1.Patients Characteristics
The mean age of the patients with EOC was 57 years old, ranged from 45-71 years. At study closure, 25 (38%) of the patients were alive. Thirty patients with benign ovarian cystadenoma served as controls(Table 1).
Table 1. Patients characteristics
Patients characteristics
|
|
Epithelial ovarian cancer(n=66)
|
n(%)
|
Age
|
|
<50y
|
8
|
≥50y
|
58
|
Initial CA125
|
|
<35U/ml
|
4
|
≥35U/ml
|
62
|
Pathological type
|
|
Serous adenocarcinoma
|
54
|
Mucinous adenocarcinoma
|
2
|
Endometrioid adenocarcinoma
|
2
|
Clear cell carcinoma
|
8
|
Stage
|
|
I,II
|
8
|
III,IV
|
58
|
Neoadjuvant chemotherapy before surgery
|
32
|
Benign ovarian cystadenoma (n = 30)
|
|
Iinitial CA125
|
|
<35U/ml
|
26
|
≥35U/ml
|
4
|
2.Immunohistochemistry for HCMV
HCMV-IE protein was detected in tumor specimens from 82% of EOC patients and 36% of those with benign cystadenomas(Table 2). HCMV-IE protein expression was extensive in 61%, focal in 21% and negative in 18% of EOC tissues(Figure 1A ). Respectively, expression was extensive in 23%, focal in 13% and negative in 64% of benign ovarian cystadenoma(Figure 1B ). HCMV-pp65 protein was detected in tumor specimens from 97% of EOC patients and 63% of those with benign cystadenomas(Table 2). The expression was extensive in 76%, focal in 21% and negative in 3% in epithelial ovarian cancer tissue(Figure 1C ). Respectively, expression was extensive in 33%, focal in 30% and negative in 37% in benign ovarian cystadenoma(Figure 1D ).
Table 2. Expression of HCMV-IE and pp65 in Epithelial Ovarian Cancer and Benign Ovarian Cystadenoma
Type of tumor
|
HCMV IE
|
HCMV PP65
|
|
Extensive, n(%)
|
Focal, n(%)
|
Negative, n(%)
|
Extensive, n(%)
|
Focal, n(%)
|
Negative, n(%)
|
Epithelial ovarian cancer
|
40/66(61)
|
14/66(21)
|
12/66(18)
|
50/66(76)
|
14/66(21)
|
2/66(3)
|
Benign ovarian cystadenoma
|
7/30(23)
|
4/30(13)
|
19/30(64)
|
10/30(33)
|
9/30(30)
|
11/30(37)
|
3.Higher Tumor HCMV Expression is Associated With More Advanced Disease
Next we analyzed the effects of HCMV on theEOC stage. HCMV-IE expression was extensive in 25% of Stage I-II tumors, 66% of Stage III-IV tumors; HCMV-pp65 expression was extensive in 38%, and 64%, respectively. Advanced tumor stage is correlated with extensive expression of HCMV-IE (P =0.0279) (Table 3).
Table 3. Expression of HCMV-IE and pp65 in EOC tissues of different stages
HCMV-IE
|
Extensive, n(%)
|
Focal/negative, n(%)
|
Chi-square
|
P
|
I,II
|
2(25)
|
6(75)
|
4.834
|
0.0279
|
III,IV
|
38(66)
|
20(34)
|
|
|
HCMV-pp65
|
Extensive, n(%)
|
Focal/negative, n(%)
|
Chi-square
|
P
|
I,II
|
3(38)
|
5(62)
|
2.036
|
0.1536
|
III,IV
|
37(64)
|
21(36)
|
|
|
4.Reactivation of Latent HCMV may be Induced by NACT
HCMV-IE expression was extensive in 75% of cancer tissue with NACT before surgery, 47% of cancer tissue without NACT; HCMV-pp65 expression was extensive in 69%, and 53%, respectively. This observation indicates that reactivation of latent HCMV within the tumor at interval debulking surery (IDS) may be induced with NACT as HCMV-IE viral proteins could be significantly extensive expressed in tumor tissue sections with NACT before surgery(P =0.0279) (Table 4).
Table 4. Expression of HCMV-IE and pp65 in EOC tissues
HCMV-IE
|
Extensive, n(%)
|
Focal/negative, n(%)
|
Chi-square
|
P
|
NACT before surgery
|
24(75)
|
8(25)
|
5.390
|
0.0202
|
No NACT before surgery
|
16(47)
|
18(53)
|
|
|
HCMV-pp65
|
Extensive, n(%)
|
Focal/negative, n(%)
|
Chi-square
|
P
|
NACT before surgery
|
22(69)
|
10(31)
|
1.726
|
0.1890
|
No NACT before surgery
|
18(53)
|
16(47)
|
|
|
5.Poor Survival Rate Among EOC Patients With Extensive HCMV-IE Expression
To further confirm the effects of HCMV on EOC clinical outcomes, we analyzed the median overall survival (OS) of EOC patients. At time of study closure, 77% of patients with focal or negative expression of HCMV-IE in their tumors were alive versus 32% of those with extensive expression. EOC patients who had focal or negative HCMV-IE expression in their tumors had significantly longer median OS than those with extensive HCMV-IE expression (41 vs.39 months, P = 0.03)(Figure 2A). Similarly, 26% of patients with focal or negative HCMV-pp65 protein expression were alive versus 61% with extensive expression; however, no significant difference in OS was observed(42 vs. 40 months, P = 0.37) (Figure 2B).