Open Journal of Obstetrics and Gynecology, 2011, 1, 55-63
doi:10.4236/ojog.2011.12012 Published Online June 2011 (http://www.SciRP.org/journal/ojog/ OJOG ).
Published Online June 2011 in SciRes. http://www.scirp.org/journal/OJOG
Preoperative evaluation of P53 and bcl-2 over expression in
clinical stage 1 endometrial carcinoma and their correlation
with surgico-pathological data and prognosis of patients
Emad A. Fyallah1, Reda A. Hemida1, Kamal I. An war 1, Nada A. Nadia2, Lotfy S. Sherif1, Mohammad T.
Sayed-Ahmed1
1Departments of Obstetrics and Gynecology, Mansoura University, Nile Delta, Egypt;
2Pathology, Faculty of Medicine, Mansoura University, Nile Delta, Egypt.
Received 29 April 2011; revised 26 May 2011; accepted 3 June 2011.
ABSTRACT
Introduction: P53 and bcl-2 over expression was re-
ported to affect the biology and prognosis of patients
endometrial carcinoma. Methods: This prospective
study included 38 patients with histologically con-
firmed endometrial carcinoma and staged clinically
as stage I. Immunohistochemical staining of the tu-
mor specimens obtained by dilatation and curettage
(D&C) with P53 an d bcl-2 mono clonal antibodies was
done. The surgical, pathological and follow up data of
all patients were studied. Results: There were 18
cases (47.4%) with positive P53 over expression. P53
over expression was found to be associated with in-
creasing grade of differentiation, advanced stage, and
non endometrioid type (significant), and increased
depth of myometrial invasion (non-significant). It
was associated with more recurrence rate (22% ver-
sus 15%) and shorter mean survival time (33.9 versus
29.2 months). Bcl-2 expression was present in24 cases
(63.2%) of the studied group. There was significant
decrease in bcl-2expression with poorly differentiated,
advanced stage, increased depth of myometrial inva-
sion, and non-endometrioid type. It was not signifi-
cantly correlated with recurrence rate and mean sur-
vival time. Conclusion: P53 over expression in the
D&C specimens was associated with adverse surgi-
copathological criteria, increased mortality rate, and
shorter survival time in patients with endometrial
carcinoma. A significant decrease in bcl-2 expression
was associated with adverse surgicopathological cri-
teria, but it was not significantly correlated with
prognosis of the patients.
Keywords: Endometrial Carcinoma; Prognosis; P53;
Bcl-2
1. INTRODUCTION
Endometrial carcinoma is the most common malignancy
of the female genital tract accounting for almost half of
all gynecologic cancers in western world. It represents
the fourth most common cancer after breast, lungs and
bowel cancers, and the seventh leading cause of death
from malignancy in women [1].
Mariani et al. [2], reported that in the pretreatment
curettage specimen, the presence of unfavorable level of
P53 and bcl-2 or non endometrioid histological feature
or combination of those, can significantly predict lymph
node status in patients with endometrial carcinoma.
P53 gene mutation was found to affect the biological
features of endometrial carcinoma, as it was found to be
associated with more aggressive histologic subtypes than
endometrioid carcinoma. Strong expression of p53 cor-
relates with advanced stage and high grade of the tumor
and was detected more frequently in endometrial cancer
with lympho-vascular space invasion [3].
Bcl-2 belongs to a family of apoptosis-regulatory
genes which may either promote cell survival or en-
courage cell death [4]. Expression of bcl-2 does not only
contribute to oncogenesis but also to chemotherapy re-
sistance in variety of tumors by inhibiting apoptosis [5].
Bcl-2 expression was found to be increased in grade 1
and 2 endometrioid adenocarcinoma, while in the serous
papillary endometrial cancer showed immuno-nega-
tivity to bcl-2 [6]. Bcl-2 may have an importance in the
progression of endometrial carcinoma [7].
To the best of our knowledge, there are few reported
studies to evaluate the correlation of pre-operative test-
ing of P53 and bcl-2 expression with the surgico-patho-

E. A. Fyallah et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 55-63 56
logical data and prognosis of patients in clinical stage 1
endometrial carcinoma. We tried to evaluate th is point in
this prospective clinical study.
2. PATIENTS AND METHODS
This prospective clinical study was conducted at the de-
partments of Gynecology and Pathology, Faculty of
Medicine, during the period from April 2005 to October
2008. The study included 38 patients with histologically
confirmed endometrial carcinoma and staged clinically
as stage I.
The routine pre-operative work up of these patients
was done. Dilatation and curettage was done, a part of
the biopsy was prepared in paraffin sections for his-
tologic examination and another part was used for im-
munohistochemical staining with P53 and bcl-2 mono-
clonal antibodies.
P53 immune staining: Immunohistochemical reaction
was carried out for detection of P53 protein over expres-
sion in endometrial tumor tissue using monoclonal
mouse anti-human P53 protein, clone; DO-7, supplied
by DAKO corporation, USA. Positive staining was de-
fined as homogenous pattern of nuclear staining (brow-
nish coloration) that involved more than 5% of the cells.
Bcl-2 immunohistochem ical staining: The primary an-
tibody used was the second generation monoclonal
mouse anti-bcl-2 protein (Biogenex, Cat no. Am 287).
Using the high power field, the immunoreactivity (posi-
tive cases) for bcl-2 was determined by the percentage of
tumor cells showing cytoplasmic (brown) staining that
involved more than 5% of the cells.
After that, patients were subjected to surgical treat-
ment, in which peritoneal cytology, extra-fascial hyster-
ectomy, bilateral salpingo-oophrectomy and pelvic
lymph node sampling were done.
The use of adjuvant radiotherapy was individualized
in the tumor board meetings .Candidates of postopera-
tive radiotherapy were suggested by use of prognostic
factors such as surgical staging, depth of myometrial
invasion, histologic type and tumor grading.
Follow up: Patients were followed up every three
months, by history, physical examinations, and ultra-
sound. MRI was done every 6 months. The surgico- pa-
thological data of all patients were studied. Overall sur-
vival, recurrence rate and duration were estimated.
2.1. Statistical Analysis
Statistical analysis was done by using SPSS (Statistical
package of social science) program version 10, 1999.
The data were parametric by using Kolmogrov-Smirnov
test. The qualitative data were presented in the form of
means, standard deviation and range. Student test was
used for comparison of the two groups. One way ANO-
VA test was used to compare more than two groups.
Man-Whitney test was used to compare the non-para-
metric data. Sensitivity, specificity and accuracy were
calculated. Kaplan-Meier survival analysis was done to
calculate the cumulative survival. Significance was con-
sidered when P value is less than 0.05.
2.2. Ethical Considerations
The research was approved by The Ethical Review
Committee of our Faculty of Medicine. Formal and
written consents were taken from all patients.
3. RESULTS
This study included 38 cases of histologically confirmed
endometrial carcinoma, clinical stage I, during the pe-
riod from April 2005 to October 2008. The mean follow
up duration from the treatment was 21.5 month, (range 6
- 40 months). After surgical staging (according to FIGO
staging 1988), there were 30 cases with stage I, 4 cases
with stage II and 4 cases with stage III.
Pretreatment study of P53 over expression by “Im-
muno-histochemical stain” was done for the studied
group; there were 18 cases (47.4%) with positive P53
over expression.
P53 over expression was found to be associated with
increasing grade of differentiation, advanced stage, and
non endometrioid type (significant), and increased depth
of myometrial invasion (non-significant) as can be con-
cluded fr om Table 1.
The relation between P53 over expression and recur-
rence of the disease in the study group: Although the
recurrence of the disease in patients with negative P53
over expression was 15% (3 of 20 cases), in the po sitive
group it was 22 % (4 of 18 cases) but this d ifference was
not statistically significant (P value 0.576).
The survival time was prolonged in P53 negative pa-
tients, as the mean survival time in p53 negative group
was 33.9 months while it was 29.21 months in p53 posi-
tive group (Table 2).
Figure 1: Kaplan-Meier estimates the influence of
P53 over expression in the recurrence of the studied
group. There was difference in the mean recurrence du-
ration in both groups.
The relation between P53 over expression and mortal-
ity of the studied group is shown in Table 3, the mortal-
ity between P53 po s itive patients was higher 16.6% (3 of
18 cases) in comparison to the mortality between nega-
tive patients, which was 5% (1 of 20 cases) the differ-
ence is significant (P value 0.026).
Figure 2: Kaplan-Meier estimates the influence of
P53 over expression in the mortality duration of the stu-
died group: There was difference in the mean mortality
duration in both groups. It was shorter in positive group.
Bcl-2 expression was studied also, bcl-2 expression
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Table 1 . Relationship between P53 over expression and degree of differentiation of the tumor, surgical staging, depth of myometrial
invasion, and histological type in the study group.
P53
Grade
Negative Positive
Total P value
G1 11 (78.6%) 3 (21.4%) 14 (100%)
G2 6 (37.5%) 10 (62.5%) 16 (100%)
G3 3 (37.5%) 5 (62.5%) 8 ( 10 0%)
Total 20 (52.6%) 18 (47.4%) 38 (100%)
0. 037
Stage
Stage I 19 (63.3%) 11 (36.7%) 30 (100%)
Stage II 1 (25.0%) 3 (75.0%) 4 (100%)
Stage III 0 (0%) 4 (100%) 4 (100%)
Total 20 (52.6%) 18 (47.4%) 38 (100%)
0. 013
Myometria l invasion
No invasion 4 (66.7%) 2 (33.3%) 6 (33.3%)
Invasion < 50% 9 (52.9%) 8 (47.1%) 17 (100%)
Invasion > 50% 7 (46.7%) 8 (46.7%) 15 (100%)
Total 20 (52.6%) 18 (47.4%) 38 (100%)
0.709
Histopathologic type
Endometrioid 18 (62.1%) 11 (37.9%) 29 (100%)
Adenosquamous 1 (25.0%) 3 (75.0%) 4 (100%)
Papillary serous 1 (20.0%) 4 (80.0%) 5 ( 1 00 % )
Total 20 (52.6%) 18 (47.4%) 38 (100%)
0. 047
Table 2. The relation between P53 over expression and the mean survival time in the study group.
P53 expression Mean S D* Minimum Maximum P value
Negative
Positive
Overall
33.9
29.21
32.78
2.77
2.79
2.25
28.46
23.73
28.36
39.34
34.68
37.2 0.461
P value: 0.461 (non significant); S D*: St andard deviation.
Table 3. The relation between P53 over expression and mortality of the study group.
P53 expression Number of cases Number of died cases P value
Negative
Positive
Total
20
18
38
1 (5%)
3 (16.6%)
4 (100%) 0.026
P value: 0.026 ( significant).

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Figure 1. Kaplan-Meier estimates of the influence of P53 over expression in the re-
currence of the studied group: As seen in this figure, the faint line represents the posi-
tive group while the dark line represents the negative group.
Figure 2. Kaplan-Meier estimates of the influence of P53 over expression in the mor-
tality duration of the studied group: As seen from this figure, the faint line represents
the positive group while the dark line represents the negative group. There was differ-
ence in the mean mortality duration in both groups. It was shorter in positive group.
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Table 4. The relation between bcl-2 expression and the degree of differentiation, surgical staging, depth of myometrial invasion and
histological type in the studied group.
Bcl-2
Grade Negative Positive Total P value
G1 2 (14.2%) 12 (14.2%) 14 (100%)
G2 6 (37.5%) 10 (62.5%) 16 (100%)
G3 6 (75.0%) 2 (25.0%) 8 (100%)
Total 14 (36.8%) 24 (63.2%) 38 (100%)
0.006
Stage
Stage I 9 (30.0%) 21 (70.0%) 30 (100%)
Stage II 2 (50%) 2 (50%) 4 (100%)
Stage III 3 (75%) 1 (25%) 4 (100%)
Total 14 (36.8%) 14 (36.8%) 38 (100%)
0.018
Myometria l invasion
No invasion 1 (16.7%) 5 (83.3%) 6 (100%)
Invasion <50% 5 (29.4%) 12 (70.6%) 17 (100%)
Invasion >50% 8 (53.3%) 7 (46.7%) 15 (100%)
Total 14 (46.7%) 7 (46.7%) 38 (100%)
0.083
Histopathological type
Endometroid 9 (31%) 20 (69%) 29 (100%)
Adenosquamous 1 (25%) 3 (75%) 4 (100%)
Papillary 4 (80%) 1 (20%) 5 (100%)
Total 14 (36.8%) 24 (63.2%) 38 (100%)
0.070
was present in 24 cases (63.2%) of the studied group.
Table 4, Shows the relation between bcl-2 expression
and the degree of differentiation, surgical staging, depth
of myometrial invasion and histologic type in the studied
group. There was significant decrease in bcl-2 expres-
sion with poorly differentiated, advanced stage, in-
creased depth of myometrial invasion, and non-endo-
metrioid type.
Ta ble 5 : Show the relation between bcl-2 expression
and the recurrence of the disease in studied group. There
was no significant relation between bcl-2 over expres-
sion and recurren ce of the disease in th e stud ied group (P
value 0.627).
Figure 3: Kaplan-Meier estimates the influence of
bcl-2 expression on the recurrence duration of the stud-
ied group: There was no significant difference in the
mean recurrence duration in both groups, the mean re-
currence duration for the negative group was 34 months
and for the positive group about 32 months.
Table 6: shows the relation between bcl-2 gene ex-
pression and the mortality in the studied group. As can
be seen from the table, there was no significant differ-
ence in the mortality rate between bcl-2 positive and
negative cases. (P value 0.615).
Figure 4: Kaplan-Meier estimates the influence of
bcl-2 expression on the mortality dur ation of the studied
group. There was no significant difference in the mean
recurrence duration in both groups, the mean mortality
duration for the negative group was 34 months and for
the positive group about 33.5 months.
4. DISCUSSION
Endometrial carcinoma is the most common malignancy
of the female genital tract accounting for almost half of
all gynecologic cancers in western world [1].
The aim of this randomized trial was to evaluate of
P53 and bcl-2 expression in clinical stage 1 endometrial
carcinoma and their correlation with surgico-pathologi-
cal data and prognosis of patients.
In this study P53 and bcl-2 expression were investi-
gated immunohisto-chemically in 38 patient with clinical
stage-1 endometrial carcinoma. After surgical staging,
stage I represented 79% of our studied group. This result
was comparable to that obtained by Creasman et al. [8].
In this work P53 over expression was detected in 18
cases (47.4%) of our studied group .This finding was

E. A. Fyallah et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 55-63 60
similar to that obtained by Pilka et al. [9].
In this study, P53 expression was increased with the
grade of malignancy (Table 1), which was statistically
significant (P 0.03). This was in accordance with the
observations reported by other authors [10,11].There
was also a positive correlation between P53 gene muta-
tion and stage of endometrial carcinoma (Ta ble 1 ). So,
P53 gene expression increased significantly in advanced
stages (P value 0.01). This report was in agree with that
of Veralucia et al. [12], but did not agree with other au-
thors [13,14].
In our study p53 gene over expression increased with
increased depth of myometrial invasion but it was not
statistically significant as noticed in Table 1, this finding
was in agree with that of other authors [14,15]. On the
other hand, Cerchi et al. [16] and Pilka et al. [9], found a
Table 5. The relation between bcl-2 expression and recurrence of the disease in the studied patients.
Bcl-2 Total number Recurrence No recurrence Percent
Negative
Positive
Overall
14
24
38
2
5
7
12
19
31
85.7%
79.2%
81.6%
P value: 0.627 (Non significant). Chi square: 0.076
Figure 3. Kaplan-Meier estimates of the influence of bcl-2 expression on the recurrence duration of
the studied group: As seen from this figure, the faint line represents the positive group while the dark
line represents the negative group. There was no significant difference in the mean recurrence dura-
tion in both groups, the mean recurrence duration for the negative group was 34 months and for the
positive group about 32 months.
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Table 6. The relation between bcl-2 expression and mortality.
Bcl-2 expre ssion Number Number of died cases P value
Negative
Positive
Over all
14
24
38
2 (14.2%)
2 (8.3%)
4(10.5%)
0.541
P value: 0.615 (Non significant).
Figure 4. Kaplan-Meier estimates the influence of bcl-2 over expression on the mortality duration of
the studied group: As seen from this figure, the faint line represents the positive group while the dark
line represents the negative group. There was no significant difference in the mean recurrence dura-
tion in both groups, the mean mortality duration for the negative group was 34 months and for the
positive group about 33.5 months.
significant positive correlation between P53 over ex-
pression and depth of myometrial invasion.
There was significant correlation between P53 gene
mutation and histologic type of the tumor (Table 1). In
endometrioid type, it was 37.9%, while in papillary se-
rous type it was 80% (P value 0.047). These findings
were in agree with that of other authors [1 3,15].
In our study there were 3 cases (3 of 20) of recurrence
in the P53 negative gr oup (15%) and 4 cases in P53 pos-
itive group (4 of 18) (22.2%) this difference was not
statistically significant (P value 0.57) .These results were
in agree with Marcia et al. [14].On the other hand, Pilka
et al. [9] and Appel [11], found that a significant correla-
tion between P53 gene mutation and recurrence of the
disease. The difference between these studies and our
study may be due to shorter follow up time and smaller
sample size in our study.
The mean survival time for P53 negative patients was
38.15 months and for the P53 positive patients was
31.68 months. So, P53 over expression in our study was
associated with increased mortality rate and shorter sur-
vival time in patients with endometrial carcinoma .These
results were supported by findings of other authors [7,
11].
Bcl-2 expression in endometrial carcinoma:
In this study bcl-2 expression was investigated in 38
cases of histologically documented endometrial carci-
noma. It was found that bcl-2 was expressed in the cyto-
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E. A. Fyallah et al. / Open Journal of Obstetrics and Gynecology 1 (2011) 55-63 62
plasm of tumor cells in 24 cases (63.2%). Nearly the
same results obtained by Erkanli et al. [15] and Appel et
al. [11].
There were negative correlation between bcl-2 ex-
pression and the grade of the tumor. These findings were
in agree with Halperin et al. [17]. There were also a sig-
nificant negative correlation between bcl-2 expression
and the stage of endometrial carcinoma (Table 2). These
findings were in agree with other authors [7,9].
Regarding the depth of myometrial invasion in our
study (Table 2), there were negative correlation between
bcl-2 over expression and the depth of myometrial inva-
sion, but the difference was not statistically significant
(P value 0.08). These findings were in agree with Marcia
et al. [14] and Appel et al. [11]. On the other hand, other
authors [7,9], reported a significant immuno-negativity
with increasing the depth of myometrial invasion.
Regarding the correlation between bcl-2 expression
and the histologic type of endometrial carcinoma in our
study (Table 2), there was high expression of bcl-2 in
endometrioid type than non-endometrioid typ es, this was
not statistically significant (P value 0.07). These findings
were in agree with that of Geisler et al. [18].
In the current study there was no significant correla-
tion between bcl-2 expression and recurrence or survival
of the patients with endometrial carcinoma (Ta b le s 6 &
7). These findings were supported by the findings ob-
tained by other authors [11,14,19].
5. CONCLUSIONS
P53 over expression in the D&C specimens was associ-
ated with adverse surgico-pathological criteria, increased
mortality rate, and shorter survival time in patients with
endometrial carcinoma.
A significant decrease in bcl-2 expression was associ-
ated with adverse surgico-pathological criteria, but it
was not significantly correlated with prognosis of the
patients.
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