Mutational analysis of the PMS2 gene in sporadic endometrial cancers with microsatellite instability

OBJECTIVE

Approximately 20% of endometrial tumors have a defect in DNA mismatch repair and exhibit microsatellite instability (MSI). We assessed the role of the PMS2 DNA mismatch repair gene in MSI-positive sporadic endometrial tumors.

METHODS

We examined 40 sporadic endometrial tumor specimens with MSI. All 15 exons of the PMS2 gene were investigated for sequence alterations by single-strand conformational variant analysis.

RESULTS

Twelve polymorphisms were identified, 8 of which were in the coding sequence. Four specimens revealed mutations in intronic sequences that are not predicted to affect the PMS2 mRNA. No mutations were detected within the coding region of the PMS2 gene.

CONCLUSION

We conclude that structural mutations in the PMS2 gene are not responsible for defective DNA mismatch repair in sporadic endometrial cancers with MSI. The identification of single nucleotide polymorphisms in the PMS2 locus may aid in the mapping and characterization of genetic diseases.

Pelvic radiation with concurrent chemotherapy compared with pelvic and para-aortic radiation for high-risk cervical cancer

BACKGROUND AND METHODS

We compared the effect of radiotherapy to a pelvic and para-aortic field with that of pelvic radiation and concurrent chemotherapy with fluorouracil and cisplatin in women with advanced cervical cancer. Between 1990 and 1997, 403 women with advanced cervical cancer confined to the pelvis (stages IIB through IVA or stage IB or IIa with a tumor diameter of at least 5 cm or involvement of pelvic lymph nodes) were randomly assigned to receive either 45 Gy of radiation to the pelvis and para-aortic lymph nodes or 45 Gy of radiation to the pelvis alone plus two cycles of fluorouracil and cisplatin (days 1 through 5 and days 22 through 26 of radiation). Patients were then to receive one or two applications of low-dose-rate intracavitary radiation, with a third cycle of chemotherapy planned for the second intracavitary procedure in the combined-therapy group.

RESULTS

Of the 403 eligible patients, 193 in each group could be evaluated. The median duration of follow-up was 43 months. Estimated cumulative rates of survival at five years were 73 percent among patients treated with radiotherapy and chemotherapy and 58 percent among patients treated with radiotherapy alone (P=0.004). Cumulative rates of disease-free survival at five years were 67 percent among patients in the combined-therapy group and 40 percent among patients in the radiotherapy group (P<0.001). The rates of both distant metastases (P<0.001) and locoregional recurrences (P<0.001) were significantly higher among patients treated with radiotherapy alone. The seriousness of side effects was similar in the two groups, with a higher rate of reversible hematologic effects in the combined-therapy group.

CONCLUSIONS

The addition of chemotherapy with fluorouracil and cisplatin to treatment with external-beam and intracavitary radiation significantly improved survival among women with locally advanced cervical cancer.

MLH1 promoter methylation and gene silencing is the primary cause of microsatellite instability in sporadic endometrial cancers

Defective DNA mismatch repair in human tumors leads to genome-wide instability of microsatellite repeats and a molecular phenotype referred to as microsatellite instability (MSI). MSI has been reported in a variety of cancers and is a consistent feature of tumors from patients with hereditary non-polyposis colorectal cancer. Approximately 20% of cancers of the uterine endometrium, the fifth most common cancer of women world-wide, exhibit MSI. Although the frequency of MSI is higher in endometrial cancers than in any other common malignancy, the genetic basis of MSI in these tumors has remained elusive. We investigated the role that methylation of the MLH1 DNA mismatch repair gene plays in the genesis of MSI in a large series of sporadic endometrial cancers. The MLH1 promoter was methylated in 41 of 53 (77%) MSI-positive cancers investigated. In MSI-negative tumors on the other hand, there was evidence for limited methylation in only one of 11 tumors studied. Immunohistochemical investigation of a subset of the tumors revealed that methylation of the MLH1 promoter in MSI-positive tumors was associated with loss of MLH1 expression. Immunohistochemistry proved that two MSI-positive tumors lacking MLH1 methylation failed to express the MSH2 mismatch repair gene. Both of these cancers came from women who had family and medical histories suggestive of inherited cancer susceptibility. These observations suggest that epigenetic changes in the MLH1 locus account for MSI in most cases of sporadic endometrial cancers and provide additional evidence that the MSH2 gene may contribute substantially to inherited forms of endometrial cancer.

Predictors of persistence of adnexal masses in pregnancy

OBJECTIVE

To determine factors predicting the persistence of sonographically identified adnexal masses in pregnancy.

METHODS

All patients from March 1988 to April 1993 diagnosed with an adnexal mass by obstetric sonography were reviewed. Examinations had been entered prospectively into our sonography database. Follow-up data were collected from the database, from hospital and pathology department records, and from interviews with referring obstetricians. Adnexal masses were characterized by size, sonographic appearance, and anatomic site. Persistence of the masses was determined by subsequent sonography, operative findings, or postpartum physical examinations.

RESULTS

The rate of adnexal masses during pregnancy was 2.3% (432 of 18,391). Complete follow-up was available for 422 of 432. Most of the adnexal masses (76%; 320 of 422) were simple cysts with a mean diameter less than 5 cm. The remainder of the masses were simple or complex, measuring 5 cm or more in diameter. Seventy of 102 large or complex masses resolved. By multivariate analysis, the best predictors for persistence of these masses were complex appearance on sonography and size of the mass (P < .05 for both categories).

CONCLUSION

Most adnexal masses identified by sonography during pregnancy were small, simple cysts that did not pose a risk to the pregnancy. Even the majority of large or sonographically complex masses resolved. The best predictors of persistence of the masses were sonographic appearance and size.

Factors affecting long-term outcome of irradiation in carcinoma of the vagina

OBJECTIVE

This report evaluates prognostic and technical factors affecting outcome of patients with primary carcinoma of the vagina treated with definitive radiation therapy.

METHODS AND MATERIALS

A retrospective analysis was performed on records of 212 patients with histologically confirmed carcinoma of the vagina treated with irradiation.

RESULTS

Tumor stage was the most significant prognostic factor; actuarial 10-year disease-free survival was 94% for Stage 0 (20 patients), 80% for Stage I (59 patients), 55% for Stage IIA (63 patients), 35% for Stage IIB (34 patients), 38% for Stage III (20 patients), and 0% for Stage IV (15 patients). All in situ lesions except one were controlled with intracavitary therapy. Of the patients with Stage I disease, 86% showed no evidence of vaginal or pelvic recurrence; most of them received interstitial or intracavitary therapy or both, and the addition of external-beam irradiation did not significantly increase survival or tumor control. In Stage IIA (paravaginal extension) and IIB (parametrial involvement) 66% and 56% of the tumors, respectively, were controlled with a combination of brachytherapy and external-beam irradiation; 13 of 20 (65%) Stage III tumors were controlled in the pelvis. Four patients with Stage IV disease (27%) had no recurrence in the pelvis. The total incidence of distant metastases was 13% in Stage I, 30% in Stage IIA, 52% in Stage IIB, 50% in Stage III, and 47% in Stage IV. The dose of irradiation delivered to the primary tumor or the parametrial extension was of relative importance in achieving successful results. In patients with Stage I disease, brachytherapy alone achieved the same local tumor control (80-100%) as in patients receiving external pelvic irradiation (78-100%) as well. In Stage II and III there was a trend toward better tumor control (57-80%) with combined external irradiation and brachytherapy than with the latter alone (33-50%) (p = 0.42). The incidence of grade 2-3 complications (12%) correlated with the stage of the tumor and type of treatment given.

CONCLUSION

Radiation therapy is an effective treatment for patients with vaginal carcinoma, particularly Stage I. More effective irradiation techniques, including optimization of dose distribution combining external irradiation and interstitial brachytherapy in tumors beyond Stage I, are necessary to enhance locoregional tumor control. The high incidence of distant metastases emphasizes the need for earlier diagnosis and effective systemic cytotoxic agents to improve survival in these patients.

Interferon-gamma and tumor necrosis factor-alpha induce synergistic cytolytic effects in ovarian cancer cell lines-roles of the TR60 and TR80 tumor necrosis factor receptors

OBJECTIVE

Utilizing ovarian cancer cell lines, we examined the effect of IFN-gamma on each type of TNF receptor. Additionally, we sought to determine the effect of receptor modulation on TNF-alpha-mediated cytolysis.

METHODS

Ovarian cancer cell lines Caov-3, A2780, and SK-OV-3 were employed. The number of TNF receptors was determined by a TNF-alpha binding assay utilizing 125I-labeled TNF-alpha. Monoclonal antibodies specific for the 55- to 60-kDa (TR60) and the 75- to 80-kDa (TR80) TNF receptors were used to determine the relative density of each receptor type. Northern blot analyses were performed employing cDNA probes for the TR60 and TR80 mRNAs. To elucidate which receptor(s) was responsible for mediating the signal for cytolysis, 24-h MTT cytolytic assays were performed in the presence of receptor-specific monoclonal antibodies.

RESULTS

IFN-gamma treatment resulted in an increase in TNF receptors in the cell lines A2780 and Caov-3 (P < 0.001), but not SK-OV-3. Northern blot analyses suggested distinct regulatory mechanisms for the two receptors. In Caov-3 and SK-OV-3 cells a synergistic increase in TNF-alpha-mediated cytolysis was seen when cells were pretreated with IFN-gamma. In both cell lines, pretreatment with IFN-gamma markedly enhanced the ability of the TR60 receptor to mediate cell lysis. Conversely, under similar treatment conditions, the TR80 receptor did not appear capable of generating a cytolytic signal.

CONCLUSIONS

TNF receptor modulation by IFN-gamma appears to be unique to individual cell lines. The TR60 TNF receptor plays a central role in the synergistic cytolytic effects of IFN-gamma and TNF-alpha. Sequential therapy with IFN-gamma and TNF-alpha and specific TNF receptor activation may provide novel translational strategies for the use of cytokines in the treatment of ovarian cancer.

Differences in patterns of TP53 and KRAS2 mutations in a large series of endometrial carcinomas with or without microsatellite instability

BACKGROUND

The correlation between tumor microsatellite instability (MSI) and the accumulation of mutations in KRAS2 and TP53 is uncertain. The authors evaluated the TP53 and KRAS2 genes for mutations in sporadic endometrial carcinomas with microsatellite instability (MSI) and matched MSI negative controls to determine whether defective DNA mismatch repair impacts the patterns of mutations in two genes known to be involved in endometrial tumorigenesis.

METHODS

Twenty-five MSI positive endometrial tumors were matched for prognostic factors with 25 MSI negative tumors. Mutations in codon 12 and 13 of KRAS2 were assessed using a polymerase chain reaction (PCR) restriction assay. Mutations in codon 61 of KRAS2 and exons 5-8 of TP53 were evaluated using PCR amplification and single strand conformation variant (SSCV) analysis. All variants were subjected to direct DNA sequencing.

RESULTS

KRAS2 and TP53 mutations were identified with equal frequency in the MSI positive and MSI negative groups. For TP53, the authors identified 5 mutations (20%) in the MSI positive specimens compared with 8 (32%) in the MSI negative group. For KRAS2, there were identified 8 mutations (32%) in the MSI positive specimens compared with 7 (28%) in the MSI negative tumors. The mutational spectra evident from sequence analysis of TP53 and KRAS2 variants were similar between MSI negative and MSI positive tumors. MSI negative tumors were more likely to have mutations in both KRAS2 and TP53 than MSI positive tumors, which were rarely mutant in both genes (P=0.046).

CONCLUSIONS

Although the overall frequency of mutations in TP53 and KRAS2 is similar, MSI positive tumors are less likely to have mutations in both genes than MSI negative sporadic endometrial carcinomas. MSI positive and MSI negative endometrial carcinomas may arise through distinct genetic pathways.

PTEN mutations in endometrial cancers with 10q LOH: additional evidence for the involvement of multiple tumor suppressors

OBJECTIVE

The aim of this study was to assess the involvement of PTEN and other putative 10q tumor suppressors in endometrioid-type adenocarcinomas characterized by loss of 10q sequences.

METHODS

PCR-based single-stranded conformational variant analysis and sequencing of individual PTEN exons in 34 tumor specimens and their corresponding normal DNA were used.

RESULTS

Thirteen of the 34 tumors (38%) revealed a PTEN mutation: 2 frameshift, 3 nonsense, 3 missense, 3 splice site alterations, and 2 homozygous deletions.

CONCLUSION

The observation that greater than 60% of endometrial cancers with 10q LOH lack PTEN mutations, in addition to previously reported LOH data, provides evidence for the existence of other tumor suppressors on 10q. Consideration of PTEN mutation status may prove important in deletion mapping studies to locate additional tumor suppressors on the long arm of chromosome 10.

Cancer among first-degree relatives of probands with invasive and borderline ovarian cancer

OBJECTIVE

The familial clustering of ovarian, breast, endometrial, colon; and prostate cancer was compared in first-degree relatives of probands with invasive and borderline ovarian cancer to determine coaggregation.

METHODS

Probands (n=392), who had been patients in the Division of Gynecologic Oncology at Washington University, were ascertained consecutively. Family history on 2192 first-degree relatives was collected by personal interviews of the probands and other family members. Estimates of prevalence of cancers in first-degree relatives of the two proband groups were compared. Survival analysis was used to examine the age-at-onset distribution of each cancer in relatives of invasive probands versus relatives of borderline probands.

RESULTS

Among the relatives were 24 cases of ovarian cancer, 46 cases of breast cancer, 13 cases of endometrial cancer, and 25 and 28 cases of colon and prostate cancer, respectively. There were no significant differences in the prevalence of any of these cancers in relatives of the invasive and borderline probands. Cumulative lifetime risk estimates did not differ between the relatives of the two groups for any cancers. Age-at-onset of ovarian cancer did not differ between probands with positive family histories of the five cancers and those with negative histories. The inability to reject the null hypothesis of no differences in the first-degree relatives of our two study groups might be from insufficient power to detect small differences, given our sample size.

CONCLUSION

These results suggest that relatives of patients with invasive and borderline ovarian cancer might share similar cancer risks and age-at-onset distributions.

Mapping an endometrial cancer tumor suppressor gene at 10q25 and development of a bacterial clone contig for the consensus deletion interval

Frequent loss of chromosome 10q sequences in endometrial cancers suggests the involvement of a tumor suppressor gene. Previous loss-of-heterozygosity (LOH)studies have pointed to the 10q25-q26 region as the likely site of a tumor suppressor involved in endometrial tumorigenesis (S. L. Peiffer et al., 1995, Cancer Res. 55: 1922-1926; S. Nagase et al., 1996, Br. J. Cancer 74: 1979-1983; S. Nagase et al.,1997, Cancer Res. 57: 1630-1633). In an attempt to define further the localization of a tumor suppressor gene at 10q25, we screened a panel of 123 endometrioid adenocarcinomas for loss of heterozygosity of 10q25.3 sequences. Forty-three (35%) revealed LOH at one or more loci. The observed patterns of allelic loss define a minimum consensus region of deletion between D10S221 and D10S610. A sequence-ready bacterial clone contig and a long-range restriction map for a 1-Mb interval spanning the deletion region were developed as the first step in experiments directed toward the discovery the 10q25 tumor suppressor.

Twice-daily fractionation of external irradiation with brachytherapy and chemotherapy in carcinoma of the cervix with positive para-aortic lymph nodes: Phase II study of the Radiation Therapy Oncology Group 92-10

PURPOSE

The purpose of this study was to evaluate the toxicity and efficacy of twice-daily external irradiation to the pelvis and para-aortics with brachytherapy and concurrent chemotherapy for carcinoma of the cervix with positive para-aortic lymph nodes.

METHODS AND MATERIALS

This study was designed to administer twice-daily radiation doses of 1.2 Gy to the pelvis and para-aortics at 4- to 6-h intervals, 5 days per week. The total external radiation doses were 24 to 48 Gy to the whole pelvis, 12 to 36 Gy parametrial boost, and 48 Gy to the para-aortics with an additional boost to a total dose of 54 to 58 Gy to the known metastatic para-aortic site. One or two intracavitary applications were performed to deliver a total minimum dose of 85 Gy to point A. Cisplatin (75 mg/m2, days 1 and 22) and 5-FU (1000 mg/m2/24 h x 4 days; days 1 and 22) were given for two or three cycles.

RESULTS

Twenty-nine patients with clinical Stages I to IV carcinoma of the cervix with biopsy-proven para-aortic lymph nodes were enrolled in this study. Hyperfractionated external radiotherapy was completed in 86% (25 of 29). Brachytherapy was given in two applications to 48% (14 of 29), 31% (9 of 29) had one intracavitary application, 14% (4 of 29) had no brachytherapy, one had three applications, and one had five HDR applications. Radiotherapy was completed per protocol in 69%. Three courses of chemotherapy were given to 24% (7 of 29), 72% (21 of 29) received two courses, and one patient did not receive chemotherapy. The acute toxicity from chemotherapy was Grade 1 in 3%, Grade 2 in 17%, Grade 3 in 48%, and Grade 4 in 28%. Radiotherapy toxicity was Grade 1 in 7%, Grade 2 in 34%, Grade 3 in 21%, and Grade 4 in 28%. One Grade 5 toxicity occurred and the patient died from a myocardial infarction from chemotherapy and radiotherapy colitis during her course of therapy. The median follow-up time was 18.9 months. The overall survival estimates were 59% at 1 year and 47% at 2 years. The probability of local-regional failure was 38% at 1 year and 49% at 2 years. The probability of disease failure at any site was 45% at 1 year and 59% at 2 years.

CONCLUSION

The results suggest that twice-daily external irradiation to the pelvis and para-aortics with brachytherapy and concurrent chemotherapy resulted in an unacceptably high rate (31%, 9 of 29) of Grade 4 nonhematologic toxicity. One patient died from complications of therapy. Radiotherapy was completed per protocol in 69%. The survival estimates appear no better than standard fractionation radiotherapy without chemotherapy. Additional follow-up is necessary for long-term survival estimates.

Analysis of MSH3 in endometrial cancers with defective DNA mismatch repair

OBJECTIVE

To clarify the origin of defective mismatch repair (MMR) in sporadic endometrial cancers with microsatellite instability (MSI), a thorough mutation analysis was performed on the human mismatch repair gene MSH3.

METHODS

Twenty-eight MSI-positive endometrial cancers were investigated for mutations in the human mismatch repair gene MSH3 using single-strand conformation variant (SSCV) analysis of all 24 exons. All variants were sequenced. Loss of heterozygosity was investigated at all MSH3 polymorphisms discovered. A subset of tumors were investigated for methylation of the 5' promoter region of MSH3 using Southern blot hybridization.

RESULTS

An identical single-base deletion (delta A) predicted to result in a truncated proteins was discovered in six tumors (21.4%). This deletion occurs in a string of eight consecutive adenosine residues (A8). Because simple repeat sequences are unstable in cells with defective MMR, the observed mutation may be an effect, rather than a cause, of MSI. Evidence of inactivation of the second MSH3 allele in tumors with the delta A mutation would strongly support a causal role for these MSH3 mutations. However, there was no evidence of a second mutation, loss of sequences, or methylation of the promoter region in any of the tumors with the delta A mutation.

CONCLUSION

Although the delta A mutation is a frequent event in sporadic MSI-positive endometrial cancers, it may not be causally associated with defective DNA MMR.

Tumor size, irradiation dose, and long-term outcome of carcinoma of uterine cervix

PURPOSE

To assess the impact of tumor size and extent, and dose of irradiation on pelvic tumor control, incidence of distant metastases, and disease-free survival in carcinoma of the uterine cervix.

METHODS AND MATERIALS

Records were reviewed of 1499 patients (Stages IA-IVA) treated with definitive irradiation (combination of external beam plus two intracavitary insertions to deliver doses of 65-95 Gy to point A, depending on stage and tumor volume). Follow-up was obtained in 98% of patients (median 11 years, minimum 3 years, maximum 30 years). The relationship between outcome and tumor size was analyzed in each stage. Pelvic tumor control was correlated with total doses to point A and to the lateral pelvic wall.

RESULTS

The 10-year actuarial pelvic failure rate in Stage IB was 5% for tumors <2 cm, 15% for 2.1-5 cm, and 35% for tumors >5 cm (p = 0.01); in Stage IIA, the rates were 0%, 28%, and 25%, respectively (p = 0.12). Stage IIB unilateral or bilateral nonbulky tumors <5 cm had a 23% pelvic failure rate compared with 34% for unilateral or bilateral bulky tumors >5 cm (p = 0.13). In Stage IIB, pelvic failures were 18% with medial parametrial involvement only, compared with 28% when tumor extended into the lateral parametrium (p = 0.05). In Stage III, unilateral parametrial involvement was associated with a 32% pelvic failure rate versus 50% for bilateral extension (p < 0.01). Ten-year disease-free survival rates were 90% for IB tumors <2 cm, 76% for 2.1-4 cm, 61% for 4.1-5 cm, and 47% for >5 cm (p = 0.01); in Stage IIA, the rates were 93%, 63%, 39%, and 59%, respectively (p < or = 0.01). Patients with Stage IIB medial parametrial involvement had better 10-year disease-free survival (67%) than those with lateral parametrial extension (56%) (p = 0.02). Stage III patients with unilateral tumor extension had a 48% 10-year disease-free survival rate compared with 32% for bilateral parametrial involvement (p < or = 0.01). The presence of endometrial extension or tumor only in the endometrial curettings had no significant impact on pelvic failure. However, in patients with Stage IB disease, the incidence of distant metastases was 31% with positive curettings, 15% with negative curettings, and 22% with admixture (p < or = 0.01). In Stage IIA, the corresponding values were 51%, 33%, and 18% (p = 0.05). The 10-year disease-free survival rates in Stage IB were 67% with positive curettings, 81% for negative curettings, and 77% for admixture (p = 0.02); in Stage IIA, the rates were 45%, 66%, and 67%, respectively (p = 0.14). Because this is not a prospective Phase II dose-escalation study, the correlation of doses of irradiation with pelvic tumor control in the various stages and tumor size groups is not consistent. Nevertheless, with Stage IB and IIA tumors <2 cm in diameter, the pelvic failure rate was under 10% with doses of 70-80 Gy to point A, whereas for larger lesions even doses of 85-90 Gy resulted in 25% to 37% pelvic failure rates. In Stage IIB with doses of 70 Gy to point A, the pelvic failure rate was about 50% compared with about 20% in nonbulky and 30% in bulky tumors with doses > 80 Gy. In Stage III unilateral lesions, the pelvic failure rate was about 50% with < or =70 Gy to point A versus 35% with higher doses, and in bilateral or bulky tumors it was 60% with doses <70 Gy and 50% with higher doses.

CONCLUSIONS

Clinical stage and size of tumor are critical factors in prognosis, therapy efficacy, and evaluation of results in carcinoma of the uterine cervix. The doses to point A suggest that for lesions <2 cm, doses of 75 Gy result in < or =10% pelvic failures, whereas in more extensive lesions, even with doses of 85 Gy, the pelvic failure rate is about 30%; and in Stage IIB-III tumors, doses of 85 Gy result in 35-50% pelvic failures. Refinements in brachytherapy techniques and/or use of agents to selectively sensitize the tumors to irradiation will be necessary to improve the present results in invasive carcinoma of t

The clinical implications of hydronephrosis and the level of ureteral obstruction in stage IIIB cervical cancer

PURPOSE

There are two criteria for the diagnosis of Stage IIIB cervical cancer in the FIGO staging system: tumor fixation to the pelvic side wall and/or the presence of hydronephrosis due to tumor. However, we often encounter hydronephrosis without tumor fixed to the pelvic side wall or the level of ureteral obstruction not corresponding to the main tumor mass in the pelvis. The clinical implication of these phenomena remains unclear. We investigated the Stage IIIB population treated at the Mallinckrodt Institute of Radiology and hypothesized that, if hydronephrosis presents without tumor fixation to the pelvic side wall or if the level of ureteral obstruction is above the main pelvic tumor mass, it most likely resulted from external compression of ureter(s) by enlarged lymph nodes and, consequently, a worse outcome is expected.

METHODS AND MATERIALS

From 1959 to 1989, there were 297 patients with Stage IIIB cervical cancer who received definitive radiation therapy at the Mallinckrodt Institute of Radiology and were assessable for the presence of hydronephrosis and the level of ureteral obstruction. There were 281 patients who presented with tumor fixed to the pelvic side wall, and 62 of them were associated with concurrent hydronephrosis. An additional 16 patients presented with hydronephrosis without tumor fixation to the pelvic side wall. Among these 78 documented cases of hydronephrosis, the level of ureteral obstruction was above the true pelvis in 39 patients, and below the true pelvis in the other 39. Radiation therapy was individualized according to tumor extension and configuration; para-aortic lymph nodes were not routinely treated except in patients with clinical evidence of nodal metastasis.

RESULTS

The progression-free survival (PFS) at 5 years was 35% in 62 patients with hydronephrosis and tumor fixed to the pelvic side wall vs. 43% in 213 patients with tumor fixed to the pelvic side wall only (p=0.12). However, PFS at 5 years decreased to 23% in 16 patients who presented with hydronephrosis without tumor fixation to the pelvic side wall (p < 0.001). When the level of ureteral obstruction was investigated, 5-year PFS was 39% vs. 22%, respectively, for the obstruction below vs. above the true pelvis (p=0.02). The majority of patients with ureteral obstruction above the true pelvis died of distant metastasis.

CONCLUSIONS

The additional presence of hydronephrosis did not significantly worsen the PFS among Stage IIIB patients with tumor fixation to the pelvic side wall. However, hydronephrosis without tumor extending to the pelvic side wall or the level of ureteral obstruction above the true pelvis was associated with poor outcome due to a significant increase in distant failure. We propose that this population be separated from current Stage IIIB classification.

The homozygous complete hydatidiform mole: a unique resource for genome studies

The most frequent type of complete hydatidiform mole is a 46, XX homozygote formed by the fertilization of an empty ovum by a single haploid sperm that later duplicates its chromosomes to give a diploid tumor. The homozygous nature of these complete hydatidiform moles makes them unique resources for human genome studies. They can serve as homozygous controls in the development of single nucleotide polymorphism (SNP) markers and provide a way to obtain long-range haplotypes that are useful in population studies. The use of a homozygous control makes it possible to estimate the allele frequencies of the SNP markers in any population by sequencing pooled DNA samples. In this report, we present evidence of homozygosity of a complete hydatidiform mole using 20 diallelic markers distributed across the genome. Furthermore, its usefulness as a homozygous control in SNP development and as a resource for long-range haplotype determination is demonstrated using 11 newly discovered loci in the BRCA2 region on chromosome 13q12-q13.

Topotecan in platinum- and paclitaxel-resistant ovarian cancer

OBJECTIVE

The purpose of this study was to define the response rate and toxicity of topotecan in patients with ovarian cancer resistant to first-line therapy.

METHODS

Twenty patients with advanced or recurrent ovarian cancer were enrolled in a phase I/II protocol, and an additional 16 patients were treated following protocol closure at Washington University Medical Center. The starting dose of topotecan was 1.25 mg/m2/day given intravenously over 30 min for 5 consecutive days. Patients were eligible for response evaluation if they completed more than one cycle of topotecan. All patients were evaluated for toxicity.

RESULTS

Of 28 patients eligible for response evaluation, 26 were resistant to both platinum and paclitaxel prior to treatment with topotecan. There were four partial responders and no complete responders for a total response rate of 14% (95% confidence interval: 4 to 33%). All responders had exhibited primary resistance to both platinum and paclitaxel. Myelotoxicity was the major toxicity, with 92% of patients experiencing Gynecologic Oncology Group (GOG) grade 3 or 4 neutropenia and 67% experiencing GOG grade 3 or 4 thrombocytopenia. Other toxicity was minimal and easily managed. Fifty percent of patients receiving more than one cycle of topotecan tolerated a dose equal or greater to the starting dose.

CONCLUSIONS

Topotecan exhibits activity in patients with ovarian cancer resistant to both platinum and paclitaxel. Further study is warranted in less heavily pretreated patients and in combination with other chemotherapeutic agents.

Recurrent ovarian tumor with low malignant potential and cardiac metastasis

BACKGROUND

Up to 20% of ovarian epithelial tumors are classified as being of low malignant potential. Most of these low malignant potential tumors are detected at an early stage and have an excellent prognosis. This is a report of a woman with cardiac metastasis from an ovarian low malignant potential tumor.

CASE

This case describes a 53-year-old woman who presented with congestive heart failure and was found to have a recurrent stage III ovarian tumor of low malignant potential. A transesophageal echocardiogram revealed compression of the inferior vena cava and a mass encompassing the right atrium. Findings at autopsy confirmed a low malignant potential ovarian tumor thrombus involving the inferior vena cava and right atrium.

CONCLUSION

Ovarian low malignant potential tumors can metastasize in an aggressive manner. A transesophageal echocardiogram may be useful when the diagnosis of cardiac tumor thrombus is considered.

Mutational analysis of MLH1 and MSH2 in 25 prospectively-acquired RER+ endometrial cancers

Mutations in the DNA mismatch repair (MMR) genes MLH1 and MSH2 have been linked to several human cancers which display the replication error (RER) phenotype. Germline mutations in these two genes have been implicated in about 90% of families with hereditary nonpolyposis colorectal cancer (HNPCC). A significant proportion of endometrial cancers, the second most common malignancy of the HNPCC syndrome, also exhibit RER. We screened 125 primary endometrial adenocarcinomas with seven microsatellite markers and identified 25 specimens with RER (20%). We used single-strand conformation variant analysis to search for mutations in MLH1 and MSH2. Direct sequencing of variants revealed only one germline mutation in MLH1 and a single somatic mutation in MSH2. However, six previously unreported sequence polymorphisms in MLH1 were identified. Four of these polymorphisms show clear population-based differences in allele frequency. In addition, a highly informative marker for MLH1 was characterized. The low frequency of mutations in MLH1 and MSH2 in this large series of cancers suggests that other MMR genes are responsible for the RER phenotype in endometrial cancers.

Randomized trial of cisplatin versus cisplatin plus mitolactol versus cisplatin plus ifosfamide in advanced squamous carcinoma of the cervix: a Gynecologic Oncology Group study

PURPOSE

Cisplatin, mitolactol (dibromodulcitol), and ifosfamide have been the most active single agents in squamous carcinoma of the cervix identified so far by the Gynecologic Oncology Group (GOG). Combinations of cisplatin plus ifosfamide and cisplatin plus mitolactol are prospectively compared with cisplatin alone.

PATIENTS AND METHODS

Patients were randomized to receive cisplatin 50 mg/m2 or the same dose of cisplatin plus mitolactol (C + M) 180 mg/m2 orally on days 2 to 6, or cisplatin plus ifosfamide (CIFX) 5 g/m2 given as a 24-hour infusion plus mesna 6 g/m2 during and for 12 hours after the ifosfamide infusion, every 3 weeks for up to six courses. Of 454 patients entered, 438 were eligible and analyzed for response and survival.

RESULTS

CIFX had a higher response rate (31.1% v 17.8%, p = .004) and longer progression-free survival (PFS) time (P = .003) compared with cisplatin alone. The median times to progression or death were 4.6 and 3.2 months, respectively. C + M showed no significant improvement in these parameters compared with cisplatin alone. Survival was associated with initial performance score (PS; 0 was more favorable; P < .001) and with age (younger was unfavorable, P = .025). There was no significant difference in overall survival between cisplatin and either of the combinations. Leukopenia, renal toxicity, peripheral neurotoxicity, and CNS toxicity were more frequent with CIFX (P < .05).

CONCLUSION

CIFX improved the response rate and PFS duration in advanced cervix cancer compared with cisplatin alone, but at the cost of greater toxicity and with no improvement in survival.

A phase II trial of paclitaxel in patients with advanced or recurrent adenocarcinoma of the endometrium: a Gynecologic Oncology Group study

OBJECTIVE

To determine the efficacy and toxicity of paclitaxel in advanced or recurrent adenocarcinoma of the endometrium.

METHODS

Thirty patients with advanced or recurrent endometrial cancer with measurable disease not previously treated with chemotherapy were treated with paclitaxel, 250 mg/m2, over 24 hr with G-CSF, 5 mcg/kg/day, from Days 2 to 12. The cycle was repeated every 21 days. Patients who had received previous pelvic radiation were treated at an initial paclitaxel dose of 200 mg/m2. Twenty-eight patients were evaluable for response, and 29 patients for toxicity. All patients were Gynecologic Oncology Group performance status 0,1, or 2.

RESULTS

Complete responses were observed in 4 (14.3%) and partial responses in 6 patients (21.4%) for a response rate of 35.7%. Severe (grade 3 or 4) leukopenia or thrombocytopenia was seen in 18 and 2 patients, respectively. Grade 3 or 4 gastrointestinal toxicity was seen in 5, neurotoxicity in 3, anemia in 2, and cardiac toxicity in 1 patients. Alopecia was reported in 16 patients.

CONCLUSIONS

This dose and schedule of paclitaxel are active in patients with advanced or recurrent adenocarcinoma of the endometrium and should be considered for inclusion in phase III trials.

Frequent deletion of chromosome 1p sequences in an aggressive histologic subtype of endometrial cancer

The molecular genetic events underlying endometrial tumorigenesis are ill-defined at present. We have identified a region on the short arm of chromosome 1 which is frequently deleted in endometrial cancers. The region of deletion has been localized to bands 1p32-33. Deletion of 1p32-33 is seen more frequently in cancers of the highly aggressive papillary serous type than in cancers of the less-aggressive endometrioid type. These data suggest the presence of a tumor suppressor gene on 1p32-33 which is specifically involved in the development of endometrial cancers with poor outcome.

Pelvic inflammatory disease. Correlation of severity with CA-125 levels

OBJECTIVE

To determine whether elevated levels of cancer antigen 125 (CA-125) correlate with the severity and clinical outcome of pelvic inflammatory disease.

STUDY DESIGN

CA-125 levels were measured prospectively in 36 women with pelvic inflammatory disease using a commercial immunoassay. Initial inclusion criteria were abdominal tenderness, cervical motion tenderness and adnexal tenderness. Patients then were categorized into three groups based on the severity of the illness. Group 1 included patients with (1) temperature > or = 38.0 but < 38.5 degrees C or (2) WBC count > or = 10 but < 15 x 10(3) cells/microL. Group 2 included patients with (1) temperature > or = 38.5 degrees C or (2) WBC count > or = 15 x 10(3) cells/microL. Group 3 included patients who fulfilled the same criteria as group 2 but who also had an adnexal mass. Differences in CA-125 levels were compared statistically using the unpaired Student t test.

RESULTS

All patients with the diagnosis of pelvic inflammatory disease had CA-125 levels > 30 U/mL, with a range of 48-656. Moreover, the levels were significantly different among the three groups (group 1 vs. 2, P = .002; 1 vs. 3, P = .001; 2 vs. 3, P = .001), and a correlation between severity of disease and CA-125 levels was found. All patients with a presumed pelvic abscess had CA-125 levels in the range for neoplastic processes.

CONCLUSION

Elevated CA-125 levels correlate with the severity of pelvic inflammatory disease and outcome. Pelvic inflammatory disease must be considered in the differential diagnosis of elevated CA-125 levels and pelvic masses.

Local staging of endometrial carcinoma: comparison of transvaginal and intraoperative sonography and gross visual inspection

OBJECTIVE

The purposes of this study were to compare transvaginal sonography (TVS), intraoperative sonography (IOS), and gross visual inspection of the uterus with the histopathologic findings in patients with endometrioid adenocarcinoma, and to compare the accuracies of TVS, IOS, and gross visual inspection in staging of the tumor.

SUBJECTS AND METHODS

Sixteen patients with endometriod carcinoma were prospectively evaluated with TVS and IOS. Intraoperative gross visual inspection was also performed. Gray-scale, duplex, and color Doppler findings were used to stage patients. The location and depth of myometrial invasion and the presence of cervical involvement were recorded. At gross visual inspection, only the absence or presence and the depth of myometrial invasion (< or = 50% or >50%) were recorded. The data were analyzed three ways. First, in uterine specimens with myometrial invasion, a site-by-site comparison was made among the TVS and IOS findings and the final histologic results regarding location and depth of tumor invasion. Next, to determine tumor stage, myometrial invasion was defined in two ways: (1) absent, 50% or less, or greater than 50%; and (2) 50% or less or greater than 50%. Then imaging findings, gross visual inspection, and the final histologic results were compared.

RESULTS

Of the 16 uterine specimens, eight had myometrial invasion, with 13 separate sites of tumor invasion. IOS correctly identified the location and depth (+/- 10% of the histologic depth) of tumor invasion at four (31%) sites, and TVS at one (8%) site. TVS and IOS overestimated myometrial invasion due to adenomyosis, bulky intraluminal tumor, and lymphovascular invasion. When myometrial invasion was defined as absent, 50% or less, or greater than 50%, TVS was correct in 60% of cases, IOS in 56%, and gross visual inspection in 53%. When myometrial invasion was defined as 50% or less or greater than 50%, TVS was correct in 93% of cases, IOS in 81%, and gross visual inspection in 80%.

CONCLUSION

TVS and IOS are inaccurate in predicting the precise location and depth of myometrial tumor invasion. However, when a less rigorous definition of invasion is used, the accuracies of TVS and IOS are comparable to gross visual inspection in staging of the tumor.

Loss of heterozygosity of chromosome 3p sequences is an infrequent event in endometrial cancer

The genetic events associated with endometrial cancer are at present poorly understood. Frequent loss of heterozygosity (LOH) in a particular chromosomal region is often indicative of the involvement of a tumor suppressor gene. Previous studies are in disagreement over the involvement of a tumor suppressor gene(s) on the short arm of chromosome 3 in endometrial tumorigenesis. A set of 75 endometrial carcinomas was examined for the presence of LOH using 10 microsatellite repeat polymorphisms which are localized to chromosome 3p. In addition, these tumors were examined for the presence of replication errors (RER). Eleven of the 64 RER-negative tumors (17.2%) displayed LOH at one or more loci on chromosome 3p. The highest frequency of LOH at a single marker was 10.8% (4/37) at the locus D3S1312. The tumors investigated did not suggest that there was any common region of deletion. There was a significant increase in the frequency of 3p LOH in high-grade versus low-grade endometrioid adenocarcinomas (P < 0.05). Our results indicate that it is unlikely that a tumor suppressor gene on the short arm of chromosome 3 plays a major role in endometrial tumorigenesis.

The role of tumor necrosis factor receptors in tumor necrosis factor-alpha-mediated cytolysis of ovarian cancer cell lines

OBJECTIVE

Our purpose was to define the expression of tumor necrosis factor receptors on ovarian cancer cells and determine what role these receptors play in tumor necrosis factor-alpha-mediated cytolysis.

STUDY DESIGN

Cell surface expression of tumor necrosis factor-alpha receptors was determined on ovarian cancer cell lines Caov-3, SK-OV-3, NIH:OVCAR-3, and A2780 by a tumor necrosis factor-alpha-binding assay that used iodine 125-labeled tumor necrosis factor-alpha. Monoclonal antibodies specific for the 55 to 60 kd (TR60) and 75 to 80 kd (TR80) tumor necrosis factor receptors were used to determine the relative density of each receptor type. To elucidate which receptor(s) was responsible for mediating the signal for cytolysis, 24-hour MTT cytolytic assays that used tumor necrosis factor-alpha and emetine were performed in the presence or absence of receptor-specific monoclonal antibodies.

RESULTS

The four ovarian cell lines expressed a similar number of surface receptors, 4500 to 7000 per cell, had similar dissociation constants, 0.3 to 0.6 nmol/L, and expressed predominately the TR60 receptor subtype. Receptor function studies showed that the presence of the monoclonal antibody to the TR60 receptor completely inhibited tumor necrosis factor-alpha-mediated cytolysis, whereas the monoclonal antibody to the TR80 receptor only partially blocked cytolysis.

CONCLUSIONS

Ovarian cancer cell lines express both tumor necrosis factor receptors, with the TR60 receptor being the dominant subtype. Tumor necrosis factor-alpha-mediated cytolysis appears to be dependent on the presence of a functional TR60 receptor. The TR80 receptor does not appear requisite for cytolysis; however, a complementary role cannot be excluded. Manipulation of tumor necrosis factor receptor subtypes on ovarian cancer cells may enhance the cytotoxic effects, thus improving the therapeutic efficacy of tumor necrosis factor-alpha.

Growth modulatory effects of granulocyte-macrophage colony-stimulating factor on human cell lines derived from gynecologic malignancies

OBJECTIVE

In spite of increased expression of granulocyte-macrophage colony-stimulating factor surface receptors on solid tumors, the growth modulatory effects of granulocyte-macrophage colony-stimulating factor have not been well defined in gynecologic malignancies. We assessed the in vitro growth effects of granulocyte-macrophage colony-stimulating factor on such cell lines.

STUDY DESIGN

By use of a chromium 51 incorporation assay the in vitro growth effects of granulocyte-macrophage colony-stimulating factor on 12 cell lines derived from human malignancies were measured.

RESULTS

No growth stimulatory or inhibitory effect was mediated by granulocyte-macrophage colony-stimulating factor on six cell lines, whereas three lines showed consistent but not statistically significant dose-dependent growth stimulation. There was, however, a statistically significant increase in growth of short duration in three other cell lines at clinically relevant doses of granulocyte-macrophage colony-stimulating factor. Fluorometric cell cycle analysis demonstrated no change in cell-cycle distribution.

CONCLUSION

Within this in vitro system, stimulation of gynecologic malignancies in patients receiving granulocyte-macrophage colony-stimulating factor for mitigation of the myelosuppressive effects of cytotoxic chemotherapy does not appear to be widespread nor sustained beyond 48 hours.

Medically inoperable stage I endometrial carcinoma: a few dilemmas in radiotherapeutic management

PURPOSE

The aggressiveness of radiation therapy for patients with medically inoperable endometrial carcinoma is controversial. Patients may die of their underlining medical disease before succumbing to cancer. We try to identify certain subgroup of patients who might benefit most from an aggressive approach and also investigate the impact of residual tumor present in dilatation and curettage (D&C) specimen obtained in second intracavitary implant (ICI).

METHODS AND MATERIALS

From 1965 to 1990, 101 patients were treated for clinical clinical Stage I endometrial carcinoma with RT alone due to medical problems. Ages ranged from 39 to 94 years (median 71 years). There were 18 patients with clinical Stage IA and 83 with clinical Stage IB disease. Histology included 44 well-differentiated, 37 moderately differentiated, and 20 poorly differentiated tumors. Radiation therapy consisted of external beam only in 3 patients, ICI alone in 26, whole pelvis plus ICI in 10, and whole pelvis plus split field plus ICI in 62. A second D&C was performed on 26 patients at the time of the second ICI. Minimum follow-up was 2 years (median, 6.3 years).

RESULTS

The 5-year actuarial disease-free survival (DFS) for the studied cohort is comparable to the expected survival of an age-matched population. Pelvic control was 100% for Stage IA and 88% for Stage IB with 5-year disease-free survivals of 80 and 84%, respectively. We also observed a greater disassociation of DFS and overall survial among patients older than 75 years (84 and 55%, respectively) than in younger patients (84 and 78%, respectively). This is mainly because older patients succumbed to their medical illness. Well-differentiated disease demonstrated the trend toward a better outcome than moderately or poorly differentiated lesions in Stage IB patients (p = 0.05), but not in Stage IA patients. Aggressive radiation therapy approach showed the trend toward a better result in Stage IB patients 75 years of age or younger. There were two failures among 19 patients with no tumor found in the D&C specimen at the time of second implant. In contrast, seven patients with residual tumor seen in the endometrial sample at the time of second implant remain disease free.

CONCLUSIONS

Radiation therapy alone is an effective treatment modality for medically inoperable Stage I endometrial carcinoma. Disease-free survival can be translated into longer overall survival in the younger age group, but not in older patients. The latter tend to die of their underlining medical illness. Tumor differentiation influenced the prognosis of Stage IB disease. No tumor seen in the endometrial sampling at the time of second implant did not correlate with a better disease control, and the treatment plan should not be modified on such information.

Low frequency of CDKN2 mutation in endometrial carcinomas

The CDKN2 gene on chromosome 9p21 encodes the p16 inhibitor of cyclin D/cyclin-dependent kinase 4 complexes. Mutations and deletions of CDKN2 have been frequently identified in cell lines, whereas most primary tumors have demonstrated a lower frequency of alteration. To assess the role of CDKN2 in endometrial tumorigenesis, 34 tumor samples were examined for loss of heterozygosity at 9p21 and mutation in CDKN2. To identify tumors that had lost 9p21, samples were genotyped with markers flanking the CDKN2 locus. The frequency of CDKN2 mutation in endometrial carcinomas was determined by single-strand conformation variant analysis and direct sequencing of variants. Of the 34 tumors examined, three revealed loss of 9p21 sequences. Two samples were characterized by point mutations in CDKN2, one of which also showed loss of 9p21 sequences.

Ability of visual tests to predict underlying cervical neoplasia. Colposcopy and speculoscopy

OBJECTIVE

To describe the attributes of colposcopy and a low-power, magnified examination that utilizes chemiluminescent illumination (speculoscopy) in the visualization of cervical epithelium in a predefined, high-risk population and to compare how the two tests predict cervical histology.

STUDY DESIGN

During this multicenter, prospective study, 395 women who were referred to our colposcopy clinic underwent a repeat cervical smear and speculoscopy followed immediately by colposcopy. Abnormal colposcopic lesions were biopsied and endocervical curettage performed when indicated. Histologic diagnoses were compared with cytology, speculoscopy and colposcopy results.

RESULTS

Colposcopy was more sensitive than speculoscopy in the detection of cervical neoplasia (97% vs. 82%) (P < .001) and was superior in visualizing focal lesions and vascular patterns. An antecedent acetowhite abnormality detected during speculoscopy was highly predictive of subsequent abnormal colposcopy (97% positive predictive value). The "overall" rate of acetowhite lesions during speculoscopy was nearly half the rate during colposcopy (P < .001).

CONCLUSION

Colposcopy is better suited than speculoscopy to the follow-up of patients with abnormal cervical cytology because it facilitates lesion grading and assists in directing biopsies. Speculoscopy is best utilized as a dichotomous screening test based on the presence or absence of at least one well-demarcated acetowhite lesion and may be more suitable than colposcopy as an adjunct to cervical cancer screening due to its lower overcall rate. The biophysical properties of blue-white chemiluminescent light as it relates to the diagnosis of cervical neoplasia are discussed.

Potential of cervical electrosurgical excision procedure for diagnosis and treatment of cervical intraepithelial neoplasia

The aim of this study was to evaluate the diagnostic potential, treatment efficacy, specimen adequacy, and acute complication rate associated with electrosurgical excision procedure (EEP) of the cervix for the management of cervical intraepithelial neoplasia (CIN). Analysis was performed retrospectively on 153 consecutive patients who underwent EEP under colposcopic guidance. Patients with negative endocervical curettage (ECC), adequate colposcopy, and biopsy-proven CIN were considered candidates for therapeutic EEP, whereas patients with a positive ECC, inadequate colposcopy, or cytology two or more grades discordant from the biopsy results underwent diagnostic EEP. Histopathologic specimens were graded as adequate, suboptimal, or inadequate. Diagnostic EEP was performed in 85 cases, and the remaining 68 procedures were performed primarily for treatment. Specimens were graded as adequate in 83%, suboptimal in 13%, and inadequate in 4% of the diagnostic EEP's. Specimen adequacy correlated most strongly with operator experience (P < 0.05). Four patients were found to have microinvasive or invasive cervical carcinoma. Complications occurred in 7% of the EEPs performed. Most consisted of immediate or delayed hemorrhage. In conclusion, EEP is a safe, well-tolerated procedure which is acceptable as both a therapeutic and diagnostic tool in the management of CIN when performed by an experienced operator. We recommend that initial EEP procedures should be performed for therapeutic indications, since adequacy of EEP specimens correlated with the level of operator experience.

Allelic loss of sequences from the long arm of chromosome 10 and replication errors in endometrial cancers

Thirty-seven endometrial cancers were subjected to an allelotype analysis in an attempt to identify chromosomal regions that are lost in a significant portion of tumors and to identify tumors characterized by replication errors. Thirty-nine highly polymorphic microsatellite markers representing all chromosomal arms, excluding the X and the short arms of the acrocentrics, were examined. An average of 20 informative cases were evaluated for each marker. Genetic alterations were detected in 30 of the 37 tumors. Replication errors were identified in 8 tumor specimens. Loss of heterozygosity was observed for loci on all chromosomes examined with the exception of chromosomes 4 and 20. The two most frequent sites of loss were at the marker loci examined on 10q (40%) and 17p (29%). Six additional simple sequence repeat markers from 10q were genotyped in an effort to refine the region of 10q loss. The chromosome 10 markers used in these studies were physically mapped with the use of a panel of somatic hybrids that retain defined portions of chromosome 10. The observed patterns of loss of sequences on 10q suggest a role for a tumor suppressor gene in the 10q23-26 region in the development or progression of endometrial cancers.

Analysis of exposure times and dose escalation of paclitaxel in ovarian cancer cell lines

BACKGROUND

Paclitaxel (Taxol, Bristol-Myers Squibb, Princeton, NJ) is a promising drug for the treatment of ovarian cancer. Exposure times and dose-response relationships should be explored to optimize future clinical applications of this drug.

METHODS

The cytotoxic effects of paclitaxel on four human ovarian cancer cell lines (Caov-3, SK-OV-3, NIH: OVCAR-3, and A2780) were analyzed using chromium-51 release assays and tetrazolium-based colorimetric assays. Cells were exposed to paclitaxel for 4 and 24 hours at concentrations ranging from 10(-10)-10(-4) M. Two paclitaxel preparations were compared: paclitaxel in DMSO and paclitaxel in cremophor EL, the carrier used in pharmacological preparations. Cell cycle analysis compared cells exposed to 10(-5) M paclitaxel in dimethyl sulfoxide for 4 hours to those exposed for 24 hours.

RESULTS

No difference in cell proliferation was demonstrated after 4 hours of treatment when compared with 24 hours of treatment with paclitaxel in dimethyl sulfoxide at 24, 48 and 72 hours after treatment in any of the cell lines tested, over all concentrations tested. When paclitaxel in cremophor was used, there was a significant decrease in cell proliferation only at 10(-4) M of paclitaxel. Similar results were seen with 10(-4) M equivalent concentration of the carrier alone. A cell cycle shift to G2/M was the same after 4 or 24 hours of exposure when assessed at 24 hours.

CONCLUSIONS

A dose escalation from 10(-10) M to 10(-4) M of paclitaxel in dimethyl sulfoxide did not inhibit cell proliferation significantly in any of these cell lines. Moreover, shorter exposure times did not appear to alter the cellular response to paclitaxel. Consequently, administration of smaller dosages over shorter time periods may not compromise the cytotoxic effect of this agent. Clinical studies must be performed to validate these observations.

Correlates of length of stay in gynecologic oncology patients undergoing inpatient surgery

Escalating economic constraints require identification of the determinants of length of stay (LOS), since optimizing these may facilitate cost-effective care. However, risk factors for increased LOS are poorly understood. In order to identify correlates of long LOS, we retrospectively reviewed the charts of 252 consecutive patients who underwent major inpatient surgery on the gynecologic oncology service at Barnes Hospital during 1990. Of these, 86 had benign disease and 38 were excluded for other reasons, leaving 128 for analysis. The recorded variables of age, race, medical history, measures of nutritional state, primary cancer, prior therapy, blood loss, operating time, and attending surgeon were subjected to regression analysis. In order to avoid reducing cell numbers to insignificant sizes, the linked factors of type of surgery and primary site were not analyzed simultaneously. A separate analysis was performed substituting type of procedure for primary site. The mean LOS was 12 days (range, 4-30). Five factors emerged as significant correlates of longer LOS: decreasing preoperative albumin level (P < 0.001) and hemoglobin level (0.029), increasing age (0.017), operative blood loss (0.039), and prior platinum-based chemotherapy (0.043). Presence of vulvar and fallopian tube primaries was associated with significantly shorter LOS (0.023 and 0.037). Together these factors accounted for 36% of total variance in LOS. Substituting procedure type for primary site accounted for 37% of total variance in LOS and showed that only bowel surgery (0.001) and preoperative intracavitary implant were significantly correlated with longer LOS. Factors not associated with LOS (P > 0.05) were race, attending physician, number of preoperative medications or medical conditions, body mass index, other radiotherapy, and other primary sites and procedures. Future studies should attempt to determine why elderly, nutritionally depleted women undergoing long or complicated procedures are at high risk for long LOS and should assess interventions designed to minimize LOS for this high-risk group.

Familial peripartum cardiomyopathy after molar pregnancy

BACKGROUND

The potential complications of molar pregnancy are numerous and well defined, but associated peripartum cardiomyopathy has not been reported.

CASE

A 16-year-old primigravida with a family history of peripartum cardiomyopathy requiring cardiac transplantation underwent suction curettage of a complete mole at 12 weeks' gestation. Three months after evacuation, she developed congestive heart failure. Radionuclide ventriculography demonstrated an ejection fraction of 30%, echocardiography revealed enlargement and ventricular hypokinesis, and a myocardial biopsy specimen contained hypertrophy and fibrosis without necrosis or active inflammation. The patient improved with medical therapy.

CONCLUSION

Peripartum cardiomyopathy is a potential complication of molar pregnancy. In spite of the poor prognosis sometimes reported for this disease, good functional outcome may follow.

Use of speculoscopy in the evaluation of women with atypical Papanicolaou smears. Improved cost effectiveness by selective colposcopy

Since up to 45% of patients with atypical Papanicolaou smears have been shown to have significant pathology, women with persistent atypia are usually referred for colposcopy. This study evaluated the use of a new adjunctive screening test, speculoscopy, in selecting women with atypical Papanicolaou smears who would most benefit from referral for colposcopy. Both screening and referral patients were evaluated with the Papanicolaou smear, speculoscopy and colposcopy at 10 study centers. Biopsies were obtained from most women with positive colposcopy. The results in patients with atypical smears were used to perform a cost-benefit analysis of each of three management protocols. Using the results of speculoscopy to select women with atypical Papanicolaou smears for colposcopy provided a cost-effective alternative to performing colposcopy either on all women or on those with persistent atypia following treatment. Even when all women undergo speculoscopy at the time of screening, this protocol provides a cost savings of up to 24% and no significant loss of diagnostic accuracy. These data suggest that speculoscopy performed at the time of initial screening can accurately select women with atypical Papanicolaou smears who require colposcopy for diagnostic biopsy in a cost-effective manner.

Divergent effects of taxol on tumor necrosis factor-α-mediated cytolysis of ovarian carcinoma cells

OBJECTIVE

Our objective was to study the combined effect of taxol and tumor necrosis factor-alpha on the cytolysis of human ovarian carcinoma cell lines, because taxol has been shown to be active against ovarian carcinoma and has also been shown to increase tumor necrosis factor-alpha release from macrophages.

STUDY DESIGN

The combined effect of taxol and tumor necrosis factor-alpha on the cell lines Caov-3, SK-OV-3, NIH:OVCAR-3, and A2780, which are sensitive to the cytolytic effect of tumor necrosis factor-alpha in the presence of inhibitors of protein synthesis, was investigated with a 24-hour chromium 51 release assay.

RESULTS

At therapeutic concentrations taxol caused a significant increase in tumor necrosis factor-alpha-mediated cytolysis of Caov-3 and A2780 (p < or = 0.05). By contrast, taxol caused a decrease in the tumor necrosis factor-alpha-mediated cytolysis of SK-OV-3 and NIH:OVCAR-3 (p < or = 0.01).

CONCLUSION

These results suggest that ovarian carcinomas have a heterogeneous response to the chemotherapeutic effect of taxol.

Effects of radiation on TNF alpha-mediated cytolysis of cell lines derived from cervical carcinomas

The effect of radiation, a primary mode of treatment for cervical malignancies, on the tumor necrosis alpha (TNF alpha)-mediated cytolysis of five cell lines derived from human cervical carcinoma cell lines (C-33 A, ME-180, HT-3, MS751, and SiHa) was analyzed. Results of this analysis showed that all of the cell lines were resistant to the cytolytic effects of TNF alpha. Although resistant when protein synthesis proceeds normally, ME-180, HT-3, MS751, and SiHa cells were sensitive to TNF alpha-mediated cytolysis in the presence of protein synthesis inhibitors. The cytolytic response of these cells to radiation was heterogeneous, with C-33 A cells being the most radiosensitive and SiHa cells being the least radiosensitive. The cell lines ME-180, MS751, and HT-3 were intermediate in their sensitivities to radiation. Because radiation is known to inhibit protein synthesis, the ability of radiation to enhance TNF alpha cytolytic activity was examined. The cell lines with intermediate sensitivities to radiation (ME-180, HT-3, and MS751) demonstrated statistically significant synergistic increases in cytolysis when exposed to TNF alpha in combination with radiation. Neither the radioresistant SiHa cell line nor the radiosensitive C-33 A cell line displayed increased cytolysis with increasing concentrations of TNF alpha at any dose of radiation. Possible mechanisms which may explain the synergy in ME-180, HT-3, and MS751 cells and lack of synergy in C-33 A and SiHa cells by TNF alpha and radiation are discussed.

The effects of cyclosporin A on the lysis of ovarian cancer cells by cisplatin or adriamycin

The major limitation to curative therapy for ovarian cancer is the development of drug resistance. Cyclosporin A (CsA), an immunosuppressive agent that has been used extensively in organ transplantation, also has been shown to decrease the resistance of cancer cells to some chemotherapeutic agents. Since cisplatin (CDDP) is the most common drug used for the treatment of ovarian cancer, we evaluated the potential of CsA to decrease resistance to CDDP in ovarian cancer cells selected for resistance to CDDP (A2780-CDDP). Although CsA significantly increased the sensitivity of A2780-CDDP cells to cytolysis by CDDP it did not increase CDDP sensitivity in the CDDP-sensitive parent cells (A2780), that is, CsA did not decrease basal resistance to CDDP. Both A2780-CDDP and A2780 are sensitive to cytolysis by Adriamycin (ADR). CsA significantly decreased the basal resistance of both cell lines to ADR. Interestingly, the effect of the protein synthesis inhibitors, emetine and cycloheximide, was similar to that of CsA, suggesting that CsA decreased selected resistance to CDDP and decreased basal resistance to ADR by affecting a protein synthesis-dependent resistance mechanism(s). In contrast to CsA and protein synthesis inhibitors, buthionine sulfoximine, an inhibitor of glutathione synthesis, decreased basal resistance of both cell lines to cytolysis by CDDP but not ADR, while verapamil, an inhibitor of P-glycoprotein, had no effect on cytolysis in either cell line. These results suggest that CsA may not decrease resistance to CDDP or ADR-mediated cytolysis by reducing glutathione or by inhibiting P-glycoprotein.

High rates of atypical cervical cytology: occurrence and clinical significance

The current literature suggests that atypical (benign atypia or class II) Papanicolaou smears occur at a frequency of 1.6-5.4% and are associated with a substantial rate of underlying cervical dysplasia. However, we noted that our rate of atypia exceeded these figures, particularly in our clinic population. To quantify this observation, 1107 consecutive Papanicolaou smears from the clinic population were audited prospectively and compared with 262 consecutive Papanicolaou smears performed contemporaneously in private patients served by the same laboratory. The rate of histologic dysplasia underlying this diagnosis was assessed by analyzing the results of 101 consecutive colposcopic examinations performed subsequently on clinic patients evaluated for persistently atypical cytology (atypical index smear followed by repeat cytology scheduled 2-4 months later). The prevalence of atypia in the clinic population was 321 of 1107 (29%; 95% confidence interval [CI] 26-32%), a rate 2.3 times that of the private patients (33 of 262, 13%) (P less than .001). Eighteen of 101 clinic patients with persistent atypia had dysplasia (18%; 95% CI 11-25%), and 25 of 101 (25%; 95% CI 17-33%) had human papillomavirus infection, both documented by the histology of directed cervical biopsies. Cervical intraepithelial neoplasia grade II or higher was present in three of these 18 women (17%; 95% CI 6-39%). We conclude that some populations have atypical cervical cytology at a frequency much greater than that reported previously. Furthermore, the pathology underlying this diagnosis is considerable and warrants evaluation. The optimal management of atypical cervical cytology in such populations is problematic.

Resistance to cytolysis by tumor necrosis factor alpha in malignant gynecological cell lines is associated with the expression of protein(s) that prevent the activation of phospholipase A2 by tumor necrosis factor alpha

Although there are a limited number of cell lines that are sensitive to cytolysis by tumor necrosis factor alpha (TNF alpha), the vast majority are resistant. The analysis of TNF alpha-sensitive cells has shown that phospholipase A2 is activated by TNF alpha in these cells and that the activity of phospholipase A2 is required for their cytolysis. Many cell lines that are resistant to TNF alpha-mediated cytolysis are dependent on the maintenance of protein synthesis for their resistance. We have recently shown that this is also true for TNF alpha-resistant cell lines derived from cervical (ME-180 and SiHa) and ovarian (SK-OV-3 and OVCAR-3) carcinomas, in that they are sensitive to cytolysis by TNF alpha only in the presence of protein synthesis inhibitors. Here we show that the TNF alpha-mediated cytolysis of these resistant cell lines in the presence of the protein synthesis inhibitor emetine is similar to that of sensitive cells, in that cytolysis is inhibited by the inhibitors of phospholipase A2. The measurement of the release of radiolabeled material from cervical and ovarian carcinoma cell lines prelabeled with [3H]arachidonic acid showed that not only was phospholipase A2 required for the cytolysis of these cells by TNF alpha in the presence of protein synthesis inhibitors, but more importantly, phospholipase A2 was not activated by TNF alpha unless protein synthesis was inhibited. These results indicate that a protein synthesis-dependent resistance mechanism expressed by these cell lines blocks TNF alpha-mediated cytolysis by preventing the activation of phospholipase A2 by TNF alpha.

Inhibition of protein synthesis enhances the lytic effects of tumor necrosis factor alpha and interferon gamma in cell lines derived from gynecological malignancies

Few clinical responses have occurred in preliminary studies using the cytokines tumor necrosis factor alpha (TNF alpha) or interferon gamma (IFN gamma) in cancer patients. This may be related to the observation that many malignant cell lines are resistant to lysis by these cytokines in vitro. Resistance to lysis by TNF alpha or IFN gamma in many cells is controlled by a protein-synthesis-dependent mechanism, such that when protein synthesis is inhibited cells become sensitive to lysis by these cytokines. Because there is some evidence that TNF alpha and IFN gamma act through different lytic mechanisms and are opposed by different resistance mechanisms, we treated a panel of eight cell lines, five derived from human cervical carcinomas (ME-180, MS751, SiHa, HT-3, and C-33A) and three derived from ovarian carcinomas (Caov-3, SK-OV-3, and NIH: OVCAR-3) with both TNF alpha and IFN gamma to determine whether such combination treatment might maximize in vitro cell lysis. Our results showed that pretreatment with IFN gamma followed by exposure to TNF alpha in the presence of protein synthesis inhibitors increased lysis of seven of the eight cell lines above that seen with either TNF alpha or IFN gamma and inhibitors of protein synthesis. Only the cell line C-33A was resistant to lysis by TNF alpha and IFN gamma, when exposed to these agents both alone and in combination with protein synthesis inhibitors. Clinically, combining the cytokines TNF alpha and IFN gamma with protein synthesis inhibitors may maximize the in vivo lytic effects of these cytokines.

Proliferative and antiproliferative effects of interferon-gamma and tumor necrosis factor-alpha on cell lines derived from cervical and ovarian malignancies

Four human cell lines derived from cervical carcinomas (ME-180, SiHa, HT-3, and MS751) and three human cell lines derived from ovarian carcinomas (SK-OV-3, Caov-3, and NIH:OVCAR-3) were analyzed in vitro to determine the effect of recombinant interferon-gamma and recombinant human tumor necrosis factor-alpha on cell growth and survival. The effects of interferon-gamma, tumor necrosis factor-alpha, and both interferon-gamma and tumor necrosis factor-alpha on cell growth were measured after 24 and 72 hours of incubation by the incorporation of chromium 51. The results of this analysis showed that all seven cell lines were resistant to the antiproliferative action of tumor necrosis factor-alpha, that the growth of most cell lines was inhibited by interferon-gamma by 72 hours of incubation, and that after 72 hours of incubation all cell lines demonstrated a synergistic antiproliferative response to the combination of interferon-gamma and tumor necrosis factor-alpha. However, the effects of these cytokines on cell growth were found to differ among cell lines and varied with the concentration and the duration of incubation. The growth of one cell line (Caov-3) was stimulated by both tumor necrosis factor-alpha and interferon-gamma. These results suggest that the clinical effects of these cytokines on the growth of gynecologic cancers may be more complex than previously supposed.

Recurrent gestational trophoblastic disease. Experience of the Southeastern Regional Trophoblastic Disease Center

Between 1968 and 1985, 28 patients with recurrent gestational trophoblastic disease (GTD) were treated at the Southeastern Regional Trophoblastic Disease Center. Sixteen patients received primary therapy at this center and had recurrence diagnosed by re-elevation of human chorionic gonadotropin (hCG) levels after three consecutive negative levels: five (2.5%) of 204 patients with nonmetastatic GTD, three (3.7%) of 81 with good prognosis metastatic disease, and eight (13%) of 61 with poor prognosis disease. The remaining 12 patients were referred for therapy after receiving primary therapy elsewhere. All episodes of recurrence were observed within 36 months of remission with 50% and 85% before 3 and 18 months, respectively. Fourteen (56%) of 25 patients who achieved secondary remission developed a second recurrence and five (45%) of 11 surviving a second recurrence developed one or more further episodes of recurrent GTD. Nineteen patients (68%) have sustained remission 18 months following therapy for recurrent GTD. Factors relating to development and survival of recurrent disease include: poor prognosis metastatic disease, inadequate initial staging and therapy, lack of adequate maintenance chemotherapy beyond the first negative hCG level, and prolonged intervals between cycles of chemotherapy. Recent regimens introduced have contributed to an increasing salvage rate: 15 of 18 patients treated since 1978 are without evidence of disease whereas only four of ten treated prior to 1978 are currently in remission (P = 0.03).

Expression of a resistance mechanism in ovarian and cervical carcinoma cells prevents their lysis by gamma-interferon

Despite extensive evidence that recombinant human gamma-interferon (IFN-gamma) exerts antiproliferative effects on a variety of cancer cell lines, IFN-gamma has not been shown to lyse cells in vitro. In order to determine whether some cancer cells might actively resist lysis by IFN-gamma, we examined eight arbitrarily selected cell lines derived from gynecological malignancies (ME-180, MS751, HT-3, SiHa, and C-33A human cervical carcinoma lines; Caov-3, SK-OV-3, and NIH:OVCAR-3 human ovarian carcinoma cell lines) for lysis by IFN-gamma. In a 24-h assay involving release of 51Cr from cells, none of these cell lines was lysed by IFN-gamma, either alone or in combination with actinomycin-D or emetine, two inhibitors of protein synthesis. However, pretreatment of cells with 100 units/ml of IFN-gamma for 24 h, followed by inhibition of protein synthesis, led to significantly increased lysis of the cell lines ME-180, MS751, and Caov-3. These results indicate that IFN-gamma induces a lytic mechanism in some cancer cells that is opposed by a protein synthesis-dependent resistance mechanism. This suggests that a combination therapy involving IFN-gamma and inhibitors of protein synthesis may be useful in the treatment of some cancers.

Reduced natural cytotoxic cell activity in patients receiving cisplatin-based chemotherapy and in mice treated with cisplatin

In mice natural cytotoxic (NC) cells are known to play a role in the rejection of tumours that are sensitive to NC-mediated lysis. We have recently shown that in vitro human and murine tumour cells become more sensitive to lysis mediated by NC cells in the presence of the anti-cancer drug cisplatin. If NC activity plays a role in tumour surveillance in humans, then the ability of NC cells to eliminate tumours in patients treated with cisplatin would not only be dependent on cisplatin increasing the sensitivity of tumours to NC mediated lysis, but would also depend on the maintenance of high levels of NC activity during chemotherapy. Here we report that patients receiving chemotherapy that included cisplatin showed a time-dependent reduction in NC activity. NC activity was normal 1 day after treatment; however, 15 days after treatment patients had an eight- to 16-fold reduction in NC activity that returned to normal levels by day 21. The reduction in NC activity of patients was coincident with a reduction in circulating monocytes. Mice treated with only cisplatin showed a similar reduction in NC activity. Mice treated with cisplatin had a reduced level of NC activity that was first apparent 8 days after treatment, reached a nadir on day 15, and returned to normal levels on day 22.

Dexamethasone used as an antiemetic in chemotherapy protocols inhibits natural cytotoxic (NC) cell activity

Because dexamethasone is often included as an antiemetic in chemotherapy protocols that involve cisplatin and because cisplatin has been shown to increase the in vitro lysis of tumor cells by natural cytotoxic (NC) effector cells, we determined the NC activity of 27 patients who received dexamethasone in conjunction with seven different cisplatin-based chemotherapy protocols. The results of this analysis showed that the NC activity of patients who received cisplatin-based chemotherapy protocols that included dexamethasone was reduced significantly 24 hours after treatment compared with before treatment (P less than 0.001). The addition of dexamethasone (at a concentration equivalent to the plasma level of patients treated with dexamethasone) to the in vitro assay of NC activity caused a significant decrease in NC activity compared with when dexamethasone was not added (P less than 0.001). There was no cumulative effect of dexamethasone in that the reduction of NC activity by dexamethasone was not significantly different in patients who had been treated previously at least four times and in patients who were treated for the first time. When dexamethasone was not included in the chemotherapy protocol the NC activity of 19 patients was not reduced 24 hours after treatment. These results indicate that dexamethasone causes a significant reduction in NC activity. Although the tumor surveillance role of human NC cells in vivo has not been established, the effect of dexamethasone on NC cells suggests that additional research of the effect of dexamethasone in cisplatin-based chemotherapy protocols is warranted.

Common expression of a tumor necrosis factor resistance mechanism among gynecological malignancies

The efficacy of tumor necrosis factor alpha (TNF alpha) as an anticancer agent is limited. This limitation might be related to the expression of a protein-synthesis-dependent resistance mechanism that prevents the lysis of tumor cells by TNF alpha. To test this possibility eight randomly selected human cell lines, three derived from ovarian carcinomas and five derived from cervical carcinomas, were tested for their in vitro sensitivity to TNF alpha-mediated lysis. The results of this analysis showed that all eight cell lines are normally resistant to lysis by TNF alpha. However, in the presence of inhibitors of protein synthesis, seven of them showed a significant increase in TNF alpha-mediated lysis. Measurement of protein synthesis showed that there is a linear correlation between the level of inhibition of protein synthesis and the level of TNF alpha-mediated lysis. The fact that seven of eight randomly selected cell lines are resistant to TNF alpha because they express a protein-synthesis-dependent resistance mechanism suggests that this mechanism of resistance may be common among gynecological cancers. The results also suggest that a therapy involving TNF alpha and inhibitors of protein synthesis might be useful for the treatment of gynecological malignancies.

In vitro analysis of the anticancer potential of tumor necrosis factor in combination with cisplatin

We have recently shown that cisplatin increases the natural cytotoxic (NC) cell-mediated lysis of a variety of human adenocarcinoma cell lines that are resistant to cisplatin or NC activity alone. Because NC lysis is mediated by tumor necrosis factor alpha (TNF) bound to the surface of NC effector cells, we analyzed the ability of TNF in combination with cisplatin to increase the lysis of tumor cells. The in vitro anticancer potential of the combination of TNF and cisplatin was determined for both dividing and nondividing populations of two human ovarian carcinoma cell lines, SK-OV-3 and OVCAR-3. Nondividing SK-OV-3 and OVCAR-3 cells are resistant to cisplatin and TNF when used as single agents. Dividing OVCAR-3 cells are approximately two times more sensitive to TNF than dividing SK-OV-3 cells, whereas dividing SK-OV-3 cells are approximately ten times more sensitive to cisplatin than dividing OVCAR-3 cells. TNF at 1000 units/ml in the presence of clinically low concentrations of cisplatin (0.6-0.25 micrograms/ml) increased the lysis of dividing OVCAR-3 cells above the value expected for the sum lysis mediated by cisplatin alone and lysis mediated by TNF alone. Similar results were obtained with dividing populations of the SK-OV-3 cell line. The combination of cisplatin and TNF did not increase the lysis of the nondividing populations of either cell line. The increased lysis of tumor cells combined with the maintenance of specificity for only dividing cells indicates that the combination of cisplatin and TNF may be useful for the treatment of tumors that are resistant to either cisplatin or TNF.