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Najwazniejsze publikacje

Local immune response depends on p16INK4a status of primary tumor in vulvar squamous cell carcinoma.

Sznurkowski JJ, Zawrocki A, Biernat W.


Oncotarget. 2017 Jul 11; 8(28): 46204–46210.



Background: The p16Ink4a is not a surrogate marker for high-risk human papilloma virus (HPV) genotypes but indicates better prognosis in vulvar squamous cell carcinoma patients. Our recent study confirmed substantial mismatch between p16Ink4a and high-risk HPV-status as well as revealed that p16Ink4a-overexpression itself is an independent prognostic factor for vulvar cancer.

Aim: To determine significance of the tumor infiltrating immune cells and p16Ink4a–status for better outcome of patients with vulvar cancer.

Methods: Intraepithelial tumor infiltrating lymphocytes: CD8+, CD4+, FOXP3+, CD56+, tumor associated macrophages: CD68+, and GZB+ cells were calculated in 85 vulvar squamous cell carcinomas with previously defined p16Ink4a and high-risk HPV-status. Number of intraepithelial CD8+, CD4+, FOXP3+, CD56+, CD68+ and GZB+ cells were compared between tumors with different p16INK4a status and overlapping high-risk HPV-status separately. Survival analyses included the Kaplan–Meier method, log-rank test and Cox proportional hazards model.

Results: p16Ink4a-negative tumors were more infiltrated by intraepithelial CD8+, CD4+ and GZB+ cells than p16Ink4a-positive tumors (p=0.032, p=0.016 and p=0.007 respectively). High-risk HPV-status did not correlate with the infiltration of immune cells. Median follow up was 89.20 months (range 1.7-189.5). High CD4+ and CD56+ indices were correlated with prognosis in p16Ink4a–positive cases (p=0.039 and p=0.013 respectively). Low CD68+ infiltrates were correlated with prognosis in p16Ink4a-negative cases (p=0.018). Conclusion: p16Ink4a-status impacts local immune surveillance as represented by tumor infiltrating immune cells. Immunologic effects contributing to clinical outcome might depend on p16Ink4a-overexpression.

The overexpression of p16  is not a surrogate marker for high-risk human papilloma virus genotypes and predicts clinical outcomes for vulvar cancer

Sznurkowski JJ, Zawrocki A, Biernat W.


BMC Cancer. 2016 Jul 13;16:465.



Background: We aimed to evaluate the correlation between p16ink4a-overexpression and high risk (hr)HPV-DNA in vulvar squamous cell carcinoma (vSCC) tumors as well as the impact of both biomarkers on the prognosis of vSCC patients.

Methods: PCR-detection of (hr)HPV-DNA and immunohistochemical staining for p16ink4a were conducted in 85 vSCC tumors. Survival analyses included the Kaplan–Meier method, log-rank test and Cox proportional hazards model.

Results: p16ink4a-overexpression and (hr)HPV-DNA were detected in 35 and 37 of the 85 tumors, respectively. Among the 35 p16ink4a-positive tumors, 10 lacked (hr)HPV-DNA (29%). Among the 50 p16ink4a-negative tumors, (hr)HPV-DNA was detected in 12 cases (24%). The median follow-up was 89.20 months (range 1.7–189.5 months). P16ink4a-overexpression, but not (hr)HPV-DNA positivity of the primary tumor, was correlated with prolonged overall survival (OS) (p=0.009). P16ink4a-overexpression predicted a better response to radiotherapy (p<0.001). Univariate analysis has demonstrated that age (p=0.025), tumor grade (p=0.001), lymph node metastasis (p<0.001), FIGO stage (p<0.001), p16ink4a-overexpression (p=0.022), and adjuvant RTX (p<0.001) were prognostic factors for OS. Multivariate analysis has demonstrated that lymph node metastasis (HR 1-2.74, 95 % CI 1.50-5.02, p=0.019), tumor grade (HR 1–2.80, 95 % CI 1.33-5.90, p = 0.007) and p16ink4a-overexpression (HR 1-2.11, 95 % CI 1.13-3.95, p=0.001) are independent prognostic factors.

Conclusion: The discovered overlap suggests the use of p16ink4a in combination with HPV-DNA detection as an ancillary test for future research and clinical studies in vSCC. The prognostic and predictive value of p16ink4a-overexpression should be tested in larger cohort studies.

En bloc pelvic resection for advanced ovarian cancer preceded by central ligation of vessels supplying the tumor bed: A description of surgical technique and a feasibility study

Sznurkowski JJ,

World J Surg Oncol. 2016 Apr 29;14:133.



Background: The resection of all visible malignancies increases the likelihood for long-term survival in epithelial ovarian cancer. The complete extinguishment of pelvic disease is possible using en-bloc pelvic resection. The no-touch isolation technique aims to reduce cancer cells flowing from the primary tumor site to the liver and other organs by ligating blood and lymphatic vessels first. Objectives: To present the operative details and to establish the feasibility of the modified technique of en-bloc pelvic resection, which begins with the central ligation of vessels supplying the tumor bed. Methods: Twenty patients with pelvic tumor extensively infiltrating into adjacent pelvic organs were uniformly operated on. The surgical plan commenced with incisions along the lateral peritoneal reflections immediately medial to the white line of Toldt followed by a retroperitoneal central ligation of ovarian and mesenteric vessels and the ovarian lymphovascular flow. Then, the routine steps of en-bloc pelvic resection were performed. Data on treatment were assessed. Results: In all cases, no gross residual disease was achieved. The median durations of the surgical procedure and the hospital stay were 320 minutes (range: 205-430 minutes) and 12 days (range: 7-44 days), respectively. Complications: Wound infection (n=1), anastomosis dehiscence (n=1), total parenteral nutrition (n=4), and death (n=1, PE). The median follow-up time period was 19 months (range: 8-31 months). No patient experienced a recurrence of pelvic disease.

Conclusions: Performing a central ligation of vessels supplying the tumor bed prior to an en-bloc pelvic resection is feasible with acceptable morbidity and mortality rates.

Vulvar cancer: initial management and systematic review of literature on currently applied treatment approaches

Sznurkowski JJ,

Eur J Cancer Care (Engl). 2016 Jul;25(4):638-46.



This review provides guidelines and aims to estimate utilization rates of treatment modalities applied in vulvar cancer. Current standards of treatment are as follows: wide local excision instead of radical vulvectomy in the case of small tumor (T<2cm), no lymph node dissection in the case of a micro-invasive tumor (invasion <1 mm), unilateral lymph node dissection in the case of a lateral tumor and inguinal-femoral lymphadenectomy by separate incisions instead of “en bloc” inguinal-femoral lymph node excision. Implementation of sentinel lymph node biopsy in patients with tumors not exceeding 4 cm is safe and efficiently eliminates redundant groin dissections. Preoperative treatment with chemo-radiotherapy reduces tumor size and improves surgical excision of inoperable primary tumors or fixed lymph nodes, but side effects are considerable. Literature search performed using PubMed database (from: 01.06.2005-01.06.2015) with the terms “consecutive”, “vulvar cancer”, “treatment” identified 7 full text manuscripts, including data on 1114 patients. Utilization rates of neoadjuvant radiochemotherapy, chemotherapy alone, surgery, adjuvant radiotherapy and adjuvant radiochemotherapy were 5.9%, 0.3%, 89.3%, 22.6% and 0.2% respectively.

An evidence based estimation of appropriate rates of surgery, radiotherapy and chemotherapy for vulvar cancer is needed to compare management reflecting guidelines with presented here real frequency of applied modalities.

Subtypes of cytotoxic lymphocytes and natural killer cells infiltrating cancer nests correlate with prognosis in patients with vulvar squamous cell carcinoma

Sznurkowski JJ, Zawrocki A, Biernat W.


Cancer Immunol Immunother (2014) 63:297–303



OBJECTIVE: Adaptive immune effectors do not influence prognosis in vulvarsquamous cell carcinoma (vSCC). Therefore, we tried to clarify the prognostic role ofinnate immunity and granzyme B-dependent cytotoxicity as defined by intratumoralinfiltrates of natural killer cells (CD56+) and lymphocytes expressing granzyme B(GrB+).METHODS: We analyzed 76 primary vSCCs and 35 lymph node metastases that wereobtained from 76 patients with a full clinical history. The distribution and density ofGrB+ and CD56+ cells within cancer tissues were evaluated by immunohistochemistryand correlated with clinicopathological features, commonly recognized prognosticfactors and overall survival (OS).RESULTS: CD56+ cells were mostly detected within the cancer nests, while GrB+ cellswere predominant in the tumor stroma.Intraepithelial (IE) CD56+ infiltrates at the primary site were correlated with depth ofinvasion (r=0.339, p=0.003) and recurrence (r=0.295, p=0.011), while IE GrB+infiltrates were correlated with tumor grade (r=0.304, p=0.009) and age (r=0.333,p=0.004).The primary cancer nests of metastatic patients were infiltrated more by intraepithelial(IE) CD56+ cells than were those of the non-metastatic patients (p=0.05).The median OS was 41.16 months (range 1.7-98.43). High IE GrB+ infiltrates predictedlonger OS among patients without metastases (p=0.028). High IE CD56+ infiltrateswere correlated with longer OS in metastatic cases (p=0.009).CONCLUSION: The combined cytotoxicity of innate and adaptive immune effectorsinfiltrating cancer nests (IE GrB+) predicts an improved clinical outcome among nonmetastaticvSCC patients. The functional status of prognostic IE CD56+ infiltrates inimmune escaped (metastatic) tumors requires further investigation.

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Impact of the new FIGO 2009 staging classification for vulvar cancer on prognosis and stage distribution.

​Tabbaa ZM1, Gonzalez J, Sznurkowski JJ, Weaver AL, Mariani A, Cliby WA.


Gynecol Oncol. 2012 Oct;127(1):147-52. doi: 10.1016/j.ygyno.2012.06.005. Epub 2012 Jun 13.



OBJECTIVE:In 2009, FIGO modified staging of vulvar cancer--the performance of the new classification relative to the prior system has not been assessed. We sought to investigate the impact of the 2009 FIGO vulvar cancer staging system on stage distribution and prognostic ability of the 2009 sub-stage classifications in a large cohort of uniformly staged cases with long-term followup.METHODS:Patients undergoing surgery for vulvar cancer were identified from 2 institutions (Mayo Clinic and Medical University, Gdansk, Poland) using a similar surgical approach. Inclusion criteria required primary surgery for invasive vulvar cancer for cases with >1 mm invasion with complete inguinal/femoral lymphadenectomy. The technique of inguinofemoral node dissection used in both institutions was designed to remove both superficial and deep inguinofemoral nodes. A retrospective review was performed and all cases were assigned stage using the 1988 and 2009 FIGO systems after reviewing pathology slides. Cause-specific survival (CSS, death due to cancer) was estimated using the Kaplan-Meier method and compared using the Cox proportional hazards model t for the first 10 years after surgery.RESULT:A total of 468 patients met inclusion criteria. Thirty-one percent (n=155) were down-staged, and 1 case up-staged using 2009 staging. The new system fails to effectively separate 10-yr CSS for stage I and II cases (p=0.52), while FIGO 1988 failed to separate stages II and III (p=0.41). We observed a difference in survival for stage I and II cases based on tumor diameter. For smaller stage II lesion (≤4 cm vs. >4 cm) we observed no difference in survival compared to all stage IB cases (p=0.25) Considering node positive disease, patients with 2009 FIGO stages ΙΙΙA, ΙΙΙB, and ΙΙΙC were not significantly different in terms of CSS (p=0.17). However, CSS approached significance between patients with extracapsular vs. intracapsular disease (p=0.072). For stages IIIA and IIIB (excluding extracapsular spread, IIIC), we observed that the number of positive nodes and diameter of lymph node metastasis were not significantly associated with CSS. When comparing bilateral nodal involvement vs. unilateral cases with at least 2 involved nodes, we found no statistical difference in CSS (p=0.30).CONCLUSION:This is the largest cohort study to evaluate the effect and prognostic performance of the new FIGO vulvar cancer staging system. The new staging does not stratify survival between stages I and II and reduces CSS in stage I cases. Our results suggest that lesion size in node negative cases is an important prognostic variable that could be addressed in future staging classifications. Among the node positive cases, the current classification results in slight differences in CSS, primarily between intra- and extra-capsular disease and not according to the number of positive nodes and lymph node metastasis diameter. Finally we observe that bilateral nodal disease does not appear to impact CSS, justifying it being omitted from the 2009 staging system and that separating node positive (2009 stage III) from node negative (2009 stage II) cases is justified.Copyright © 2012 Elsevier Inc. All rights reserved.

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Expression of indoleamine 2,3-dioxygenase predicts shorter survival in patients with vulvar squamous cell carcinoma (vSCC) not influencing on the recruitment of FOXP3-expressing regulatory T cells in cancer nests.

Sznurkowski JJ, Żawrocki A, Emerich J, Sznurkowska K, Biernat W.


Gynecol Oncol. 2011 Aug;122(2):307-12. doi: 10.1016/j.ygyno.2011.04.050. Epub 2011 May 25.


OBJECTIVE:Regulatory T cells (Tregs), and the enzyme indoleamine 2,3-dioxygenase (IDO), have potential regulatory properties for immune escape in cancer. Inhibitors of IDO are available and could potentially be used in vulvar cancer if IDO was proved to drive progression of the disease. The aim of this study was to evaluate the expression of factor forkhead boxP3 (FOXP3), a marker of Tregs, and IDO in vulvar squamous cell carcinoma (vSCC), and to verify their prognostic significance.METHODS:76 primary tumors and 35 lymph node metastases derived from 76 patients with full clinical history were analyzed. The intratumoral infiltration of Tregs and IDO expression within cancer were evaluated by immunohistochemistry.RESULTS:The number of Tregs in primary tumor and in corresponding lymph node metastasis was significantly correlated. Intensity of Treg infiltrates in the primary and metastatic sites was not correlated to IDO expression and had no influence on the overall patient survival. High IDO expression was associated with significantly worse overall survival among vSCC patients and was found to be an independent prognostic factor similarly to the tumor grade and patient's age.CONCLUSIONS:The degree of intratumoral Treg infiltrates is an individual feature and remains stable throughout the course of the disease without impact on the patient's survival. IDO expression predicts shorter survival of vSCC patients. If immunologic tolerance of the tumor is promoted by the overexpression of IDO it will not influence the number of intratumoral Tregs. IDO expression seems to be an independent prognostic factor in patients with vSCC.

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Prognostic significance of CD4+ and CD8+ T cell infiltration within cancer cell nests in vulvar squamous cell carcinoma.

Sznurkowski JJ, Zawrocki A, Emerich J, Biernat W.


Int J Gynecol Cancer. 2011 May;21(4):717-21. doi: 10.1097/IGC.0b013e3182131f36.


BACKGROUND:The clinicopathological significance of the local spontaneous immune reaction in vulvar squamous cell carcinoma remains unclear. The purpose of this study was to clarify the role of the subtypes of tumor-infiltrating lymphocytes, both individually and synergistically.METHODS:Seventy-six patients with verified histopathological data and complete clinical history were included into the study. We collected 76 paraffin-embedded samples of the primary tumor. The presence of CD4+ and CD8+ T cells was evaluated by immunohistochemistry and compared with commonly recognized prognostic factors. The primary end point analyzed was the overall survival.RESULTS:CD4+ and CD8+ T cells were detected both within the nests of carcinoma and in the stroma, but only the infiltration within cancer cell nests was further analyzed. There was significant positive correlation (Spearman rho test R = 0.282, P = 0.014) between the number of intratumoral CD4+ and CD8+ T cells. No correlation was observed between the number of tumor-infiltrating CD4+ and CD8+ T cells and the patients' survival. Patients were classified into the following 4 groups (CD4+/CD8+, CD4⁻/CD8⁻ CD4+/CD8⁻, CD4⁻/CD8+), but none of them correlated with overall survival.CONCLUSIONS:These data support the statement that CD4⁻ and CD8+ T cells cooperate within cancer cell nests, but this spontaneous immune reaction is an individual feature not influencing the prognosis. Intratumoral CD4+ T cells might control or reflect the immune responses against cancer cells, whereas CD8+ T cells do not seem to work as sufficient effectors in tumor tissues.

Prognostic factors and a value of 2009 FIGO staging system in vulvar cancer.

Sznurkowski JJ, Milczek T, Emerich J.


Arch Gynecol Obstet. 2013 Jun;287(6):1211-8. doi: 10.1007/s00404-012-2683-x. Epub 2012 Dec 22.


OBJECTIVE:In 2009, International Federation of Gynecology and Obstetrics (FIGO) modified staging of vulvar cancer-the prognostic significance of the new classification relative to the prior system as well as to the commonly recognized prognostic factors has not been assessed. The aim of this study was to test prognostic ability of 2009 staging in a cohort of uniformly treated and staged cases with long-term follow-up.METHODS:Pathologic characteristics were obtained by blind review of the original tissue samples. 76 patients who qualified for surgery on the basis of the same criteria, with full clinical history, were included in the study. The histological analyses were performed on 76 and 35 paraffin-embedded tissue samples from primary tumors and lymph nodes, respectively. Survival analyses included the Kaplan-Meier method, log-rank test and Cox proportional hazards model.RESULTS:Univariate analysis has demonstrated that age (p = 0.0170), lymph node metastasis (p = 0.0393), tumor grade (p = 0.0086) and FIGO1994 stage (p = 0.001) were the significant prognostic factors for overall survival. Multivariate analysis has demonstrated that growing age (HR 2.25, 95 % CI 0.79-3.71, p = 0.0321), tumor grade (G1 vs. G2 and G3) (HR 1-3.11, 95 % CI 1.6-4.62, p = 0.0057) and FIGO1994 stage (HR 1.78, 95 % CI 0.55-3.01, p = 0.0061) are independent prognostic factors with respect to overall survival.CONCLUSIONS:The results indicate the prognostic advantage of the 1994 FIGO staging as it has become an independent prognostic factor in contrast to the new FIGO system. This should be tested in future larger cohort studies. Differentiation grade turned out to be a very valuable independent prognostic factor and should be incorporated as a routine component of the histopathologic reports in vulvar cancer.

Endometriomas are more frequent on the left side.

Sznurkowski JJ, Emerich J.


Acta Obstet Gynecol Scand. 2008;87(1):104-6.


OBJECTIVE:To investigate whether asymmetry exists in the left- and right-distribution of ovarian cystic lesions in women with endometriosis.METHODS:We evaluated operative reports of women who underwent surgical treatment of endometrioma(n = 253) from January 1999 to December 2003. We included only those cases that had not been previously operated on (n = 234). Data of all operative findings consisted of a written report and a diagram, fulfilling the revised American Fertility Society Classification of endometriosis.RESULTS:Endometrioma was found in the left ovary in 113 women, in the right ovaryin 67, and bilaterally in 54. Left ovarian unilateral endometrioma was found more frequently (62.8%) than right endometrioma (p < 0.001, odds ratio (OR) 2.8, 95% confidence interval (CI) 1.9, 4.4). The frequencies of left and right ovarian endometrioma were compared with the expected 50% using Pearson's chi(2)-test. The results confirmed asymmetry(p = 0.001). We found 4 cases of ovarian cancer associated with left endometrioma without histological proof of transition.CONCLUSION:Our results confirm a left lateral predisposition of endometrioma. This predisposition may be caused by the presence of the sigmoid colon in the left side of the pelvis, which decreases peritoneal fluid movement. Our findings may support the transplantation theory of the origin for endometriosis.

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