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Arab Journal of Urology (2013) 11, 106–112 Arab Journal of Urology (Ofﬁcial Journal of the Arab Association of Urology) www.sciencedirect.com UROSCIENCE ORIGINAL ARTICLE The expression of p63 in bladder cancer vs. chronic bilharzial bladder a, b c b Khaled Mursi , Ayman Agag , Olfat Hammam , Mahmoud Riad , Mahmoud Daw Urology Department, Faculty of Medicine, Cairo University, Egypt Urology Department, Theodor Bilharz Research Institute, Ministry of Scientiﬁc Research, Egypt Pathology Department, Theodor Bilharz Research Institute, Ministry of Scientiﬁc Research, Egypt Received 9 September 2012, Received in revised form 10 December 2012, Accepted 14 December 2012 Available online 4 February 2013 KEYWORDS Abstract Objective: To investigate the immunohistochemical expression of p63 in bladder cancer and the variation of expression in relation to histological type, grade P63; and stage of the tumour, and whether bilharziasis (endemic in Egypt) has an effect Diagnosis; on its expression, in an attempt to better understand the tumour behaviour and the Bilharziasis; possibility of using p63 as a prognostic marker. Cancer; Patients and methods: In a prospective study, biopsies were taken from the blad- Bladder ders of 70 patients, who were divided into three groups; group A comprised 10 with a normal urothelium, group B comprised 20 with chronic cystitis (bilharzial and non- ABBREVIATIONS bilharzial) and group C contained 40 with bladder cancer. The biopsies were exam- SCC, squamous cell ined for the expression of p63, using immunohistochemical techniques. carcinoma; Results: The mean (SD) ages of groups A, B and C were 45.2 (9.5), 50.5 (11.7) and CIS, carcinoma in situ; 60.5 (9.9) years, respectively. There was a statistically signiﬁcant decrease in the TCC, transitional cell expression and immunoreactivity in group C (P< 0.05), and a signiﬁcant decrease carcinoma with advancing tumour stage and grade (P < 0.01). In cases of squamous cell Corresponding author. Address: 5 El-Sheikh Al-Khodary St, Heliopolis, 11341 Cairo, Egypt. Tel.: +20 (12) 222 35 232; fax: +20 (2) 2419 6314. E-mail addresses: firstname.lastname@example.org, khaledmursi@ hotmail.com (K. Mursi). Peer review under responsibility of Arab Association of Urology. Production and hosting by Elsevier 2090-598X ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.aju.2012.12.008 The expression of p63 in bladder cancer vs. chronic bilharzial bladder 107 carcinoma there was a statistically signiﬁcant lower immunoreactivity than in tran- sitional cell carcinoma (P < 0.05). There was a tendency for a statistically signiﬁcant decrease in the immunoreactivity in bilharzial cystitis (P < 0.05), but in the malig- nant group, bilharziasis had no apparent effect on the pattern of expression. Conclusion: p63 might be a helpful biomarker and adjunct in predicting the bio- logical behaviour and progression of tumours. Further studies are recommended to elucidate more clearly its role as a prognostic indicator and its utility as a tumour marker. ª 2013 Arab Association of Urology. Production and hosting by Elsevier B.V. All rights reserved. Thus we evaluated the immunohistochemical expres- Introduction sion of p63 in bladder cancer and the variation of expression in relation to histological type, grade and In Egypt, bladder cancer is intimately related to the par- stage of the tumour, and whether bilharziasis has an ef- asitic blood ﬂuke Schistosoma, which has been endemic fect on its expression. in Egypt at least since 1900 BCE, and is endemic in 74 countries throughout the world [1,2]. Patients and methods Carcinoma of the bladder is the foremost oncological problem in Egypt, constituting 30.3% of all cancers, The study included 70 patients admitted to the Urology 40.6% of male cancers and 14.3% of female cancers, department of Theodor Bilharz Research Institute, as recorded at the National Cancer Institute . World- Egypt. The patients were prospectively enrolled in the wide it is an important health problem, with 386,300 study and divided into three groups; a control group newly diagnosed cases and 150,200 deaths in the year (A) of 10 patients who underwent cystoscopy for any 2008 . urological disease other than cystitis or bladder tumour; Various methods are currently used for detecting a cystitis group (B) of 20 patients with chronic cystitis bladder cancer, of which the most recent is the use of tu- (bilharzial and non-bilharzial); and a malignancy group mour markers as a complement to the tumour grade and (C) of 40 patients with bladder cancer. According to the stage, to reﬂect the potential behaviour of the tumour results of the biopsy, group B patients were retrospec- and the possibility of its progression or recurrence . tively divided into bilharzial and non-bilharzial, and The gene p63 is a homologue of the p53 tumour-sup- group C into those with TCC or squamous cell carci- pressor gene located at 3q27–3q29 . It is expressed noma (SCC). selectively in the basal cells of stratiﬁed epithelium, All patients had a detailed history taken, a full clini- including the urothelium . It is suggested to play a cal examination, routine laboratory investigations, urine critical role in the normal development and maintenance cytology, and imaging in the form of abdominal and pel- of the human urothelium . vic ultrasonography, intra-venous urography (IVU) and Several studies have assessed the role of p63 in malig- computed tomography scan (CT) of the abdomen and nant transformation, as well as tumour progression. pelvis in selected cases. There were no patients with Some of these studies showed a downregulation in mus- associated upper tract TCC in the study. cle-invasive tumours, and others proposed an impaired After signing an informed consent, all patients under- expression with biological aggressiveness, and of being went cysto-urethroscopy and biopsy. For groups A and a common feature of high-grade invasive carcinomas, B the biopsies were taken from the urothelium using a suggesting a role in tumour progression and biochemical cold-cup biopsy forceps, while for group C we used a differentiation [8,9]. Considering the urothelium as a resectoscope to take biopsies from the tumour and from unit acting in the same manner throughout the urinary the surrounding apparently normal urothelium. In pa- tract, similar studies on the upper urinary tract transi- tients with invasive bladder cancer who had a radical tional cell carcinoma (TCC) showed a signiﬁcant de- cystectomy, the biopsy was taken from the cystectomy crease in immunoreactivity with advancing tumour specimen after surgery. stage, and an association with a poor prognosis . The biopsy specimens were immediately ﬁxed with By contrast, other studies showed that the designation formalin 10%, and assessed histopathologically after of p63 as an oncogene or a tumour-suppressor gene staining with haematoxylin and eosin, and for the might be difﬁcult, because its isoforms might have immunohistochemical study of p63 expression. Schisto- opposing functions . 108 Mursi et al. somal infestation was diagnosed by detecting Schisto- Table 1 The stages and grades of different malignant lesions soma eggs in the tissues. in group C. Although there was a discrepancy in the number of Stage or grade n or n (%) patients in the three groups we assessed the results using TCC SCC Total statistical analysis, computing the mean (SD) of the Total 25 15 40 variables and using Student’s t-test to compare two means, and for more than two means we used a one- Stage way anova with the least-signiﬁcant difference test. Ta 5 (20) 0 5 (13) The correlation between the p63 tissue expression and T1 7 (28) 0 7 (18) T2 10 (40) 7 17 (43) histopathological stage, grade and clinical data was as- T3 3 (12) 8 11 (28) sessed by Spearman’s correlation coefﬁcient. Grade I 8 (32) 0 8 (20) Results II 14 (56) 9 23 (58) III 3 (12) 6 9 (23) The study included 60 patients with different bladder le- sions (neoplastic and non-neoplastic) and 10 with a nor- mal urothelium, classiﬁed into three groups. The mean (SD) ages of groups A, B and C were 45.2 (9.5), 50.5 Table 2 The effect of a bilharzial association on the tumour stage and grade in group C. (11.7) and 60.5 (9.9) years, respectively. Five of the 10 patients in group A, 12 of 20 (60%) in group B and Category Non-bilharzial Bilharzial Total 37/40 (93%) in group C were men. No. of patients 10 30 40 For group A, the original indication for cystoscopy Stage was ureteroscopy for a stone in the lower ureter (six), Superﬁcial 2 10 (33) 12 (30) retrograde ureteropyelography (three) and transurethral Invasive 8 20 (67) 28 (70) resection of the prostate (TURP) (one). Total 10 (25) 30 (75) 40 (100) In group C (40 patients), 25 (63%) and 15 (38%) had Grade TCC and SCC, respectively. Using the classiﬁcation of I 1 7 (23) 8 (20) urothelial tumours outlined by Eble et al. , ﬁve I and II 9 23 (77) 32 (80) (13%), seven (18%), 17 (43%) and 11 (28%) were staged Total 10 (25) 30 (75) 40 (100) Ta, T1, T2 and T3, respectively. Eight (20%), 23 (58%) and nine (23%) had Grades I, II and III, respectively (Table 1). There were no cases of carcinoma in situ Although the positive expression was similar in both (CIS) in this group. TCC and SCC tumours (84% vs. 80%) the immunore- Among all groups (70 patients), 40 (57.1%) were activity showed a statistically signiﬁcant decrease, from associated with bilharziasis, i.e. 10 of 20 (50%) in group strong and moderate in 16/25 (64%) of patients with B and 30 of 40 (75%) in group C, of which, 20 of 30 TCC, to ﬁve of 15 (33%) of those with SCC, respectively (67%) were invasive tumours and 23 (77) were both (P = 0.03). Also, there was a statistically signiﬁcant in- Grade II and Grade III tumours (Table 2). crease in immunoreactivity, from negative and moderate in nine of 25 patients with TCC, to 10/15 with SCC, Immunoexpression of p63 respectively (P = 0.03; Table 3). With increasing tumour stage there was a signiﬁcant The non-neoplastic urothelium showed nuclear immu- decrease in both the expression and immunoreactivity. noreactivity with a slightly decreasing gradient from The positive expression decreased from all ﬁve to 22/ the basal to the luminal cells (with the superﬁcial um- 28 (79%) of Ta and T2 + T3 tumours, respectively brella cells remaining unstained) and with no staining (P = 0.01). Strong immunoreactivity decreased from of the stromal cells. In malignant lesions all layers four of ﬁve to 9/32 (32%) of Ta and T2 + T3 tumours, showed the expression of the p63. respectively (P = 0.04), and negative immunoreactivity The expression was positive in all 10, all 20 and in 33 increased from none of ﬁve to 6/28 (21%) of Ta and of the 40 patients in groups A, B and C, respectively. T2 + T3 tumours, respectively (P = 0.01; Table 3). Strong immunoreactivity decreased signiﬁcantly from In patients with TCC there was a signiﬁcant decrease all 10 in the group A, to 17/20 (85%) in group B in both expression and immunoreactivity from non- (P = 0.04), to 16/40 (40%) in group C, with a statisti- muscle-invasive to muscle-invasive tumours. The posi- cally signiﬁcant difference (P < 0.01; Table 3). Also, tive expression decreased from 11/12 to 10/13, with negative expression increased signiﬁcantly from none decreasing strong and moderate immunoreactivity from in both groups A and B to 18% of group C 10/12 to six of 13, and increasing negative and mild (P < 0.01; Table 3). immunoreactivity from two of 12 to seven of 13 in The expression of p63 in bladder cancer vs. chronic bilharzial bladder 109 Table 3 The expression of p63 in the three groups. Category (n) Nuclear p63 immunoreactivity, n (%) Total +ve Negative Mild Negative Moderate Strong Moderate (0–10%) (11–30%) +Mild (31–60%) (61–100%) +Strong Group A (10) 0 0 0 0 10 10 10 Group B (20) Non-bilharzial (10) 0 0 0 0 10 10 10 a a Bilharzial (10) 0 0 0 3 7 10 10 b b Total (20) 0 0 0 3 (15) 17 (85) 20 (100) 20 (100) Group C (40) a a l j l a Non-bilharzial (10) 3 3 6 22 4 7 l k m m l Bilharzial (30) 4 9 13 3 14 17 (57) 26 (87) e cde cdi cde TCC bilharzial (15) 1 2 3 210 12 14 f f SCC (15) 3 7 10 14 5 12 fh fh ab g fh ab fh Total 7 12 19 (48) 5 16 (40) 21 (53) 33 (83) Group C (40) TCC (25) 4 5 9 4 12 16 (64) 21 (84) Superﬁcial (12) 1 1 2 3 7 10 11 g g Invasive (13) 3 4 7 15 6 10 SCC (15) 3 7 10 1 4 5 12 Total (40) 7 12 19 (48) 5 16 (40) 21 (53) 33 (83) Stage (40) Ta (5) 0 0 0 1 4 5 5 T1 (7) 1 1 2 2 3 5 6 a c h b h a T2 T3 (28) 6 11 17 (61) 29 11 22 (79) Grade (40) I (8) 0 1 1 1 6 7 8 d i e i d II (23) 3 912 38 11 20 (87) f i f i f III (9) 4 26 12 3 5 Normal adjacent mucosa j j TCC (25) 1 24 (96) Urothelial hyperplasia (7/25) 0 0 1 6 Low-grade dysplasia (10/25) 0 0 3 7 High-grade dysplasia (8/25) 0 1 3 4 b c a a b Total 0 1 7 17 (68) 25 (100) k k SCC 0 15 (100) Squamous metaplasia (10/15) 0 0 2 8 Low-grade dysplasia (2/15) 0 0 1 1 High-grade dysplasia (3/15) 0 0 1 2 e f d df e Total 0 0 4 11 15 (100) a b c For initial group A–C comparisons: P = 0.03 vs. chronic non-bilharzial cystitis; P = 0.04 vs. control; P = 0.01 vs. non-bilharzial malignant d e f g h i lesion; P = 0.01 vs. SCC; P = 0.02 vs. SCC; P < 0.01 vs. control; P = 0.01 vs. control; P < 0.01 vs. cystitis; P = 0.04 vs. total tumour; j k l P < 0.01 vs. chronic non-bilharzial cystitis; P < 0.01 vs. chronic bilharzial cystitis; P = 0.02 vs. chronic bilharzial cystitis. a b c d e f For group C section: P = 0.01 vs. Ta; P = 0.04 vs. Ta; P < 0.01 vs. Ta; P = 0.04 vs. Grade I; P = 0.03 vs. Grade I; P = 0.02 vs. Grade I. a b c d e For normal adjacent mucosa: P < 0.01 vs. control; P = 0.02 vs. total TCC; P = 0.04 vs. total TCC; P = 0.02 vs. control; P = 0.04 vs. SCC; P < 0.01 vs. SCC. a b c For combined groups Negative +Mild and Moderate +Strong: P < 0.01 vs. control; P < 0.01 vs. chronic cystitis; P = 0.03 vs. non- d e f g h bilharzial tumour; P = 0.02 vs. total tumour; P < 0.01 vs. SCC; P = 0.03 vs. TCC; P = 0.03 vs. superﬁcial TCC; P < 0.01 vs. Ta; i j k l m P = 0.01 vs. Grade I; P < 0.01 vs. TCC; P < 0.01 vs. SCC; P < 0.01 vs. chronic non-bilharzial cystitis; P < 0.01 vs. chronic bilharzial cystitis. non-muscle-invasive and muscle-invasive tumours, Effect of bilharziasis on p63 immunoreactivity respectively (P= 0.03; Table 3). Similarly, there was a statistically signiﬁcant decrease Although all 20 patients of group B (bilharzial and non- in the expression and immunoreactivity with increasing bilharzial) showed positive expression, there was a dif- tumour grade. The positive expression decreased from ference in the immunoreactivity. All 10 non-bilharzial all eight to ﬁve of nine (P = 0.04), and strong immuno- patients showed strong expression, which decreased to reactivity decreased from six of eight to two of nine in seven of 10 and three of 10 for strong and mild expres- Grade I and III tumours, respectively (P= 0.03). Also, sion in the bilharzial patients, respectively (P = 0.04; negative immunoreactivity increased from none of eight Table 3). to four of nine for Grade I and III tumours, respectively In group C, there was an increase in the expression (P= 0.04; Table 3). with bilharzial association, but with varied immunoreac- 110 Mursi et al. tivity. The positive expression increased signiﬁcantly healthy bladder, to evaluate its diagnostic value in blad- from seven of 10 to 87% of non-bilharzial and bilharzial der cancer and whether bilharziasis (which is endemic in malignant tumours, respectively. Although strong Egypt) has an effect on its expression. immunoreactivity increased signiﬁcantly from two of All of the non-neoplastic urothelium showed strong 10 to 14/30 (47%) of non-bilharzial and bilharzial malig- nuclear immunoreactivity with a decreasing gradient nant tumours, respectively (P = 0.01), there was a sig- from the basal to the luminal cells, with no staining of niﬁcant decrease in the negative expression from three the stromal cells. Compe´ rat et al.  stated that of 10 to 4/30 (13%) in non-bilharzial and bilharzial staining was always nuclear and there was no staining malignant tumours, respectively (P = 0.03; Table 3). in the smooth muscle cells, adipocytes or the neural As all of the non-bilharzial malignant tumours were cells. TCC, on comparing the non-bilharzial- and the bilhar- All 10 patients in the control group had a strong po- zial-associated TCC there was a signiﬁcant increase in sitive expression of p63. Similar results were reported by strong expression, from two of 10 to 10/15, respectively others who studied the expression in the non-neoplastic (P= 0.01; Table 3). There was a signiﬁcant increase in upper urinary tract [10,14–16]. Also, the expression was strong and moderate expression, from four of 10 to positive in all 20 patients in group B (cystitis) but the 12/15, in the non-bilharzial and the bilharzial-associated immunoreactivity decreased with bilharzial association, TCC, respectively (P = 0.03), and a signiﬁcant decrease from strong in all non-bilharzial patients, to strong in negative and mild expression, from six of 10 to three and moderate in seven of 10 and three of 10 of the bil- of 15 in the non-bilharzial and the bilharzial-associated harzial patients, respectively. We are not sure whether TCC, respectively (P = 0.03; Table 3). this decrease in the immunoreactivity from the normal All of the SCC tumours were associated with bilhar- pattern is attributed to the local inﬂammatory effect of ziasis, so we compared the bilharzial-associated TCC to bilharziasis, but we recommend more studies to address SCC, ﬁnding a signiﬁcant decrease in the strong immu- the effect of bilharziasis, as the published studies are noreactivity in the SCC tumours, from 10/15 to four of deﬁcient in this point. 15, respectively (P= 0.01; Table 3). There was a signif- In group C (malignant) there was 83% positive icant decrease in strong and moderate expression, from expression (33/40) with varied immunoreactivity, being 12/15 to ﬁve of 15, in the bilharzial-associated TCC and strong and negative in 40% (16/40) and 18% (7/40), SCC, respectively (P < 0.01), and a signiﬁcant increase respectively. Ud Din et al.  reported an 88% positive in negative and mild expression, from three of 15 to expression (44/50), and Compe´ rat et al.  reported 10/15, in the bilharzial-associated TCC and SCC, 81.2% positive expression (39/48), with 41.6% (20/48) respectively (P < 0.01; Table 3). having strong immunoreactivity. Although we had no patients with an associated upper tract TCC, reviewing Expression of p63 in the apparently healthy mucosa the results of Langner et al. , who assessed the upper adjacent to the malignant tumours urinary tract TCC, they had 96.2% (51/53) positive expression, with strong and negative immunoreactivity There was a change in the expression of p63 in the adja- in 45.3% (24/53) and 3.8% (2/53), respectively. This cent mucosa. In TCC tumours there was urothelial shows that the whole urothelium behaves in the same hyperplasia, low-grade and high-grade dysplasia in 7/ way concerning the expression of p63. In group C there was a statistically signiﬁcant de- 25, 10/25 and 8/25 patients, respectively. There was a crease in immunoreactivity with increasing clinical stage signiﬁcant decrease in the strong and moderate expres- of the TCC tumours. The immunoreactivity decreased sion, from 10/10 and none of 10 in the control cases, from being strong and moderate in all patients with to 17/25 (68%) and 7/25 (28%) in the adjacent mucosa Ta disease to 11/28 of those with T2 T3 (P < 0.01). of TCC cases, respectively (P< 0.01; Table 3). In SCC tumours there was squamous metaplasia, low-grade and Also, the immunoreactivity increased from being nega- high-grade dysplasia in 10/15, 2/15 and 3/15 patients, tive and moderate in none of the patients with Ta tu- respectively. There was a signiﬁcant decrease in the mours, to 17/28 (61%) of those with T2 T3 disease strong and moderate expression, from 10/10 and none (P < 0.01). Studying 160 patients with TCC, Urist of 10 in the control cases, to 11/15 and four of 15 in et al.  showed that invasive tumours expressed low the adjacent mucosa of SCC cases, respectively levels of p63, with only an average of 16% of cells posi- (P = 0.02; Table 3). tive (mild immunoreactivity), and the difference between non-muscle-invasive and invasive TCC was signiﬁcant. Discussion There was a decrease in p63 expression with increas- ing tumour stage, from Ta to T1 and from T1 to T2 + T3, and a statistically signiﬁcant decrease from The immunohistochemical expression of p63 was as- Ta to T2 + T3 (P = 0.01). The expression decreased sessed in the urothelium of 60 patients with different from all ﬁve, to six of seven, and to 22/28 (79%) in bladder lesions, and in 10 with an apparently normal The expression of p63 in bladder cancer vs. chronic bilharzial bladder 111 Ta, T1, and T2 + T3, respectively. In Ta tumours the As to the histopathological type of malignancy (TCC immunoreactivity was strong and moderate in four of vs. SCC), the expression was similar (84% vs. 80%) but ﬁve and one of ﬁve, respectively. In the T1 group of se- the difference was in the immunoreactivity, which de- ven cases, the immunoreactivity decreased to be strong, creased from being strong and moderate in 16/25 moderate, mild, and negative in three, two, one and one, (64%) patients with TCC, to ﬁve of 15 (33%) with respectively, with a greater decrease in 28 invasive tu- SCC (P = 0.03). There was also a statistically signiﬁcant mours (T2 + T3) of nine (32%), two (7%), 11 (39%) increase in immunoreactivity, from being negative and and six (21%), respectively. moderate in nine of 25 (36%) with TCC, to 10/15 with Compe´ rat et al.  reported a similar decrease in the SCC (P = 0.03). To our knowledge, there are no reports expression from all 12 tumours, four of ﬁve, to 22/31 on the expression of p63 in either SCC or bilharzial- (70%) of Ta, T1, and T2 T3 cases, respectively. In associated bladder cancer. the present Ta group, the immunoreactivity was strong Comparing the expression in the bilharzial- and non- and mild in 10 of 12 and two of 12, respectively. The bilharzial-associated TCC, there was a statistically sig- immunoreactivity decreased in the T1 group of ﬁve to niﬁcant decrease in strong and moderate immunoreac- be strong, mild, and negative in three, one and one, tivity, and a statistically increase in negative and mild respectively, with a greater decrease in the immunoreac- immunoreactivity, respectively (P = 0.03). tivity in the invasive group of 31 (T2 + T3) tumours of All of the SCC cases were associated with bilharzia- seven (22%), 15 (48%) and nine (29%), respectively. sis; thus, when comparing the expression in the bilhar- In 2006, Compe´ rat et al.  studied retrospectively zial-associated TCC to SCC, there was a statistically 158 patients who had either endoscopic resection of signiﬁcant decrease in the immunoreactivity from strong non-invasive tumours or cystectomy for invasive tu- and moderate in 12/15 of the TCC cases, to mild and mours. They found a statistically signiﬁcant difference negative in 10/15 of the SCC cases, respectively between the stages of pTa, pT1, and PpT2 cases. In (P< 0.01). 93% (52/56) of pTa tumours the expression was homog- That the pattern of expression was higher in the bil- enous and strong. The expression was more heteroge- harzial-associated TCC than in the non-bilharzial-asso- neous, with negative, mild and strong staining in 6/45 ciated TCC contradicts the results in group B, where (13%), 15/45 (34%) and 24/45 (53%), and in 13/57 there was a decrease in the immunoreactivity in the bil- (23%), 26/57 (46%) and 18/57 (31%) of pT1 and harzial cases, which might be attributed to the grade and PpT2 cases, respectively. stage of the tumour rather than bilharzial association. For tumour grade there was a statistically signiﬁcant Also, the pattern of decreased immunoreactivity in the decrease in both the expression and immunoreactivity SCC (all associated with bilharziasis) in relation to the with increasing grade. All eight Grade I tumours showed bilharzial-associated TCC is similar to that of the histo- a positive expression, which decreased to 20/23 (87%) pathological type, i.e. TCC vs. SCC and hence, it might (P = 0.04) and ﬁve of nine (P = 0.02) of Grade II and be attributed to the histopathological type of the tumour III tumours, respectively. Also, the immunoreactivity rather than the bilharzial association. Hence, according decreased from strong and negative in six and none of to the present results, but because of the discrepancy in the eight Grade I tumours, respectively, to mild and neg- the number of patients in the different groups, we rec- ative in two and four of the nine Grade III tumours, ommend more studies to address the effect of bilharzia- respectively (P= 0.02). Urist et al.  reported a statis- sis on the expression of p63 in the healthy and diseased tically signiﬁcant inverse association between the immu- bladders. noreactivity and the increase in the grade within non- As to the expression in the apparently normal mucosa muscle-invasive tumours. Low-grade papillary tumours adjacent to the TCC tumours, the immunoreactivity was expressed p63 strongly in 93% of the tumour cells, with strong and moderate in six of seven and one of seven, a signiﬁcant reduction in the positivity to 68% (moder- and three of 10, four of eight and three of eight for uro- ate immunoreactivity) in intermediate- to high-grade thelial hyperplasia, low-grade and high-grade dysplasia non-muscle-invasive tumours. specimens, respectively. In the SCC patients, the immu- Zigeuner et al.  investigated 53 upper urinary tract noreactivity was strong and moderate in eight and two TCC specimens and noted a normal strong pattern of of 10, one and one of two, and two and one of three with expression in one of 22 (4.5%) pT3 cases, compared to squamous metaplasia, low-grade and high-grade dyspla- 13/31 (42%) of pT1–T2 cases. There was a normal pat- sia, respectively (Table 3). tern of expression also in 10/28 (36%) and 4/25 (16%) Comparing the adjacent mucosa in the patients with Grade II and III tumours, respectively, with a trend to TCC or SCC to that in the control patients, there was decreased immunoreactivity in the poorly differentiated a signiﬁcant decrease in both strong and moderate tumours. Their results are similar to ours, indicating a expression in the adjacent mucosa of patients with similarity in the behaviour of the whole urothelium in TCC (P< 0.01), and in those with SCC, respectively this respect. (P = 0.02; Table 3). 112 Mursi et al.  Park BJ, Lee SJ, Kim JI, Lee SJ, Lee CH, Chang SG, et al. To our knowledge, this is the ﬁrst study to investigate Frequent alteration of p63 expression in human primary bladder the pattern of p63 expression in the apparently normal carcinomas. Cancer Res 2000;60:3370–4. mucosa adjacent to the malignant tumour, and these  Choi W, Shah JB, Tran M, Svatek R, Marquis L, Lee I-L, et al. changes in the expression might imply a ﬁeld change P63 expression deﬁnes a lethal subset of muscle-invasive bladder that can be used in the follow-up of resected non-mus- cancers. PLoS ONE 2012;7:e30206.  Koga F, Kawakami S, Fujii Y, Saito K, Ohtsuka Y, Iwai A, et al. cle-invasive tumours. Impaired p63 expression associates with poor prognosis and In conclusion, although the histopathology of the tu- uroplakin III expression in invasive urothelial carcinoma of the mour cells remains the standard method in the diagnosis bladder. Clin Cancer Res 2003;9:5501–7. of bladder cancer, the expression of p63 might have a  Zigeuner R, Tsybrovskyy O, Ratschek M, Rehak P, Lipsky K, role in assessing the pathogenesis and progression of Langner C. Prognostic impact of p63 and p53 expression in upper urinary tract transitional cell carcinoma. Urology bladder cancer. We recommend further research on 2004;63:1079–83. p63 to conﬁrm its usefulness as a predictor and as a  Urist JM, Di Como CJ, Lu M-L, Charytonowicz E, Verbel D, prognostic marker. The diagnostic value of using p63 Crum CP, et al. Loss of p63 expression is associated with tumor as part of the routine follow-up of patients after com- progression in bladder cancer. Am J Pathol 2002;161:1199–206. plete resection of high-risk non-muscle-invasive TCC  Eble JN, Sauter G, Epstein JI, Sesterhenn IA. World Health Organization classiﬁcation of tumors. Pathology and genetics of needs to be accurately addressed. Also, additional stud- tumours of the urinary system and male genital organs. Lyon: ies are needed on the possibility of malignant transfor- IARC Press; 2004, http://www.iarc.fr/en/publications/pdfs- mation in patients with a bilharzial bladder. online/pat-gen/bb7/BB7.pdf.  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Arab Journal of Urology – Taylor & Francis
Published: Mar 1, 2013
Keywords: P63; Diagnosis; Bilharziasis; Cancer; Bladder; SCC, squamous cell carcinoma; TCC, transitional cell carcinoma; CIS, carcinoma in situ
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