecells)andmonocyte/macrophage(CD68positivecells)betweentheCD73positiveandCD73negativegroup.However,thereweresignificantlymoreTreg(regulatoryTcell,FOX-P3positivecells)intheCD73negativegroupcomparedtotheCD73positivegroup(Table4).MultivariateanalysisusingCox regressionhazardmodel
showedthatage,stage,optimaldebulkingsurgery,differen-tiation,andtumorsizewereindependentprognosticfactors,butCD73overexpressionwasnot(Table5).
Table 3. The frequencies of CD73 overexpression according to clinicopathologic variables
Clinicopathologic variable No. of patients
CD73 over-expression (%) p-value*
Histologic type 0.001
Serous adenocarcinoma 73 41 (56.2)
Mucinous adenocarcinoma 40 36 (90.0)
Endometrioid adenocarcinoma 31 20 (64.5)
Clear cell carcinoma 21 18 (85.7)
Transitional cell carcinoma 2 2 (100)
Stage 0.001
I 61 54 (88.5)
II 24 14 (58.3)
III 71 43 (60.6)
IV 11 6 (54.5)
Grade 0.001
Well differentiation 48 41 (85.4)
Moderate differentiation 37 30 (81.1)
Poorly differentiation 82 46 (56.1)
Cytology 0.035
Negative 113 85 (75.2)
Positive 54 32 (59.3)
Ascites 0.052
Absent 69 54 (78.3)
Present 98 63 (64.3)
Lymphovascular involvement 0.012
Negative 101 78 (77.2)
Positive 66 39 (59.1)
Maximal size of residual tumor (cm) 0.021
No macroscopic 90 72 (80.0)
<1 28 17 (60.7)
<2 28 15 (53.6)
≥2 21 13 (61.9)
*Chi-square test.
Fig. 2. Survival analysis according to the expression status of CD73. Five year overall survival of CD73 positive (n=117) and negative (n=50) group was 73.0% and 50.1%, respectively (p=0.023, Log rank test).
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DISCUSSION
Inthisstudy,weobservedthatCD73overexpressionwasmorefrequentlyobservedinepithelialovariancancerpatientswithknowngoodprognosticfactors, includinglowerstage,well/moderatedifferentiation,negativeperitonealcytology,nolymphovascularinvolvement,andnomacroscopicresidualtumor.TheseresultedinpatientsshowingCD73overexpres-sionhadbettersurvivaloutcomecomparedtothosewithoutCD73expression.However,CD73overexpressionwasnotindependentprognosticfactor inmultivariateanalysisusingCoxregressionhazardmodel.ThesefindingswereunexpectedbecauseCD73expressedin
tumortissuehasbeenreportedtobedetrimentaltoimmuno-logiccontroloftumorinanimalstudies,andhasbeenshowntobeassociatedwith tumorproliferation,metastasis,andinvasion[19-21].Previousstudiesshowedthatelevatedlevelsofadenosineinsolidtumorsresultinimpairedkillingoftumorcellsbyimmuneeffectorcellsviamultipleimmuneresponses,suchasinhibitionofcytotoxicandhelperTlymphocytefunc-tion, inhibitionoftheadhesionofcytotoxicTlymphocytetocancercells,andinhibitionofnaturalkillercellfunction[18,19].Onepossibleexplanation for theunexpectedbetterout-
comeintheCD73positivegroup is thatoverexpressionofCD73wasmore frequentlyobserved inwell/moderatedif-
ferentiatedcarcinomacellsinthisstudy.Itiswellknownthatawelldifferentiatedcancercelltypeisassociatedwithlowerstage.Lowerstageresultsinmoreoptimalsurgeryandbetterprognosis.Therefore,theresultofourstudymeansthatfavor-abledifferentiationandstagehavemoreinfluenceonsurvivaloutcomethantheadverseeffectofCD73perseonthehost’slocalimmunesystem.OurfindingsaresupportedbythoseofRackleyetal. [22].
Rackley’sgroupreportedthatCD73(5’-nucleotidase)activitywaslowerinprostaticcarcinomasthaninbenignprostatichy-perplasia[22].TheyshowedthattheCD73activityofprostaticcarcinomacorrelateswellwiththedegreeofhistologicaldif-ferentiation;thatis,thetissueextractsofpoorlydifferentiatedcarcinomascontainlowerlevelsofCD73[22].OurfindingthatnegativeexpressionofCD73wasassociatedwithpoorlydif-ferentiatedcarcinomaisinthesamelinewiththatofRackleyetal. [22].Thus, itcanbespeculatedthatwelldifferentiatedcancercellstendtoproducemorenormalproteinsincludingCD73thanpoorlydifferentiatedcancercells.AssociationofTcellinfiltrationinovariancancertissueswith
survivaloutcomeisawellknownphenomenon[1-5,23].Inourstudy,however,therewasnosignificantdifferenceinCD8+Tcells infiltration levelsbetweenCD73positiveandnegativepatients. Instead,regulatoryTcellswerefoundless inCD73positivepatientsshowingbetterprognosis,ascomparedtoCD73negativepatients.Thisdataisconsistentwiththedataofothergroupsintheaspectthatpatientshavinglowerregu-latoryTcells infiltrationhavebetterprognosis[5].However,consideringthatCD73ontumorcellsadverselyaffect the
Table 4. Comparison of immune cells deposition in ovarian cancer tissue between the patients with CD73 negative and CD73 positive expression
Variable CD73 negative (n=50)
CD73 positive (n=117) p-value
CD8+ Negative 14 46 0.107*
Grade 1 23 55
Grade 2 12 12
Grade 3 1 4
FOX-P3+ Numbers 5.8±6.0 2.1±3.6 <0.001†
Negative 12 62 0.001*
Positive 38 55
CD68+ Negative 6 11 0.717*
Grade 1 18 53
Grade 2 22 46
Grade 3 4 7
CD8 and CD68 cytoplasmic and membrane expression levels were graded on a scale of 0 to 3 based on the proportion of positive mononuclear cells infiltrated in the intratumoral and peritumoral stromal tissue. Arbitrary cutoff points at 1% (grade 0), 5% (grade 1), 25% (grade 2), and 50% (grade 3) for each positive cell per infiltrated immune cells were used. FOX-P3 nuclear expression was counted as positive mononuclear cells in 3 high power fields (x400) in each tumor core.*Chi-square test. †Independent t-test.
Table 5. Multivariate analysis using Cox regression hazard model (non-stepwise) with regard to overall survival
Variable OR (95% CI) p-value
Age 1.058 (1.022-1.095) 0.001
Stage III 22.436 (2.608-193.004) 0.005
Optimal debulking surgery (no macroscopic residual) 0.184 (0.037-0.921) 0.039
Well differentiated 0.177 (0.033-0.946) 0.043
Tumor size 1.067 (1.004-1.134) 0.038
Lymphovascular involvement 0.822 (0.319-2.113) 0.683
Cytology 1.547 (0.687-3.484) 0.292
Ascites 0.671 (0.248-1.810) 0.430
CA-125 1.000 (0.999-1.000) 0.256
CA 19-9 1.001 (1.000-1.001) 0.124
CD73 overexpression 1.025 (0.460-2.287) 0.951
CD8+ cells infiltration 1.335 (0.567-3.142) 0.509
FOX-P3+ cells infiltration 0.985 (0.900-1.077) 0.740
CD68+ cells infiltration 2.764 (0.668-11.442) 0.161
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hostimmunologicresponseagainsttumorcells,ourfindingisunexpected.ThereasonforalackofdifferenceinCD8+T-cellinfiltrationlevelsbetweenthetwopatientgroupsispresentlyunknown.Similarly,wefoundnodifferenceintheinfiltrationstatusofCD68+cells(monocytes/macrophages)betweenthetwopatientgroups.Inthisstudy,CD73overexpressionwasmorefrequentlyob-
servedinepithelialovariancancerpatientswithknowngoodprognostic factors, includingwell/moderatedifferentiationandlowerstage.Thesefindingsshowthatdifferentiationsta-tusandstagehavemoreinfluenceonthesurvivaloutcomethantheadverseeffectofCD73on immunologicenviron-ment.BecausetheeffectofCD73targetingtherapywillbelimitedtopatientswithepithelialovariancancerwithCD73overexpression,CD73targetingtherapywillnotbebenefi-cialtopatientswithpoorlydifferentiatedovariancarcinomawithoutCD73expression.Thelimitationsofthecurrentstudyincludethefactthatitwasaretrospectivestudy,ithadalim-itednumberofenrolledpatients,anditdidnotevaluatethefunctionsoflymphocytes.
CONFLICT OF INTEREST
Nopotentialconflictof interestsrelevanttothisarticlewasreported.
ACKNOWLEDGMENTS
ThisworkwassupportedbythegrantofResearchInstituteofMedicalScience,CatholicUniversityofDaegu(2010).
REFERENCES
1. AdamsSF,LevineDA,CadungogMG,HammondR,Facci-abeneA,OlveraN,etal. IntraepithelialTcellsandtumorproliferation: impactonthebenefitfromsurgicalcytore-ductioninadvancedserousovariancancer.Cancer2009;115:2891-902.
2. ClarkeB,TinkerAV,LeeCH,SubramanianS,vandeRijnM,TurbinD,etal. IntraepithelialTcellsandprognosisinovariancarcinoma:novelassociationswithstage,tumortype,andBRCA1loss.ModPathol2009;22:393-402.
3. SatoE,OlsonSH,AhnJ,BundyB,NishikawaH,QianF,etal. IntraepithelialCD8+tumor-infiltrating lymphocytesandahighCD8+/regulatoryTcell ratioareassociatedwith favorableprognosis inovariancancer.ProcNatl
AcadSciUSA2005;102:18538-43.4. StumpfM,HasenburgA,RienerMO,JuttingU,WangC,
ShenY,etal. IntraepithelialCD8-positiveTlymphocytespredictsurvivalforpatientswithserousstageIIIovariancarcinomas: relevanceofclonalselectionofT lympho-cytes.BrJCancer2009;101:1513-21.
5. CurielTJ,CoukosG,ZouL,AlvarezX,ChengP,MottramP,etal.SpecificrecruitmentofregulatoryTcells inovariancarcinomafostersimmuneprivilegeandpredictsreducedsurvival.NatMed2004;10:942-9.
6. WooEY,ChuCS,GoletzTJ,SchliengerK,YehH,CoukosG,etal.RegulatoryCD4(+)CD25(+)Tcellsintumorsfrompatientswithearly-stagenon-smallcell lungcancerandlate-stageovariancancer.CancerRes2001;61:4766-72.
7. KryczekI,WeiS,ZhuG,MyersL,MottramP,ChengP,etal.RelationshipbetweenB7-H4, regulatoryTcells,andpatientoutcome inhumanovariancarcinoma.CancerRes2007;67:8900-5.
8. AokiY,TakakuwaK,KodamaS,TanakaK,TakahashiM,TokunagaA,etal.Useofadoptive transferof tumor-infiltrating lymphocytesaloneor incombinationwithcisplatin-containingchemotherapy inpatientswithepithelialovariancancer.CancerRes1991;51:1934-9.
9. EdwardsRP,GoodingW,LemberskyBC,ColonelloK,HammondR,ParadiseC,etal.Comparisonof toxicityandsurvivalfollowingintraperitonealrecombinantinter-leukin-2 forpersistentovariancancerafterplatinum:twenty-four-hourversus7-dayinfusion.JClinOncol1997;15:3399-407.
10. GulleyJL,ArlenPM,TsangKY,YokokawaJ,PalenaC,PooleDJ,etal.PilotstudyofvaccinationwithrecombinantCEA-MUC-1-TRICOMpoxviral-basedvaccinesinpatientswithmetastaticcarcinoma.ClinCancerRes2008;14:3060-9.
11. HodiFS,ButlerM,ObleDA,SeidenMV,HaluskaFG,KruseA,etal. ImmunologicandclinicaleffectsofantibodyblockadeofcytotoxicTlymphocyte-associatedantigen4inpreviouslyvaccinatedcancerpatients.ProcNatlAcadSciUSA2008;105:3005-10.
12. ReinartzS,KohlerS,SchlebuschH,KristaK,GiffelsP,RenkeK,etal.Vaccinationofpatientswithadvancedovariancarcinomawiththeanti-idiotypeACA125:immunologicalresponseandsurvival(phaseIb/II).ClinCancerRes2004;10:1580-7.
13. VladAM,BudiuRA, LenznerDE,WangY, Thaller JA,ColonelloK,etal.AphaseIItrialof intraperitoneal inter-leukin-2inpatientswithplatinum-resistantorplatinum-refractoryovariancancer.Cancer Immunol Immunother2010;59:293-301.
14. GajewskiTF,MengY,HarlinH.Immunesuppressioninthe
Overexpression of CD73 and survival in ovarian cancer
J Gynecol Oncol Vol. 23, No. 4:274-281 www.ejgo.org 281
tumormicroenvironment.JImmunother2006;29:233-40.15. GabrilovichDI,ChenHL,GirgisKR,CunninghamHT,Meny
GM,NadafS,etal.Productionofvascularendothelialgrowthfactorbyhumantumors inhibitsthefunctionalmaturationofdendriticcells.NatMed1996;2:1096-103.
16. ColganSP,EltzschigHK,EckleT,ThompsonLF.Physio-logicalrolesforecto-5'-nucleotidase(CD73).PurinergicSignal2006;2:351-60.
17. RestaR,YamashitaY,ThompsonLF.Ecto-enzymeandsignalingfunctionsof lymphocyteCD73. ImmunolRev1998;161:95-109.
18. HoskinDW,Mader JS,FurlongSJ,ConradDM,Blay J.InhibitionofTcell andnatural killercell functionbyadenosineand itscontributionto immuneevasionbytumorcells(Review).IntJOncol2008;32:527-35.
19. SpychalaJ.Tumor-promoting functionsofadenosine.PharmacolTher2000;87:161-73.
20. WangL,ZhouX,ZhouT,MaD,ChenS,ZhiX,etal.Ecto-5'-nucleotidasepromotesinvasion,migrationandadhesionofhumanbreastcancercells. JCancerResClinOncol2008;134:365-72.
21. JinD,FanJ,WangL,ThompsonLF,LiuA,DanielBJ,etal.CD73ontumorcells impairsantitumorT-cellresponses:anovelmechanismoftumor-inducedimmunesuppre-ssion.CancerRes2010;70:2245-55.
22. RackleyRR,LewisTJ,PrestonEM,DelmoroCM,BradleyELJr,ResnickMI,etal.5'-nucleotidaseactivityinprostaticcarcinomaandbenignprostatichyperplasia.CancerRes1989;49:3702-7.
23. LeffersN,GoodenMJ,deJongRA,HoogeboomBN,tenHoorKA,HollemaH,etal.Prognostic significanceoftumor-infiltratingT-lymphocytes inprimaryandmeta-static lesionsofadvancedstageovariancancer.CancerImmunolImmunother2009;58:449-59.