Malignant Mammary Tumors Research Articles

Clinical and prognostic implications of serum and tissue prolactin levels in canine mammary tumours

The biological implications of serum and tissue prolactin levels in canine mammary tumours (CMT) have been previously described although the influence of this hormone on inflammatory mammary carcinomas as well...

Expression of vimentin filaments in canine malignant mammary gland tumors: A simulation of clinicopathological features of human breast cancer.

Canine malignant mammary gland tumors (CMMGTs) are the most common malignancies observed in females. Several biological similarities have been reported between CMMGTs and human breast cancer (HBC). The present study aimed to assess the correlation of vimentin filaments overexpression, as part of the process of epithelial-mesenchymal transition (EMT) and the clinicopathological characteristics in CMMGTs. The clinicopathological characteristics of 42 CMMGTs were collected. Paraffin-embedded blocks underwent immunohistochemistry staining, which was performed using vimentin (to assess the evolution of the EMT process), Ki-67 (for evaluation of tumor proliferation) and cluster of differentiation 34 (CD34) (for evaluation of angiogenesis) antibodies. The tumor stage, grade, vascular invasion, margin status, rate of expression of the vimentin filaments, microvessel density-CD34 and proliferation rate data were obtained. Finally, the association between the expression of the vimentin filaments and those parameters was resolved statistically. A significant association was shown between the overexpression of the vimentin filaments and tumor size (r=0.71, P=0.03), tumor grade (r=0.80, P=0.021), angiogenesis (r=0.57, P=0.043), proliferation coefficient (r=0.06, P=0.001) and vascular invasion (r=0.76, P=0.043). Vimentin overexpression did not statistically correlate with the tumor stage or the margin status. Similar to the findings of the present study, certain recent studies have indicated that vimentin filament expression in HBC and CMMGTs is associated with the severity of cancer. Thus, spontaneous canine mammary tumor models appear to be an appropriate animal model for breast cancer research, and the results of the present study could aid to reinforce the association.

COX-2, mPGES-1 and EP2 receptor immunohistochemical expression in canine and feline malignant mammary tumours.

Prostaglandin (PG) signalling is involved in human and animal cancer development. PG E2 (PGE2 ) tumour-promoting activity has been confirmed and its production is controlled by Cyclooxygenase-2 (COX-2) and microsomal PGE synthase-1 (mPGES-1). Evidence suggests that mPGES-1 and COX-2 contribute to carcinogenesis through the EP2 receptor. The aim of our study was to detect by immunohistochemistry COX-2, mPGES-1 and EP2 receptor expression in canine (n = 46) and feline (n = 50) mammary tumours and in mammary non-neoplastic tissues. COX-2 positivity was observed in 83% canine and 81% feline mammary carcinomas, mPGES-1 in 75% canine and 66% feline mammary carcinomas and the EP2 receptor expression was observed in 89% canine and 54% feline carcinomas. The frequency of COX-2, EP2 receptor and mPGES-1 expression was significantly higher in carcinomas than in non-neoplastic tissues and adenomas. COX-2, mPGES-1 and EP2 receptor expression was strongly associated. These findings support a role of the COX-2/PGE2 pathway in the pathogenesis of these tumours.

Survivin and Related Proteins in Canine Mammary Tumors

Survivin is reexpressed in most human breast cancers, where its expression has been associated with tumor aggressiveness, poor prognosis, and poor response to therapy. Survivin expression was evaluated in 41 malignant canine mammary tumors (CMTs) by immunohistochemistry, in relation to histological grade and stage, and correlated with that of some related molecules (β-catenin, caspase 3, heat shock proteins) to understand their possible role in canine mammary tumorigenesis. An increase in nuclear survivin expression, compared with healthy mammary glands, was observed in CMTs, where nuclear immunolabeling was related to the presence of necrosis. No statistically significant relation was found between the expression of the investigated molecules and the histological grade or stage. The present study may suggest an important involvement of survivin in CMT tumorigenesis. Its overexpression in most of the cases evaluated might suggest that targeting survivin in CMTs may be a valid anticancer therapy.

Aberrant cytoplasmic accumulation of retinoblastoma protein in basal cells may lead to increased survival in malignant canine mammary tumours

The retinoblastoma susceptibility gene RB-1 is a tumour suppressor gene that encodes a protein (Rb) that regulates the transition from the G1 phase to the S phase of the cell cycle. Inactivation of the Rb gene has been shown in a variety of human tumours, including breast, ovarian, hepatic, prostatic, and endometrial carcinomas. Although Rb protein is normally expressed in the nuclei of healthy cells, during carcinogenesis there is a partial or complete loss of nuclear expression. Recently, some reports have indicated aberrant cytoplasmic expression of Rb protein. However, little is known about its cytoplasmic expression and significance as a prognostic marker in canine mammary tumours (CMT). The present study was performed on 36 malignant CMT cases in order to assess the mutational status and prognostic significance of Rb in primary malignant CMT. We report an almost complete loss of nuclear expression of Rb protein with corresponding gain of aberrant cytoplasmic expression in basal/myoepithelial cells in CMT. Strikingly, our analysis reveals a significant positive correlation between survival time and cytoplasmic expression of Rb protein in basal cells. Moreover, cytoplasmic expression of Rb protein in basal cells was also correlated with tumour grade and stage.  

Urokinase plasminogen activator expression in canine malignant mammary tumours by immunohistochemical study

Abstract Immunohistochemical expression of urokinase plasminogen activator (uPA) was studied in 37 canine malignant mammary tumours to define the relationship between their histopathological type and grade. In 29 (78.4%) cases, expression of uPA by neoplastic cells was more than 10% and in 34 samples (91.9%) uPA expression by stromal cells (fibroblasts) was more than 10%. The uPA was expressed in epithelial and myoepithelial cells of carcinomas and carcinosarcomas and mesenchymal population of carcinosarcoma, chondrosarcoma, and carcinomas arising in benign tumours. The intensity and percentage of expression of uPA by stromal cells was associated with their histological grade (P < 0.05). However, no significant relationship was detected between uPA expression by neoplastic cells (epithelial, myoepithelial, and mesenchymal cell) and histological grade. Increased expression of uPA by tumour stroma was associated with poor prognostic factors. Stromal expression of uPA could be a prognostic indicator for canine mammary tumours.

Canine Mammary Tumors

Although there have been several studies on the use of immunohistochemical biomarkers of canine mammary tumors (CMTs), the results are difficult to compare. This article provides guidelines on the most useful immunohistochemical markers to standardize their use and understand how outcomes are measured, thus ensuring reproducibility of results. We have reviewed the biomarkers of canine mammary epithelial and myoepithelial cells and identified those biomarkers that are most useful and those biomarkers for invasion and lymph node micrometastatic disease. A 10% threshold for positive reaction for most of these markers is recommended. Guidelines on immunolabeling for HER2, estrogen receptors (ERs), and progesterone receptors (PRs) are provided along with the specific recommendations for interpretation of the results for each of these biomarkers in CMTs. Only 3+ HER2-positive tumors should be considered positive, as found in human breast cancer. The lack of any known response to adjuvant endocrine therapy of ER- and PR-positive CMTs prevents the use of the biological positive/negative threshold used in human breast cancer. Immunohistochemistry results of ER and PR in CMTs should be reported as the sum of the percentage of positive cells and the intensity of immunolabeling (Allred score). Incorporation of these recommendations in future studies, either prospective or retrospective, will provide a mechanism for the direct comparison of studies and will help to determine whether these biomarkers have prognostic significance. Finally, these biomarkers may ascertain the most appropriate treatment(s) for canine malignant mammary neoplasms.

Acoustic radiation force impulse (ARFI) imaging of preliminary mucosa associated lymphoid tissue (MALT) lymphoma in the breast: a case report.

Primary lymphoma is a rare neoplasm in the breast accounting for between 0.04% and 0.5% of all malignant mammary tumors. The majority of cases lack typical features of breast malignancy or lymphoma, and likely to be misdiagnosed during daily clinical practice. In this report we describe a case of primary breast lymphoma assessed with acoustic radiation force impulse (ARFI) technology.

Concurrent Expression of Cyclo-oxygenase-2 and Epidermal Growth Factor Receptor in Canine Malignant Mammary Tumours

Canine mammary tumours (CMTs) are reported to express cyclo-oxygenase (COX)-2 and epidermal growth factor receptor (EGFR); however, no studies have evaluated concurrent expression of these proteins. In this study, 43 malignant CMTs were evaluated immunohistochemically for concurrent expression of COX-2 and EGFR and expression was correlated with malignancy. High COX-2 expression was associated with tumour size (P = 0.033), mitotic index (P = 0.040), nuclear grade (P = 0.021), histological grade of malignancy (P = 0.020) and lymph node metastasis (P = 0.029). High EGFR immunoreactivity was associated with tumour size (P = 0.001), necrosis (P = 0.001), mitotic index (P = 0.022), histological grade of malignancy (P = 0.041) and lymph node metastasis (P = 0.005). Simultaneous high-expression of COX-2 and EGFR was associated with high-nuclear grade (P = 0.049), high-histological grade of malignancy (P = 0.031) and the presence of lymph node metastasis (P = 0.025). A positive correlation between COX-2 and EGFR expression (r = 0.474; P = 0.001) was also observed. These results suggest that combined use of selective inhibitors of COX-2 and EGFR may be a useful approach to the treatment of malignant CMTs.

Loss of PPARγ expression in mammary secretory epithelial cells creates a pro‐breast tumorigenic environment

Breast cancer is the leading cause of new cancer diagnoses among women. Using peroxisome proliferator-activated receptor (PPAR)γ(+/−) mice, we showed normal expression of PPARγ was critical to stop 7,12-dimethylbenz[a]anthracene (DMBA)-induced breast tumorigenesis. PPARγ is expressed in many breast cell types including mammary secretory epithelial (MSE) cells. MSEs proliferate as required during pregnancy, and undergo apoptosis or reversible transdifferentiation during involution once lactation is complete. Thus, MSE-specific loss of PPARγ was hypothesized to enhance DMBA-mediated breast tumorigenesis. To test this, MSE cell-specific PPARγ knockout (PPARγ-MSE KO) and control (PPARγ-WT) mice were generated, mated and allowed to nurse for three days. One week after involution, dams were treated with DMBA to initiate breast tumors, and randomized on week 7 to continue receiving a normal chow diet (DMBA Only: PPARγ-WT, n = 15; PPARγ-MSE KO, n = 25) or one supplemented with a PPARγ activating drug (DMBA + ROSI: PPARγ-WT, n = 17; PPARγ-MSE KO, n = 24), and monitored for changes in breast tumor outcomes. PPARγ-MSE KOs had significantly lower overall survival and decreased mammary tumor latency as compared to PPARγ-WT controls. PPARγ activation significantly reduced DMBA-mediated malignant mammary tumor volumes irrespective of genotype. MSE-specific PPARγ loss resulted in decreased mammary gland expression of PTEN and Bax, increased superoxide anion production, and elevated serum eotaxin and RANTES, creating a protumorigenic environment. Moreover, PPARγ activation in MSEs delayed mammary tumor growth in part by down-regulating Cox-1, Cox-2 and cyclin D1. Collectively, these studies highlight a protective role of MSE-specific PPARγ during breast tumorigenesis, and support a novel chemotherapeutic role of PPARγ activation in breast cancer.

EGFR and microvessel density in canine malignant mammary tumours

The epidermal growth factor receptor (EGFR) is a transmembrane tyrosine kinase receptor which has been shown to have an important role in human breast cancer. Its role appears to be associated with increased angiogenesis and metastasis. In order to clarify its role in canine mammary tumours (CMT), 61 malignant neoplasms were studied by using immunohistochemistry, comparing expression of EGFR, microvessel density (MVD) by CD31 immunolabelling and characteristics of tumour aggressiveness. High EGFR immunoexpression was statistically significantly associated with tumour size, tumour necrosis, mitotic grade, histological grade of malignancy and clinical stage. High CD31 immunoreactivity was statistically significantly associated with tubule formation, histological grade of malignancy and clinical stage. A positive correlation between EGFR and CD31 immunoexpression (r=0.843; P<0.001) was also observed. Results suggest that an over-expression of EGFR may contribute to increased angiogenesis and aggression in malignant CMT, presenting the possibility of using EGFR inhibitors in the context of metastatic disease treatment.

Versatile lipid profiling by liquid chromatography–high resolution mass spectrometry using all ion fragmentation and polarity switching. Preliminary application for serum samples phenotyping related to canine mammary cancer

Lipids represent an extended class of substances characterized by such high variety and complexity that makes their unified analyses by liquid chromatography coupled to either high resolution or tandem mass spectrometry (LC–HRMS or LC–MS/MS) a real challenge. In the present study, a new versatile methodology associating ultra high performance liquid chromatography coupled to high resolution tandem mass spectrometry (UHPLC–HRMS/MS) have been developed for a comprehensive analysis of lipids. The use of polarity switching and “all ion fragmentation” (AIF) have been two action levels particularly exploited to finally permit the detection and identification of a multi-class and multi-analyte extended range of lipids in a single run. For identification purposes, both higher energy collision dissociation (HCD) and in-source CID (collision induced dissociation) fragmentation were evaluated in order to obtain information about the precursor and product ions in the same spectra. This approach provides both class-specific and lipid-specific fragments, enhancing lipid identification. Finally, the developed method was applied for differential phenotyping of serum samples collected from pet dogs developing spontaneous malignant mammary tumors and health controls. A biological signature associated with the presence of cancer was then successfully revealed from this lipidome analysis, which required to be further investigated and confirmed at larger scale.

Markers of lipid peroxidation and α‐tocopherol levels in the blood and neoplastic tissue of dogs with malignant mammary gland tumors

Excess reactive oxygen species due to oxidative stress and the ensuing lipid peroxidation are believed to be involved in mammary gland tumor (MGT) pathogenesis. The purpose of this study was to evaluate the extent of lipid peroxidation as evidenced by thiobarbituric acid-reactive substances (TBARS) formation, and the concentration of α-tocopherol as an inhibitor of lipid peroxidation, in blood and neoplastic tissue of dogs with malignant MGT. The correlation between inflammatory cell infiltration score and TBARS or α-tocopherol in MGT was also evaluated. Sixteen intact female dogs with malignant MGT and 12 clinically healthy and age/weight-matched controls were included in the study. In all dogs, serum TBARS, α-tocopherol, total cholesterol, and triglycerides were measured. Tissue TBARS and α-tocopherol levels were determined in 1 cm(3) sized tissue samples collected from MGT and adjacent, ipsilateral, normal mammary gland tissue from the 16 affected dogs. The degree of inflammatory cell tumor infiltration was evaluated histologically. There were no statistically significant differences in serum levels of TBARS, α-tocopherol, total cholesterol, and triglycerides between dogs with and without malignant MGT. TBARS were significantly higher, whereas α-tocopherol was lower in neoplastic tissue when compared with normal mammary gland tissue. There was no correlation between TBARS or α-tocopherol concentration and the inflammatory cell infiltration score in neoplastic tissue. The increased level of TBARS suggests oxidative stress induction in canine malignant MGT. The origin of this phenomenon is not clear, as a potential oxidative burst could not be attributed to inflammatory cells infiltrating the tumors.

Molecular Mechanisms of Hormone Resistance of Breast Cancer

More than 70% malignant mammary tumors contain steroid hormone receptors; this suggests the possibility of hormone therapy in the majority of patients with breast cancer (BC). The main cause of inefficiency of hormone therapy in BC is hormone resistance (tumor resistance to hormonal cytostatics). Here we discuss the main mechanisms of hormone resistance of BC and the mechanisms underlying the formation of hormone resistance of the tumors are analyzed at the molecular level. The data on the signal pathways of estrogen receptors (ER), the key regulators of BC cell proliferation, are presented. The most important factors of BC hormone resistance are: high activity/expression of receptor tyrosine kinases; high activity of proteins regulating cell defense mechanisms (Akt PI3K, mTOR); changes in the activities of cell cycle regulator proteins (Myc, c-Fos, Cyclin D1). Our experiments have demonstrated that estrogen-independent BC cell growth is supported by VEGF/VEGFR2 and EGF/EGFR mitogenic signal pathways. Our data indicate that NF-kappaB transcription factor is directly involved in the regulation of hormone-resistant BC cell growth and survival, while NF-kappaB suppression determines cell sensitivity to apoptotic activity of antitumor compounds. On the whole, the results indicate good prospects of using EGFR, HER-2/neu, mTOR, VEGFR, PI3K/Akt molecular pathways as targets for BC therapy, including therapy for BC resistant forms.

Abstract 470: Electrovaccination of domestic cats with a hybrid heterologous Her2 DNA vaccine overcomes immune tolerance to self Her2.

Abstract About 20% of non-castrated female domestic cats develop malignant mammary tumors with similar histopathology and disease progression as human breast cancer. Her2 over-expression is reported in 40-85% of feline mammary carcinomas, indicating this disease is particularly suited for testing Her2 DNA vaccination. To corroborate these findings, expression of Her2 was evaluated in 4 feline mammary tumors resected from three feline patients. Immunohistochemistry analysis with anti-human Her2 mAb showed regions of intense membrane staining in all four tumor samples, indicating high frequency of Her2 expression among feline mammary tumors and immune cross-reactivity of human and feline Her2. Feline mammary tumor lines K248 (Minke, et. al. 1991) and K12 (Modiano, et. al. 1991) both express Her2 as measured by flow cytometry, further demonstrating Her2 as a common antigen in feline mammary tumors. Feline Her2 cDNAs cloned from K248 and K12 (GenBank Accession JN990983) are identical to each other and show 93% sequence identity with human Her2. To test the feasibility of conducting DNA electrovaccination in cats, 3 pathogen-free domestic short hair cats between 1-2 years of age were injected i.m. in the biceps femoris of the hind legs or triceps of the front legs with vaccine DNA. Each cat received admix of 1.5mg of pE2Neu encoding a hybrid human Her2 and rat neu fusion protein and 1.5mg of feline pGM-CSF. Each injection site was subjected to electroporation with a NEPA21 electroporator, consisting of three 50msec 100V degenerating bipolar pulses. The vaccination was repeated at 3 week intervals and blood was drawn 2 weeks after each vaccination. Anti-human Her2 antibody was detected in the immune serum after 2 vaccinations, as demonstrated by binding to SKOV3 cells that over-express human Her2. After 4 vaccinations, anti-human Her2 antibody titers ranged from 50,000 to 200,000. Therefore, DNA electrovaccination is an effective means to induce immune response in cats. To test if immunization with heterologous pE2Neu induced cross-reactive antibody to self feline Her2, immune serum was incubated with 3T3/fHer2 cells that express feline Her2. Specific binding to 3T3/fHer2 was observed after 3 vaccinations at 1:100 serum dilutions. These results provide the first evidence that immune tolerance in cats to self Her2 is overcome by a hybrid DNA vaccine encoding a fusion protein of two heterologous genes: human Her2 and rat neu. This vaccine regimen is a candidate veterinary therapeutic agent and the insight gained from cat vaccination provides strong support for human vaccine trials. Citation Format: Heather M. Gibson, Richard Jones, Marie Piechocki, Joyce Reyes, Michele Sauerbrey, Ulka Vaishampayan, Wei-Zen Wei. Electrovaccination of domestic cats with a hybrid heterologous Her2 DNA vaccine overcomes immune tolerance to self Her2. [abstract]. In: Proceedings of the 104th Annual Meeting of the American Association for Cancer Research; 2013 Apr 6-10; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2013;73(8 Suppl):Abstract nr 470. doi:10.1158/1538-7445.AM2013-470

Comparative mammary oncology: canine model.

Comparative mammary oncology: canine model.

Different role of COX-2 and angiogenesis in canine inflammatory and non-inflammatory mammary cancer

Human inflammatory breast cancer (IBC) and canine inflammatory mammary cancer (IMC) are the most aggressive and fatal types of mammary cancer, and both have a very poor prognosis and low survival rate. Human IBC is characterised by exacerbated angiogenesis, lymphangiogenesis, and lymphangiotropism. Lymphangiotropism is also characteristic of IMC, but microvascular density (MVD) and lymphangiogenesis have not been previously studied in canine IMC. In this study immunohistochemical expression of several angiogenesis-related factors (cyclooxygenase [COX]-2, vascular endothelial growth factors A and D [VEGF-A, VEGF-D], and vascular endothelial growth factor receptor 3 [VEGFR-3]), MVD, lymphatic proliferation index (LPI), and Ki-67 tumour proliferation index (PI) were studied in 21 canine IMC samples, 20 canine high-grade malignant non-IMC mammary tumours (MMTs), and four normal mammary gland samples (NMGs).All mammary neoplasms were histologically categorised as grade III. COX-2 values were also analysed by RT-PCR in seven IMCs, six MMTs and four NMGs. The expressions of COX-2, VEGF-A, and VEGF-D were significantly higher in IMC, MVD and LPI tumours, but not PI. In MMTs, COX-2 immunoexpression was significantly associated with VEGF-A, while in IMCs COX-2 was associated with VEGF-D (lymphangiogenic factor), its receptor VEGFR-3, and LPI. These results suggested that lymphangiogenic pathway stimulation isa specific role of COX-2 in IMC angiogenesis, which justifies the use of COX-2–based targeted palliative therapies in dogs. The exacerbated angiogenesis and lymphangiogenesis and the increased expression of angiogenesis-related factors further support canine IMC as a natural model for the study of human IBC.

Expression of inflammation-mediated cluster of genes as a new marker of canine mammary malignancy.

Because canine mammary tumours constitute a serious clinical problem and there are no good prognostic markers (only histopathological variables are used), the aim of the presented study was to find new malignancy markers as well as to identify intracellular pathways and biological processes characteristic for canine mammary malignancy. We compared gene expression of the most malignant mammary tumours (poorly differentiated cancers of the 3rd grade of malignancy) with less malignant tumours (well differentiated cancers of the 1st grade of malignancy). The results of our study indicated that in dogs the number of tumour-infiltrating myeloid cells or expression of myeloid-specific antigens by cancer cells is related to the cancer progression and may constitute a new marker of malignancy, however further studies in this field are required.

Identification of prognostic factors in canine mammary malignant tumours: a multivariable survival study

BackgroundAlthough several histopathological and clinical features of canine mammary gland tumours have been widely studied from a prognostic standpoint, considerable variations in tumour individual biologic behaviour difficult the definition of accurate prognostic factors. It has been suggested that the malignant behaviour of tumours is the end result of several alterations in cellular physiology that culminate in tumour growth and spread. Accordingly, the aim of this study was to determine, using a multivariable model, the independent prognostic value of several immunohistochemically detected tumour-associated molecules, such as MMP-9 and uPA in stromal cells and Ki-67, TIMP-2 and VEGF in cancer cells.ResultsEighty-five female dogs affected by spontaneous malignant mammary neoplasias were followed up for a 2-year post-operative period. In univariate analysis, tumour characteristics such as size, mode of growth, regional lymph node metastases, tumour cell MIB-1 LI and MMP-9 and uPA expressions in tumour-adjacent fibroblasts, were associated with both survival and disease-free intervals. Histological type and grade were related with overall survival while VEGF and TIMP-2 were not significantly associated with none of the outcome parameters. In multivariable analysis, only a MIB-1 labelling index higher than 40% and a stromal expression of MMP-9 higher than 50% retained significant relationships with poor overall and disease-free survival.ConclusionsThe results of this study indicate that MMP-9 and Ki-67 are independent prognostic markers of canine malignant mammary tumours. Furthermore, the high stromal expressions of uPA and MMP-9 in aggressive tumours suggest that these molecules are potential therapeutic targets in the post-operative treatment of canine mammary cancer.

Expression of autophagy-related protein beclin-1 in malignant canine mammary tumors

BackgroundAutophagy is a self-catabolic mechanism that degrades unnecessary cellular components through lysosomal enzymes. Beclin-1, an autophagy-related protein, establishes the first connection between autophagy and tumorigenesis. The purpose of this study is to assess the Beclin-1 expression pattern and to determine its prognostic significance in patients with malignant canine mammary tumor (CMT).ResultsWe examined Beclin-1 expression in 70 cases of malignant CMTs by immunohistochemistry. Cytoplasmic Beclin-1 expression was significantly weaker in cancer cells than in nearby normal mammary glands (p < 0.001). Low cytoplasmic expression (57.14%) was associated with older age, lower degree of tubular formation, increased mitotic activity, higher histologic grade, and extensive necrosis. Low nuclear expression (40%) was connected with older age, lower degree of tubular formation, extensive necrosis, and negative for Her2/neu overexpression. Univariate survival analysis showed that Beclin-1 cytoplasmic expression was a poor prognostic factor for overall survival rate (p < 0.001). Multivariate survival analysis demonstrated that Beclin-1 cytoplasmic expression is an independent prognostic factor (p = 0.016).ConclusionsLoss of Beclin-1 is associated with aggressive clinicopathologic features and poor overall survival. The results suggest that Beclin-1 plays an important role in tumor progression of malignant CMTs.