Molecular tumor classification, which includes PR and ER expression, is an integral part of the disease characteristics. The presence of steroid receptors ER-α, PR-A and PR-B has been quantitatively associated with histologic differentiation [
30,
31], response to therapy [
32] and metastatic potential [
33]. ER-α expression was found to be decreased in EC [
18,
34] and is further decreased as EC grading is advanced [
35‐
38]. In correlation, our results demonstrate significantly reduced expression of ER-α in both glands and stroma of endometrioid tumor in relation to non-malignant endometrial tissue (Figure
1). The expression of ER-α is lower in the stroma than in the glands of EC, indicating that stroma cells are significantly more affected than the epithelial cells. ER-β quantification faced technical problems and therefore was not assessed in the current study. Loss of ER suggests an advanced molecular pathology of the tumor with the deregulation of signaling pathways. Common deregulation courses include PTEN inactivation by mutation [
39],
de novo methylation of ER-α gene and aberrant methylation of CpG islands [
1]. These epigenetic alterations occur in a wide variety of tumors [
8,
40‐
44], including endometrial cancer [
36,
45].
PR expression of either one or both of the two PR isoforms was found to be reduced or absent in endometrial cancer [
16‐
18,
46], mostly lower for the higher histological grade [
47‐
49] and inversely correlates with myometrium invasion [
50,
51]. Our results demonstrate that PR-A shows the exact same pattern of expression as ER-α in the gland and stroma cells, as well as in the different portions of EC specimens (Figure
2). It is well documented in the literature that the transcription of
PR gene is induced by estrogen and inhibited by progesterone in the majority of estrogen responsive cells, so the expression of ER and PR is considered to be coordinated [
27,
37,
52,
53]. As described, we found significantly and differentially altered expression of sex steroid receptors in superficial and deep sections of the specimens. Previous reports, which support our findings, describe total protein expression in the tissue. Our findings, describing the expression of PR-A and ER-α in the stroma and epitheial cells in EC solely, is implicated in the mitogenic response of epithelial cells to estrogen, which is mediated indirectly by stromal ER [
54]. A model for this assumption was demonstrated by co-culture of non-expressing ER stroma cells and ER-positive epithelial cells [
55]. No epithelial proliferation in response to estrogen was detected in this model, or in a model of pure epithelial cultures, an induction observed in co-cultures of normal uterine stroma and epithelial cells [
55]. Evidently estrogen induced epithelial proliferation requires an ER-positive stroma. Response of uterine epithelial cells to progesterone was also found to be mediated by stromal PR [
56]. This mediated operation between the cells may be implicated and result in the altered pattern of receptors expression in the transformed cells, found in our study. In addition to the well-known growth inhibiting effect of progesterone, it plays an important role in regulating invasive properties of endometrial cancer cells. A correlation was found between decreased PR expression in EC tumors and the expression of E-cadherin and myometrial invasion [
57,
58]. An extensive myometrial invasion may be a progeny of epithelial to mesenchymal transition (EMT) which is highly implicated in EC tumors invasive characteristics [
59,
60]. Therefore, the reduced expression of ER-α and PR-A in the tumor cells, particularly the significantly reduced expression in the stroma cells, may indicate an invasive characteristics of the tumor, as described for ER-α [
61], and the deep portion of the tumor is of special interest. These findings in both superficial and deep portions of the tumor stand against the extra-tumoral portion of the tumor, which was found to be affected as well, but to a lower extent. PR-B quantification showed reduced expression in the epithelial glands of superficial and deep portions of EC (Figure
3). Supporting our findings, PR-B promoter was previously found to be methylated in endometrial carcinoma [
62] and the loss of expression was referred to as an independent prognostic factor for cause-specific survival in high risk patients [
63]. The significantly high expression of PR-B in the extra-tumoral portion of the malignant specimens may imply a certain protective reaction opposing invasive properties of the tumor cells. In a study conducted by Balmer NN et al. [
64], in which tumoral- and extra-tumoral- portions were examined by immunohistochemistry, resembling the current study methodology, PR-B expression was found to be significantly higher in carcinoma-associated nonmalignant endometrium compared to endometrial carcinoma. Zafran et al. [
65] found that a state of PR-B dominance, like in the cell line HEC-1A, was less invasive than cell lines that PR-A is the predominantly expressed variant. PR-A may be associated with a cell- and promoter specific repression of PR-B [
66] and imbalance in PR-A to PR-B ratio is frequently associated with carcinogenesis [
67]. The relative over-expression of PR-B, which is referred to as an endometrial estrogen agonist [
68], without transcriptional repression by PR-A, as shown in our findings, may also be related to the metastatic potential and partially cause deviation from sex steroidal dependency in endometrial cancers [
33]. Our results show higher expression of Ki-67 in the malignant tissue than in the nonmalignant, as seen in previous studies [
22‐
25,
69]. A wide score range of Ki67 expression was found in the non-malignant biopsies. These results correlate with the expression of Ki67 in normal cyclical endometrium, in which Ki-67 staining is intense and diffused in the proliferative phase, but decreases dramatically in the early and mid-secretory phase.