目的：以免疫組織化學染色法研究bcl-2, p53, Ki-67及PTEN在上尿路移行細胞癌的表現，並探討其表現與腫瘤惡性度、臨床侵犯程度及病患存活情形之相關性。
材料及方法：蒐集石臘包埋的原發性上尿路移行細胞癌標本，分兩組進行免疫組織化學染色。第一組含91個病例，做bcl-2, p53 及Ki-67抗體染色處理；第二組含93名病例，標本均同時含有腫瘤及正常細胞，做PTEN抗體染色處理。處理過的標本以半定量的方式，根據被染色細胞的數量，分為三個等級：第一級，僅有稀少的細胞被染色；第二級，局部的細胞被染色；第三級，細胞廣泛地呈色。再將免疫反應的程度與腫瘤惡性度、臨床侵犯程度進行統計分析，並評估其表現是否可作為病患存活之預後因子。
結果：
第一組：Bcl-2的表現在91個病例中，除一例可到達局部程度的呈色外，其餘均只有稀少的呈色表現。廣泛的p53突變佔了48.4%的病例，次多的是局部突變表現 （佔26.4%）及稀少的突變表現（佔25.3%）。而Ki-67的染色表現在91例中，廣泛呈色有6位，局部呈色有21位，而稀少呈色佔66位。p53的表現和腫瘤惡性度有統計相關 (p=0.004)，Ki-67的免疫染色表現和腫瘤侵犯程度也有統計相關 (p=0.031)。但bcl-2, p53及Ki-67三者在上尿路移型細胞癌的表現，與病患存活情形並無統計之相關性。
第二組：全部93例的腫瘤細胞質均有廣泛程度的PTEN染色反應。而在腫瘤細胞核的部分，稀少的PTEN呈色有18位（佔19.4%），局部染色有35位，佔37.6%，大部分是廣泛的免疫染色反應，有40位，佔43.0%。PTEN在腫瘤細胞核的不表現，和腫瘤侵犯程度的臨床分期呈現正相關 (p=0.019)。PTEN也在鄰近腫瘤細胞的纖維細胞染色表現。細胞核有24例 (25.8%)呈稀少染色分布，59例 (63.9%)呈局部染色，10例 (10.8%)呈廣泛性的呈色反應。分化較差的腫瘤標本，其上的纖維細胞核較無PTEN染色的反應 (p=0.028)。多數標本 (58%)腫瘤細胞旁的纖維細胞質呈現稀少的PTEN染色反應，其次為廣泛呈色（23例、24.7%）及局部呈色（16例、17.2%）。PTEN在上尿路移型細胞癌的免疫組織染色表現，與病患存活時間無統計之相關性。
結論：我們觀察到腫瘤分化程度與p53突變之間、臨床侵犯程度與Ki-67免疫染色反應之間均有統計上的關聯性。同時，PTEN在腫瘤細胞核的不表現，正相關於高度侵犯的上尿路移行細胞癌。而且在分化較差的癌細胞標本上，與腫瘤相鄰的纖維細胞核較無PTEN免疫染色反應。然而，就病患的存活時間來看，這些因子均無統計相關的表現。因此，偵測bcl-2, p53, Ki-67及PTEN在上尿路移型細胞癌的表現，尚難以決定這些患者的預後。

Purpose: To determine the expressions of bcl-2, p53, Ki-67 and PTEN on the basis of immunohistochemistry methods in upper urinary transitional cell carcinoma (TCC), and to correlate their presentations in specimens with clinical tumor stage, grade and patient survival.
Material and Method: Paraffin-embedded primary upper urinary TCC specimens were divided into 2 groups for immunohistochemical study: Group 1 including 91 cases were treated with bcl-2, p53 and Ki-67 antibodies; group 2 including 93 specimens contained both tumor and benign tissues were treated with PTEN antibody. Semi- quantitatively, according to the amount of the stained cells, they were divided into 3 levels: level 1, scanty; level 2, focal; and level 3, diffuse. Association of immunoreactivity with tumor grade and stage was examined. Prognostic significance of tumor marker expression in patients’ survival was accessed.
Results:
Group1: Of the 91 tumors most (98.9%) of the specimens showed level 1 bcl-2 expression and only 1 patient had level 2 expression. The p53 mutations were identified level 3 expression in 48.4% of the cases, followed by level 2 (26.4%) and level 1 (25.3%) identifications. The Ki-67 expression was recognized level 3 in 6 patients, level 2 in 21 and level 1 in 66 cases. Significant correlations were seen between p53 expression and tumor grading (p=0.004) and between immunostain of Ki-67 and clinical stage (p=0.031). The p53, bcl-2 and Ki-67 expressions in upper urinary tract TCC specimens were not a significant factor of patients’ survival.
Group 2: Of the tumors all cytoplasm has level 3 PTEN expressions and the nuclei, 18 (19.4%) showed scanty expression, 35 (37.6%) revealed focal expression, and diffuse expression was noted in 40 (43.0%) cases. Loss of PTEN expression in tumor nuclei was positively correlated with pathologic stage (p=0.019). Of the fibrocytes adjacent to tumor cells, the nuclei showed 24 (25.8%) scanty, 59 (63.4%) focal and 10 (10.8%) diffuse distribution of PTEN expressions. Poorly differentiated tumor (grade 3) specimens were correlated with loss of PTEN expression in fibrocytic nuclei adjacent to tumor (p=0.028). Most (58%) fibrocytic cytoplasm was scanty PTEN expression, followed by 23 (24.7%) diffuse and 16 (17.2%) focal immunostaining. PTEN expressions in upper urinary tract TCC specimens were not a significant factor of patients’ survival.
Conclusions: We examined 93 surgical specimens of upper urinary tract TCC for the expression of PTEN and 91 cases for bcl-2, p53 and Ki-67 by immunohistochemical stained. Correlation between tumor grading and p53 mutations and correlation between clinical stage and Ki-67 immunoreactivity were observed. Meanwhile, loss of PTEN expression in tumor nuclei of upper urinary TCC is correlated significantly with advanced tumor stage, and poorly differentiated tumor specimens were correlated with loss of PTEN expression in normal nuclei adjacent to tumor cells. However, no correlation between overall survival rate and tumor markers was identified. Thus, the detection of p53, bcl-2, Ki-67 and PTEN would be not enough for evaluation the prognosis of upper TCC.

誌謝…………………………………………………………………………………2
中文摘要…………………………………………………………………….………5
Abstract 英文摘要…………………………………………………………………7
Introduction 前言………………………………………………………………….9
Transitional cell carcinoma……………………………………………………...9
B cell lymphoma gene 2 (Bcl-2) ………………………………………………..10
p53………………………………………………………………………………..10
Ki-67……………………………..………………………………………………11
Tumor Suppressor Gene PTEN……….…….………………………………….11
Materials and Methods 材料與方法….……..….……………………………………16
Collection of Clinical Samples………………………………………………….16
Immunohistochemical analysis of p53, Ki-67 and bcl-2………..…………….16
Immunohistochemical Study of PTEN…….…………………….……………17
Analysis of bcl-2, p53, Ki-67 and PTEN Immunohistochemical Staining…..17
Statistical analysis……………….……………………………………………..18
Results 結果…………………………………………………………………………….19
Group 1
Patient Databases and Tumor Characteristics………………………………………..19
Bcl-2, p53 and Ki-67 Expression in Human Upper urinary Transitional Cell Carcinomas…………………………………………………………………………19
Correlation with Tumor Differentiation and Pathologic Stage………………………20
Group 2
Patient Databases and Tumor Characteristics…………………………………..21
PTEN Expression in Human Transitional Cell Carcinomas……………………21
Correlation of PTEN Expression with Tumor Differentiation and Pathologic
Stage…………………….………………………………………………………..21
Discussions 討論…………………………………………………………………………22
References 參考文獻…………………………………………………………………….29
Tables 表………………………………………………………………………………….34
Figures 圖………………………………………………………………………………...37

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