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Clinical Cancer Research 14, 2263, April 15, 2008. Published Online First March 27, 2008;
doi: 10.1158/1078-0432.CCR-07-4837
© 2008 American Association for Cancer Research
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Human Cancer Biology

Endometrial Glandular Dysplasia with Frequent p53 Gene Mutation: A Genetic Evidence Supporting Its Precancer Nature for Endometrial Serous Carcinoma

Lin Jia1,3, Yongjuan Liu4, Xiaofang Yi2,5, Alexander Miron6, Christopher P. Crum7, Beihua Kong3 and Wenxin Zheng1,4

Authors' Affiliations: 1 Departments of Pathology and Obstetrics and Gynecology and 2 Department of Obstetrics and Gynecology and Arizona Cancer Center, University of Arizona College of Medicine, Tucson, Arizona; 3 Department of Obstetrics and Gynecology, Qilu Hospital, Shandong University, Shandong, China; 4 Department of Pathology, Shanghai Medical College and 5 Hospital of Obstetrics and Gynecology, Fudan University, Shanghai, China; and 6 Department of Cancer Biology, Dana-Farber Cancer Institute and 7 Division of Women's and Perinatal Pathology, Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts

Requests for reprints: Wenxin Zheng, Department of Pathology, University of Arizona, 1501 North Campbell Avenue, #5224A, Tucson, AZ 85724. Phone: 520-626-6758; Fax: 520-626-1027; E-mail: zhengw{at}email.arizona.edu or Beihua Kong, Qilu Hospital, Shandong University, 107 Wenhuaxi Road, Ji'nan, Shandong, China 250012, Email: kongbeihua@sdu.edu.cn.


   Abstract
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 Abstract
Materials and Methods
 Results
 Discussion
 References
 
Purpose: Endometrial glandular dysplasia (EmGD) has been recently proposed to be a putative precursor to endometrial serous carcinoma (ESC). The purpose of this study is to determine if EmGD is genetically linked to ESC and if it can be used for early detection.

Experimental Design: The tumor suppressor p53 gene was sequenced from serial samples of benign and neoplastic endometria with serous differentiation. The study group contained 15 neoplastic uteri and the control group had 12 age-matched benign uteri. A total of 139 informative samples were obtained, including 55 resting endometrium, 37 EmGD, 25 serous endometrial intraepithelial carcinoma (EIC), and 22 ESC. At least one representative section from each uterus was used for p53 immunohistochemical staining to correlate p53 overexpression with gene mutation status.

Results: The mutations of p53 were detected in 0%, 43%, 72%, and 96% in resting endometrium, EmGD, serous EIC, and ESC, respectively. More than 50% of the neoplastic uteri showed at least one identical p53 gene mutant among lesions of EmGD, serous EIC, and/or ESC. The majority of lesions showed overexpression of p53 protein, which was significantly correlated with p53 gene mutation (P < 0.01).

Conclusions: This genetic evidence strongly supports that EmGD represents the precancer of ESC or serous EIC. Mutation of p53 gene is probably one of the most important factors to initiate the endometrial serous carcinogenesis. Correct identification of EmGD will provide us an opportunity of early diagnosis and a potentially effective therapeutic modality to control ESC.

Endometrial cancer is diagnosed in ~39,080 women yearly in the United States and causes ~7,400 deaths, with a worldwide incidence and mortality of 142,000 and 42,000, respectively (1, 2). A dualistic model of endometrial carcinogenesis has been proposed since the 1980s based on light microscopic appearance, clinical behavior, and epidemiology (3, 4). Type I, those with endometrioid histology, comprise 70% to 80%, whereas type II, those of serous and clear cell carcinomas (CCC), comprise ~15% of newly diagnosed cases of endometrial cancer. Type I cancers, with a relatively good prognosis, arise from proliferating endometrium, are associated with unopposed estrogen exposure, and are often preceded by atypical endometrial hyperplasia or endometrial intraepithelial neoplasia. In contrast, type II endometrial cancers, with a disproportional patient death, develop from resting endometrium (RE), have no hormonal risk factors, and are often preceded by endometrial glandular dysplasia (EmGD; refs. 5–8).

In the last decade, progress has been greatest in molecular and histologic resolution of precursor of type I cancer, resulting in a cohesive model of endometrial carcinogenesis encompassing both genetic and hormonal factors, revised precancer diagnostic criteria, and novel prevention strategies (9). In contrast to type I precancer, studies on the type II precancer are very much limited until recent years. Serous endometrial intraepithelial carcinoma (EIC) was used to be considered as putative precursor lesion of endometrial serous carcinoma (ESC), a prototype of type II cancer. However, serous EIC is now considered as an early form of ESC (10) because it is frequently associated with extrauterine serous carcinoma (7, 10–17). Instead of serous EIC, EmGD as an entity we described recently shows much better evidence in clinicopathologic level as a precancer for both serous and CCC of the endometrium (18–21). However, definitive establishment of EmGD as a precancer for type II endometrial cancer awaits further studies. Genetic evidence of EmGD as a precancer is particularly needed.

The development of cancer is a multistep process with accumulation of somatic gene mutation, including activation of oncogenes and/or inactivation of tumor suppressor genes. Experimental data support that mutation of p53 tumor suppressor gene plays an important role in endometrial carcinogenesis, particularly in the development of ESC, including serous EIC (11, 15, 17, 22–24). Mutations of p53 gene in endometrial cancers are diverse. Each p53 mutation seems to be unique. Comparing specific p53 gene mutation in different sites of tumors has been successfully applied to differentiate clonal (metastatic) process from synchronous or independent growth (25, 26). The objectives of this study were to examine if p53 gene mutation actually occurs in the putative precancer EmGD and to determine if development of ESC or serous EIC is a clonal growth from EmGD by direct DNA sequencing analysis from laser capture microdissected (LCM) endometrial samples.


   Materials and Methods
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 Abstract
 Materials and Methods
Results
 Discussion
 References
 
Case selection and sample targets. A total of 27 cases were retrieved from the Department of Pathology at the University of Arizona Medical Center and Yale-New Haven Hospital from 2000 to 2007. They were all from hysterectomy specimens, including 15 cases in a study group and 12 cases in a control group. All specimens were obtained under the approval of the Human Investigative Committee of both institutions.

Within the study group, we had pure ESC (n = 9), mixed serous and CCC (n = 2; cases 13 and 15), serous EIC (n = 3; cases 9, 12, and 14), and EmGD (n = 1; case 1). All cancer cases contained areas of EmGD and/or serous EIC. The cases of serous EIC also contained areas of EmGD for the study. Tissue sections containing areas of ESC, serous EIC, EmGD, as well as benign RE were selected for LCM as well as for p53 immunohistochemical stainings. Topographically, lesions of EmGD separated by >2 mm were considered as multifocal because the majority of lesions of EmGD are <1 mm in size. Endometrial neoplastic lesion in endometrial polyps or in endometrium without polyp was not separately assessed because we did not find significant difference in our previous study (20). Cases with mixed serous and CCC contained at least 50% serous component, and the areas of serous EIC and EmGD show no clear cell differentiation. Cases in which the entire endometrium was replaced by invasive cancers were not included. Other histologic types (endometrioid, clear cell, mucinous carcinomas, squamous, villoglandular carcinomas, and carcinosarcomas) were also excluded. In 11 of the 15 neoplastic uteri, the entire endometrium had been examined histologically, whereas the remaining 4 had at least six endomyometrial sections for each uterus. Seven of the 15 uteri contained endometrial polyps, which was involved by either ESC or serous EIC or EmGD. The diagnosis and histologic classification of the endometrial carcinomas were made by using the criteria of the International Federation of Gynecologists and Obstetricians and the WHO (27). Serous EIC was defined as serous intraepithelial carcinoma without stromal or myometrial invasion (11). Diagnosis of EmGD was mainly based on the morphologic criteria described previously (20). By definition, the degree of nuclear atypia of EmGD falls short of serous EIC. Immunophenotypically, the majority of lesions of EmGD display an intermediate p53 immunohistochemical score and MIB-1 labeling index (20).

Within the benign control group, 12 uteri were removed because of noncancerous lesions, including uterine prolapses (n = 6), leiomyomata (n = 3), and postmenopausal bleeding (n = 3). Endometria from these uteri were atrophic (n = 5), weakly proliferative (n = 4), and proliferative (n = 3).

Laser capture microdissection. All cases were fixed in 10% buffered formalin and processed routinely for paraffin embedding. Sections (8 µm) for LCM were cut and placed on glass slides coated with PEN membrane (Arcturus Bioscience, Inc.). A section of each specimen was then stained with H&E and examined microscopically to confirm the diagnosis. Most tissue sections for LCM contained areas of ESC, serous EIC, EmGD, and RE. Many single sections contained multiple foci of targeted areas. Targeted epithelial cells were selectively microdissected using the Veritas Laser Capture Microdissection System (Arcturus Bioscience) according to standard protocols. Approximately 300 to 500 cells of each target area were procured.

DNA extraction. Cells were captured on a thin film attached to a plastic cap, which was then attached to an Eppendorf tube containing 50 µL digestion buffer [40 mmol/L Tris-HCl (pH 8.0), 1 mmol/L EDTA, 0.5% Tween 20, 0.5 µg/µL proteinase K] and incubated at 37°C in inverted position for 24 to 48 h. After a brief spin at 1,000 rpm, the supernatant was transferred into a 1.5-mL centrifuge tube. The proteinase K was inactivated at 95°C for 10 min and the solution was kept at –20°C in aliquot. The DNA concentration was determined by Biophotometer (Eppendorf AG) before PCR amplification.

PCR and p53 gene mutation analysis. Touchdown PCR was done to amplify exons 5 to 8 of the p53 gene using tailed primers, which are summarized in Table 1 . A secondary PCR was done using T7 (5'-gtaatacgactcactataggggcgtactagcgtaccacgtgt-3') and T3 (5'-gattaaccctcactaaagggagacgatacgacgggcgtacta-3') primers specific to the tail sequence used in the primary amplification, eventually yielding the products of 343, 411, 357, and 347 bp for exons 5 to 8, respectively, which was described elsewhere (28). Amplified PCR products were electrophoresed on 1.2% agarose gel and visualized with ethidium bromide under UV light.


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  		Table 1. Primer sequences for PCR amplification of p53 exons 5 to 8

 
The amplified PCR products were purified on GFX columns (Amersham Biosciences) and then submitted to the Genomic Analysis and Technology Core Facility of University of Arizona for direct sequencing analysis by using an Applied Biosystems 3730 DNA Analyzer from both strands. Candidate mutations were obtained by comparing the p53 mutation database.8

p53 immunohistochemical analysis and score assessment. At least one representative section from each case was stained with p53 monoclonal antibody PAB1801 (Ab-2; Oncogene Science), which is affinity purified and recognizes a linear epitope in the human p53 protein located between amino acids 32 and 79 (23). The method of immunohistochemistry was described elsewhere (17). ESC from three patients with known p53 alteration, including p53 overexpression and mutation, served as positive controls (23). Negative controls were carried out by replacing primary antibodies with class-matched mouse IgG proteins on parallel sections. Immunostaining was repeated at least twice for each case. Quantitative assessment of immunohistochemical results for p53 was based on distinct nuclear staining. Overexpression of p53 was scored according to our previous definition using a 0- to 3-point score system for percentage of cells stained, intensity, and heterogeneity in a range of total scores from 0 to 9 (17). Intensity was judged based on a known positive control case, which was always included in each batch of staining. Heterogeneity was defined as nonuniform or sporadic immunostaining patterns in representative areas. Occasional cytoplasmic p53 staining was ignored. When multiple lesions were present in a single uterus, the lowest immunohistochemical score for p53 was taken. Extreme different scores, such as one lesion with intense diffuse staining (score, 7-9) and the other lesion with negative p53 staining (score, <6), were observed.

Statistical analysis. The frequency of p53 gene mutation obtained from each disease category was compared by {chi}2 test or Fisher's exact test, where appropriate. Nonevaluable samples, defined as samples without adequate DNA for analysis, were not included for the analysis. Correlation between p53 staining and mutational results was analyzed by Pearson's {chi}2 test. The P value was two sided and P < 0.05 was considered statistically significant.


   Results
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 Abstract
 Materials and Methods
 Results
Discussion
 References
 
Clinicopathologic features. A total of 27 cases were studied, including 15 neoplastic uteri in study group and 12 benign uteri in control group. The age of patients with neoplastic uteri ranged from 61 to 78 years, with an average age of 68.4 years. All tumor cases, including ESC and serous EIC, had tumor cells with high nuclear grade (grade 3). International Federation of Gynecologists and Obstetricians stage ranged from I to IV. These included stages IA (n = 3), IB (n = 2), IC (n = 1), IIA (n = 2), IIIA (n = 1), IIIC (n = 4), and IVB (n = 1). Within the control group (n = 12), we had all benign uteri from postmenopausal women who underwent hysterectomy for a noncancerous reason. Their ages ranged from 58 to 79 years, with an average of 66.7 years. No patient with a history of prior radiation or chemotherapy was included in this study. The clinicopathologic features are summarized in Table 2 .


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  		Table 2. Clinicopathologic data of 15 cases with neoplastic uteri

 
Overall p53 mutations detected in the studied cases. Among the 27 cases, we analyzed a total of 146 LCM samples, including 24 ESC, 26 serous EIC, 41 EmGD, 31 RE from neoplastic uteri, and 24 RE from benign uteri. Among the 15 neoplastic uteri, 12 (80.0%) cases showed at least one p53 mutation in each of the disease category (EmGD, serous EIC, and ESC). No p53 gene mutations were found in RE samples. Sixty mutations from exons 5 to 8 were identified in the total of 122 LCM samples from 15 neoplastic uteri. They were 13 (21.7%) in exon 5, 8 (13.3%) in exon 6, 36 (60.0%) in exon 7, and 3 (5.0%) in exon 8, respectively. Among all p53 gene mutations, 53 were missense mutations and 7 were nonsense mutations. Within the missense mutation category, mutations at codon 248 from CGG to TGG (Arg->Trp) or CAG (Arg->Gln) were most frequent. Interestingly, the nonsense mutation occurred in exon 5 (TGC to TGA at codon 176) in samples obtained from case 9. Representative picture of LCM from different endometrial lesions with corresponding p53 mutations is presented in Fig. 1 .


Figure 1
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  		Fig. 1. p53 gene sequencing results from LCM samples. Representative images of RE, EmGD, and serous EIC (Ser EIC) were shown. Left, before LCM; middle, after LCM; right, captured glands. Original magnification, x400. Corresponding DNA sequencing results showed that identical p53 gene mutations of exon 7 at codon 248 from CGG to TGG (Arg to Trp) were observed in both lesions of EmGD and serous EIC. Identical mutation was also seen in ESC (data not shown) in the same uterus (case 5).

 
EmGD contained frequent p53 gene mutations. Forty-one samples of EmGD collected from 15 neoplastic uteri were subjected to p53 gene sequence analysis covering exons 5 to 8. Among them, 37 DNA samples were informative. Sixteen of 37 (43.2%) EmGD lesions contained at least one p53 gene mutations in one of the four exons studied. Among the 15 neoplastic uteri, which contained at least one focus of EmGD, 7 (46.7%) uteri showed at least one p53 mutation in one of the four exons. Missense mutations were most common, occurring in six of the seven (85.7%) uteri. There were five different missense mutations detected in EmGD lesions. The most common missense mutation was at codon 248. Among all seven uteri containing p53 mutations in lesions of EmGD, six uteri (cases 3, 4, 5, 8, 9, and 11) showed at least two EmGD lesions with p53 mutations. They all showed identical codon mutations, except case 4, which showed CGG->CAG at codon 248 of exon 7 in one EmGD and CGG->CTG at codon 152 of exon 5. Case 9 contained four lesions of EmGD and all of them showed an identical nonsense mutation at codon 176 of exon 5. In terms of EmGD with p53 mutation in individual exon, the most frequent mutations occurred in exon 7, followed by exons 5 and 6. No mutation was detected in exon 8 in this study. The detailed mutation data with corresponding amino acid changes are summarized in Table 3 (negative results were not included).


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  		Table 3. Summary of all microdissected lesions with p53 gene mutations

 
Load of p53 mutations increased from lesions of EmGD to serous EIC and/or ESC. Within the cancer group, we collected 26 serous EIC and 24 ESC DNA samples with 25 and 22 informative, respectively, for the study. Among the 25 informative serous EIC, 18 (72.0%) lesions showed at least one p53 gene mutation. Likewise, 21 of the 22 (95.5%) informative ESC samples were found to have p53 gene mutation. In contrast, no single p53 mutation was identified in all 55 RE (31 from neoplastic and 24 from benign control uteri) samples in any exon sequenced. Compared with EmGD, serous EIC and ESC had a significantly higher p53 mutation frequency (P < 0.05). The difference of p53 mutation rate between serous EIC and ESC approached but did not reach the level of statistical significance. Detailed mutation data are summarized in Tables 3 and 4 .


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  		Table 4. Frequencies of p53 mutation in all lesion foci from 27 cases

 
High-concordant p53 mutations in lesions of EmGD, serous EIC, and/or ESC. Among the 15 uteri in the study group, there were 14 cases of EmGD with coexisting lesions of ESC or both of ESC and serous EIC, whereas 1 uterus contains lesions of EmGD only. Among the 14 uteri, 11 had multiple p53 gene mutations. The remaining three uteri were negative for any p53 mutation. In those 11 uteri, 6 (54.5%) uteri (cases 3, 4, 5, 8, 9, and 11) showed multiple foci of p53 mutations in lesions of EmGD and ESC or serous EIC. At least one identical p53 gene mutation was found in lesions of EmGD and ESC or serous EIC within the same uterus in all the six cases. Representative pictures for those lesions with identical mutations are shown in Fig. 1. The remaining five cases (cases 2, 6, 7, 10, and 13) showed p53 mutations only in lesions of serous EIC and ESC but not in EmGD. Interestingly, four of these five cases showed at least one identical p53 mutation. Case 6 showed different p53 mutations in lesions of serous EIC and ESC. One serous EIC contained mutation of GTT->GCT at codon 147 of exon 5. The other two ESC lesions showed multiple missense mutations in exons 5 and 7. The detailed data are summarized in Table 3.

Overexpression of p53 protein highly correlated with gene mutation. When cases with an immunohistochemical score of ≥6 were considered as overexpression of p53 protein, 14 of 15 (93.3%) neoplastic cases were positive, whereas only 1 case was negative (case 9). All 12 control cases were negative for p53 overexpression and did not have p53 mutations. Twelve of the 15 (80.0%) uteri cases had a p53 gene mutation. Case 9 with negative p53 immunohistochemical staining turned out to contain a nonsense mutation at codon 176 with TGC to TGA, resulting in a truncated p53 protein. Representative pictures of this case with negative p53 staining but with positive p53 mutation are shown in Fig. 2 . The concordance rate in neoplastic uteri between immunohistochemical and sequence-proven analysis was 85.2% (23 of 27), which was significantly correlated (P = 0.0002) as shown in Table 5 .


Figure 2
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  		Fig. 2. A case of neoplastic uterus showing negative p53 immunohistochemical staining but positive p53 gene mutation. Top, representative H&E-stained pictures of RE, EmGD, and serous EIC from case 9. Please note that the degree of nuclear atypia in EmGD (middle) clearly exceeds the RE (left) but falls short of serous EIC (right). The two small nonatypical endometrial glands present in the middle and right panels represent RE glands adjacent to lesions of EmGD and EIC, respectively. Original magnification, x200. The case was negative for p53 immunohistochemical staining (data not shown). However, p53 gene analysis at exon 5 showed point mutation of TGC to TGA (Cys to stop) at codon 176 in both lesions of EmGD and serous EIC. This nonsense mutation resulted in a truncated p53 protein expression, which perfectly explained the negative results by immunohistochemical p53 staining.

 

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  		Table 5. Comparison of p53 protein expression with gene mutations

 

   Discussion
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 Abstract
 Materials and Methods
 Results
 Discussion
References
 
Recently, EmGD has been proposed as a putative precursor for ESC and its morphologically noninvasive counterpart serous EIC (19, 20). However, no solid genetic data have yet been described to conclusively link EmGD to serous carcinomas. Mutations in the p53 tumor suppressor gene have been frequently found in ~90% of ESC and in 80% of serous EIC (22, 29). The majority of EmGDs have shown overaccumulation of p53 protein (20) and about one third showed loss of heterozygosity of TP53 (19). Such a broad spectrum of p53 alterations in endometrial serous neoplastic lesions is indicative of its important role in the pathogenesis of ESC and may also serve as a marker for early detection. Based on this understanding, we hypothesized that if EmGD is a true precancer of ESC/serous EIC, a significant number of p53 gene mutations should be identified and the identical mutations should be present in lesions of EmGD and ESC/serous EIC in the same uteri.

In this study, we found that 16 of 37 (43.2%) informative EmGD lesions contained at least one p53 gene mutations in one of the four exons studied. A significantly higher p53 mutation rate was found in serous EIC (72.0%) and ESC (95.5%). In contrast, there was no single p53 mutation identified in 55 benign endometrial samples. The high incidence of p53 gene mutations in EmGD supports that lesions of EmGD are neoplastic. From these findings, we conclude that p53 gene mutation may represent one of the earliest genetic alterations in the process of endometrial serous carcinogenesis because EmGD is the earliest morphologically identifiable lesion. This is similar to the findings of a recently proposed precursor for pelvic serous cancer that has been described in the distal fallopian tube (30). There is evidence within our study group cases that not every EmGD contains p53 mutation. In one uterus (case 1), three lesions of EmGD were identified without coexisting ESC/serous EIC. One of the three EmGDs showed two missense mutations, whereas no mutations were detected in the other two EmGDs and three foci of RE. The reason that not all EmGDs contain p53 mutation may be due to the analysis done in exons 5 to 8 only and possible participation of other genetic alterations in the initial process of endometrial serous carcinogenesis.

Clonal proliferation of a single cell carrying specific mutations in cancer-related genes is a well-accepted model of carcinogenesis. Among the 11 p53 mutation-positive uteri, 6 (54.5%) showed at least one identical p53 mutation among lesions of EmGD and ESC or serous EIC in the same uterus. Such a high concordance of p53 mutation in specific codons indicates that at least some of ESCs/serous EICs are derived from lesions of EmGD. An alternative interpretation is "field effect," which postulates that the entire tissue "field" simultaneously is predisposed to neoplasia because of prolonged exposure to the same carcinogen(s). This would result in multiple tumors that arise independently from independent precancerous lesions (31). This model is supported by case 4, in which separate foci of EmGD display different p53 codon mutations. In addition, cases 3, 5, and 7 showed discordant p53 gene mutations in foci of serous EIC and ESC within the same uteri. Therefore, both clonal expansion and synchronous growth occur in the process of endometrial serous carcinogenesis. In keeping with the concept that cancerous lesions have more genetic alterations than their precursors, the number of p53 gene mutations significantly increased from EmGDs to serous EICs (P = 0.0375; Table 4) and ESCs (P = 0.0001; Table 4). Overall, the findings in this study, together with our previous clinicopathologic study and loss of heterozygosity analysis, further support that ESC develops from EmGD through serous EIC (8, 19, 20).

Immunohistochemical staining of p53 protein in tissue sections has been successfully used to aid the diagnosis of endometrial serous neoplasm, including EmGD (11, 15, 17, 20, 23, 24, 32, 33). However, p53 overaccumulation does not necessarily signify p53 gene mutation. Therefore, direct DNA sequencing is a more reliable method for p53 mutation analysis. However, compared with sequence analysis, p53 immunohistochemistry is much simpler and easier to use in clinical practice. The results of this study, together with others previously published (22), indicate that strong diffuse nuclear staining correlates very well with p53 gene mutation. Based on p53 scoring system described previously (17), a score of 5 to 6 or more is a characteristic for EmGD lesions (8, 20). The findings of current study support that EmGD lesions with positively stained p53 protein are likely to have p53 gene mutation. Therefore, p53 immunohistochemical staining or p53 protein-based immunoassays may be useful for early detection of endometrial serous cancer because p53 alteration in benign endometria is extremely rare. We have recently identified EmGDs in uteri before the development of ESC/serous EIC with a window period ranging from 9 to 60 months, with an average of 16 months (34), suggesting that identifying EmGD lesions before developing into a full-blown ESC may provide us an opportunity to prevent the development of ESC. This is mainly because serous EIC is associated with a high incidence of extrauterine disease, although there is thus far no such association reported in lesions of EmGD.

In conclusion, p53 gene mutations occur frequently in EmGD, which provides a solid genetic evidence that EmGD is the precancer of ESC. The findings of this study further support the model of ESC development, which is from RE to EmGD, to serous EIC, and then to ESC. Mutation of p53 gene is probably one of the most important factors to initiate the endometrial serous carcinogenesis. Correct identification of ESC precancer provides an opportunity for early detection and potentially effective intervention of the aggressive type of endometrial cancer.


   Footnotes
 
Grant support: Arizona Cancer Center Core Grant P30 CA23074, Arizona Cancer Center Better Than Ever grant, and University of Arizona Department of Pathology start-up fund (W. Zheng). L. Jia is a cotrained Ph.D. candidate of Shandong University, China, where partial financial support was issued to support her research.

The costs of publication of this article were defrayed in part by the payment of page charges. This article must therefore be hereby marked advertisement in accordance with 18 U.S.C. Section 1734 solely to indicate this fact.

Note: L. Jia and Y. Liu contributed equally to this work.

8 http://p53.free.fr/Database/p53_database.html Back

Received 11/ 6/07; revised 12/21/07; accepted 1/ 9/08.


   References
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 Results
 Discussion
 References
 

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X. Zhang, S. X. Liang, L. Jia, N. Chen, O. Fadare, P. E. Schwartz, B. Kong, and W. Zheng
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