DNA fragmentation factors 40 and 45 (DFF40/DFF45) and B-cell lymphoma 2 (Bcl-2) protein are underexpressed in uterine leiomyosarcomas and may predict survival

Figures & data

Table 1 Patient characteristics for uterine leiomyosarcoma (uLMS), uterine leiomyoma (uLM), and normal myometrium cases (uM)

	Uterine leiomyosarcomas (uLMS) n=53	Uterine leiomyomas (uLM) n=53	Uterine control myometrium (uM) n=53	p-value
Median age at therapy, years (IQR); min–max		51.00 (8.00); 44.00–70.00		n/a
Menopausal status, n (%)				n/a
Pre–		30 (56.61%)
Post		23 (43.39%)
FIGO stage, n (%)		n/a	n/a	n/a
I	27 (50.95%)
II	5 (9.43%)
III	12 (22.64%)
IV	9 (16.98%)
Grade, n (%)		n/a	n/a	n/a
1	6 (11.32%)
2	10 (18.87%)
3	37 (68.81%)
Median primary tumor size, cm (IQR); min–max	5.00 (7.00); 2.00–15.00	6.00 (2.00); 3.00–13.00	n/a	0.733
Mitotic index, no of mitoses per 1 high power field, n (%)		n/a	n/a	n/a
≤50	38 (71.70%)
>50	15 (28.30%)
Adjuvant treatment, n (%)		n/a	n/a	n/a
None	21 (39.63%)
Radiotherapy (RTH)	5 (9.43%)
Chemotherapy (CHT)	22 (41.51%)
Combination of RTH and CHT	5 (9.43%)
Median age of first menstrual period, years (IQR); min–max	12.00 (2.00); 9.00–15.00	12.00 (2.00); 10.00–15.00	13.00 (1.00); 10.00–15.00	p=0.009^*
Median age of menopause, years (IQR); min–max (n=23)	54.00 (2.00); 49.00–55.00	52.00 (4.00); 48.00–55.00	52.00 (1.00); 50.00–54.00	p=0.061
Median duration of menstrual cycle, days (IQR); min–max	28.00 (2.00); 24.00–32.00	28.00 (1.00) 25.00–34.00	28.00 (0.00) 26.00–31.00	p=0.408
Median duration of menstruation, days (IQR), min–max	4.00 (1.00); 3.00–7.00	4.00 (1.00); 3.00–7.00	4.00 (1.00); 3.00–6.00	p=0.281
Menstrual cycles, n (%)				p=0.164
Regular	36 (67.92%)	32 (60.38%)	42 (79.25%)
Irregular	17 (32.08%)	21 (39.62%)	11 (20.75%)
Menstrual cycles, n (%)				p=0.510
Painful	13 (24.53%)	15 (28.31%)	9 (16.98%)
Painless	40 (75.47%)	38 (71.69%)	44 (83.08%)
Type of menstrual bleeding, n (%)				p=0.038^*
Scant	4 (7.55%)	2 (3.77%)	4 (7.55%)
Normal	37 (69.81%)	36 (67.92%)	46 (86.79%)
Heavy	12 (22.64%)	15 (28.31%)	3 (5.66%)
Parity, n (%)				p=0.403
Nullipara	5 (9.43%)	3 (5.66%)	2 (3.77%)
Primipara	4 (7.55%)	9 (16.98%)	5 (9.43%)
Multipara	44 (83.02%)	41 (77.36%)	46 (86.80%)

Abbreviations: FIGO, International Federation of Gynecology and Obstetrics classification of uLMS; IQR, interquartile range.

Figure 1 Weak DFF40, DFF45, and Bcl-2 expression (400×) in uterine leiomyosarcomas (red arrows) compared to strong DFF40, Bcl-2, and moderate DFF45 expression in uterine leiomyomas (blue arrows).

Abbreviations: DFF40, DNA fragmentation factor 40; DFF45, DNA fragmentation factor 45; Bcl-2, B-cell lymphoma 2 protein.

Table 2 Immunoexpression of DFF40, DFF45, and Bcl-2 in uterine leiomyosarcomas (uLMS)

Immunoexpression*	Uterine leiomyosarcomas (uLMS)	Uterine myometrium from hysterectomy specimen for leiomyosarcomas (uLMS-M)	Uterine leiomyomas (uLM)	Uterine myometrium from hysterectomy specimen for leiomyomas (uLM-M)	Uterine control myometrium (uM)
DFF40
Negative	23 (43.40%)	4 (7.55%)	0 (0.00%)	3 (5.66%)	4 (7.55%)
Low	23 (43.40%)	25 (47.17%)	16 (30.19%)	28 (52.83%)	30 (56.60%)
Moderate	7 (13.20%)	18 (33.96%)	18 (33.96%)	18 (33.86%)	16 (30.19%)
High	0 (0.00%)	6 (11.32%)	19 (35.85%)	4 (7.55%)	3 (5.66%)
DFF45
Negative	31 (58.49%)	5 (9.43%)	1 (1.89%)	3 (5.66%)	3 (5.66%)
Low	22 (41.51%)	42 (79.25%)	41 (77.36%)	35 (66.04%)	40 (75.47%)
Moderate	0 (0.00%)	6 (11.32%)	9 (16.98%)	14 (26.41%)	10 (18.87%)
High	0 (0.00%)	0 (0.00%)	2 (3.77%)	1 (1.89%)	0 (0.00%)
Bcl-2
Negative	25 (47.17%)	11 (20.75%)	0 (0.00%)	13 (24.53%)	9 (16.98%)
Low	25 (47.17%)	22 (41.51%)	15 (28.30%)	15 (28.30%)	20 (37.74%)
Moderate	3 (5.66%)	18 (33.97%)	17 (32.08%)	19 (35.85%)	21 (39.62%)
High	0 (0.00%)	2 (3.77%)	21 (39.62%)	6 (11.32%)	3 (5.66%)

Notes: Data presented as n (%). Uterine myometrium from hysterectomy specimens for leiomyosarcomas (uLMS-M); leiomyomas (uLM-M); uterine myometrium from hysterectomy specimen for leiomyomas (uLM-M) and uterine control. Samples of uLMS-M and uLM-M were obtained 1 cm from the primary tumor margin.

* Immunoexpression was described as following: negative: 0; low: 1–2; moderate: 3–4; and high: 6–9.

Abbreviations: DFF40, DNA fragmentation factor 40; DFF45, DNA fragmentation factor 45; Bcl-2, B-cell lymphoma 2 protein.

Figure 2 Disease-free survival (DFS) in women with leiomyosarcomas depending on DFF40 (A), DFF45 (B), and Bcl-2 (C) expression and disease stage (D) according to FIGO classification, tumor grade (E), and mitotic index (F); *p<0.05 is statistically significant.

Abbreviations: DFF40, DNA fragmentation factor 40; DFF45, DNA fragmentation factor 45; Bcl-2, B-cell lymphoma 2 protein; FIGO, International Federation of Gynecology and Obstetrics.

Figure 3 Overall survival (OS) in women with leiomyosarcomas depending on DFF40 (A), DFF45 (B), and Bcl-2 (C) expression, and disease stage (D) according to FIGO classification, tumor grade (E), and mitotic index (F); *p<0.05 is statistically significant.

Abbreviations: DFF40, DNA fragmentation factor 40; DFF45, DNA fragmentation factor 45; Bcl-2, B-cell lymphoma 2 protein; FIGO, International Federation of Gynecology and Obstetrics.

Table 3 Cox’s proportional hazard regression analysis of the prognostic value of clinical and immunohistochemical variables in 53 women with uterine leiomyosarcomas

Prognostic factor	Disease free survival (DFS)		Overall survival (OS)
	HR (CI)	p-value	HR (CI)	p-value
Age	0.973 (0.921–1.029)	0.348	0.964 (0.910–1.020)	0.206
Stage 3+	9.024 (1.196–81.968)	<0.001#	14.153 (6.061–33.049)	<0.001#
Grade 3	2.226 (1.064–4.656)	0.031#	2.396 (1.148–4.999)	0.019#
MI >50	4.674 (2.184–10.014)	<0.001#	18.601 (5.703–60.670)	<0.001#
Negative DFF40 staining	3.254 (3.254–6.459)	0.007#	6.315 (2.712–14.704)	<0.001#
Negative DFF45 staining	1.359 (0.715–2.583)	0.349	1.587 (0.829–3.044)	0.164
Negative Bcl-2 staining	3.893 (1.940–7.812)	<0.001#	11.476 (4.454–29.564)	<0.001#

Note:

# p, significant p value.

Abbreviations: DFF40, DNA fragmentation factor 40; DFF45, DNA fragmentation factor 45; Bcl-2, B-cell lymphoma 2 protein; CI, confidence intervals; HR, hazard ratio; MI, mitotic index.