The impact of the absolute number and ratio of positive lymph nodes on survival of endometrioid uterine cancer patients

The aim of the study was to determine the impact of the absolute number and ratio of positive lymph nodes on the survival in node-positive endometrioid uterine cancer. Data were obtained from the National Cancer Institute Registry from 1988 to 2001. Analyses were performed using Kaplan–Meier and Cox proportional hazard methods. A total of 1222 women were diagnosed with stage IIIC-IV node-positive endometrioid corpus cancer. The 5-year disease-specific survival of women with 1, 2–5, and >5 positive nodes were 68.1, 55.1, and 46.1%, respectively (P<0.001). Increasing lymph node ratio, expressed as a percentage of positive nodes to total nodes identified (⩽10, >10–⩽50, and >50%), was associated with a decrease in survival from 77.3 to 60.7 to 40.9%, respectively (P<0.001). The absolute number of positive nodes and the lymph node ratio remained significant after adjusting for stage (IIIC vs IV) and the extent of lymphadenectomy (⩽20 vs >20 nodes). On multivariate analysis, the absolute number of positive nodes and lymph node ratio were significant independent prognostic factors for survival. Increasing absolute number of positive nodes and lymph node ratio are associated with a poorer survival in women with node-positive uterine cancers. The stratification of node-positive uterine cancer for prognostic and treatment purposes warrants further investigation.

The prognostic factors responsible for survival of women with neuroendocrine small-cell cervical carcinoma—A study of 188 women

5539

Background: To determine the clinical and pathological factors associated with survival in women with neuroendocrine small-cell cervical carcinoma. Methods: A review of the literature identified 136 patients with neuroendocrine small-cell carcinoma and an additional 52 patients identified from tumor registry databases at four hospitals. Survival analyses and predictors of outcome were analyzed using Kaplan-Meier method and Cox regression analysis. Results: Of 188 patients, the median age was 41.5 years (range: 20–87 years); 135 had stages I-IIA, 45 IIB-IVA, and 8 had stage IVB disease. Of all patients, 55.3% underwent primary surgery, 16.0% had chemoradiation therapy, 12.8% primary radiation therapy, 3.2% chemotherapy alone, and 12.8% had unknown or no primary treatment. Of the women who had initial surgery, 46.8% patients underwent a radical hysterectomy, and 6.4% had a simple hysterectomy. 49.5% of patients with nodal information had lymph node metastases. After initial surgery, 15.4% of all patients had adjuvant radiation therapy, 13.8% chemoradiation, 6.9% chemotherapy, and 2.1% had neoadjuvant chemoradiation. Of the 81 patients who received chemotherapy, 51.9% had etoposide and cisplatin combinations, 25.9% other cisplatin combinations, and 7.4% had cisplatin alone. The 5-year disease-specific survivals for those stage I-IIA, IIB-IVA, and IVB were 36.8%, 9.8%, and 0.0%, respectively (p<0.001). Those with tumors <2 cm showed a trend toward better survival (67.4% vs. 34.4%) compared to those with larger tumors (p=0.057). Women with stage I-IIA disease who underwent a radical hysterectomy had a survival of 42.5% vs. 38.4% without radical surgery. Chemotherapy (adjuvant or radiation sensitizer) was associated with improved survival in patients with stages IIB-IVA disease compared to those who did not receive chemotherapy (17.8% vs. 6.0%; p=0.043). On multivariable analysis, early stage of disease and chemotherapy were independent prognostic factors for improved survival. Conclusions: Advanced stage of disease is a poor prognostic factor for survival in neuroendocrine small-cell cancer of the cervix. Chemotherapy appears to offer a survival advantage, particularly in patients with stage IIB-IVA disease.

No significant financial relationships to disclose.

Biomarker and in vitro chemoresistance profiles of undifferentiated ovarian cancers

2532

Background: To determine the biomarker expression and drug resistance patterns of undifferentiated ovarian cancers. Methods: Biomarker expression was determined by immunohistochemistry. In vitro drug resistance profiles were analyzed by assays exposing tumors to suprapharmacologic doses of chemotherapy. Results: Of 177 ovarian cancer specimens, 63 were classified as undifferentiated tumors and 114 well-differentiated cancers were used for comparison. Of the undifferentiated tumors, 46.7% were primary cancers and the remainder were recurrent cancers. Most of the well-differentiated tumors were obtained from primary (82%) vs. recurrent disease specimens. The average DNA index and S-phase fraction were significantly higher in the undifferentiated vs. well-differentiated tumors (1.42 vs. 1.23, p=0.025 for DNA index; 1.69 vs. 3.06, p<0.0001 for S phase fraction). In addition, the percent of tumors with p53 mutations was also higher in the undifferentiated compared to the well-differentiated tumors (47.8% vs. 17.8%; p=0.005). The mean percent cell inhibition was significantly lower in the undifferentiated tumors compared to well-differentiated cancers after exposure to etoposide (54%±21 vs. 80%±18; p=0.0002), doxorubicin (59%±28 vs. 80.0%±21; p=0.07), and topotecan (61.7%±20 vs. 71%±21; p=0.015). Compared to well-differentiated tumors, undifferentiated tumors tended to be more resistant to etoposide (40% vs. 11%), doxorubicin (22% vs. 9%), and topotecan (19% vs. 16%). However, the drug resistance patterns after exposure to taxanes (paclitaxel and taxotere) and platinums (carboplatin and cisplatin) were similar. Conclusions: Undifferentiated tumors of the ovary have a significantly different biomarker expression and drug resistance profiles compared to well-differentiated tumors. Given that undifferentiated cancers provide a treatment challenge for the clinician, this data can provide additional prognostic and therapeutic information, and warrants further investigation.

No significant financial relationships to disclose.

Characteristics of a phase II study that predict for a positive phase III trial—A study of 383 clinical trials

6604

Background: To identify the characteristics of a phase II study that predict for a subsequent positive phase III trial. Methods: All phase II studies and subsequent phase III clinical trials on biologics in advanced cancers published from 1985 to 2005 were extracted. Chi-square test and logistic regression models were used for analyses. Results: 383 phase III clinical trials and their preceding phase II studies were identified. 183 (47.8%) phase III trials were “positive” and 200 (52.2%) were negative. 220 trials (57.4%) used biologics alone and 162 (42.3%) used a combination of biologics and chemotherapy. Over the study periods 1985–1990, 1991–1995, 1996–2000, 2001–2005, the percentage of phase II studies that led to positive phase III trials increased from 37.7% to 33.3% to 56.0% to 76.8% (p<0.001). The interval between the publication of phase II and III studies, 0.5–5, 6–10, 11–15, and 16–20 years were also associated with the success of phase III trial, 55.6%, 42.2%, 32.6%, and 10.0%, respectively (p<0.001). Phase II studies from multiple rather than single institutions were more likely to have a successful trial (60.4% vs. 39.4%; p<0.001). The percent of successful trials from pharmaceutical companies was significantly higher compared to academic, cooperative groups, and research institutes (89.5% vs. 44.2%, 45.2%, 46.3%; p=0.002). The publication of the phase II studies in journals with an impact factor of 8 or greater compared to those less than 8 was also predictive (44.1% vs. 58.0%; p=0.024). Phase II studies with a lower attrition rate were also associated with a positive phase III trial (61.1% vs. 41.8%; p=0.025). On multivariable analysis, all factors, except for journal impact factor, were independent predictive factors for a positive phase III trial. Conclusions: In phase II biologic studies, characteristics such as larger number of patients, more recent year of study, multiple vs. single institution participation, shorter time period between publication of phase II to phase III trial, and lower rate of attrition were predictive factors of success in a phase III trial. Investigators need to be cognizant of these phase II study characteristics before designing phase III trials.

No significant financial relationships to disclose.

A case of mixed adult Wilms' tumour and angiosarcoma responsive to carboplatin, etoposide and vincristine (CEO)

Here we report an unusual case of mixed Wilms' tumour and angiosarcoma in a 38-year-old female patient who presented with haematuria and right lower back pain. A computed tomographic (CT) scan confirmed a massive renal tumour associated with extensive retroperitoneal lymph node involvement, bony metastases and a right hip fracture. She was initially managed with palliative nephrectomy, which was followed by rapid postoperative deterioration. Histopathology revealed differentiated adult Wilms' tumour with renal angiosarcoma, whereas the pathology of the para-aortic lymph node and bone metastasis revealed angiosarcoma only. In view of her cachexia and cytopaenia, emergency chemotherapy was initiated using a modified regimen of carboplatin, etoposide and vincristine (CEO) in preference to the more traditional but less well-tolerated VAC (vincristine, actinomycin D, cyclophosphamide). Four cycles of this protocol yielded a dramatic response on re-staging CT scan. This case suggests that highly angiogenic tumours such as angiosarcoma may be effectively palliated using agents usually reserved for refractory Wilms' tumour, and supports the view that adult Wilms' tumour is more sensitive to such agents.

The potential therapeutic role of lymph node resection in epithelial ovarian cancer: a study of 13918 patients

The aim of the study is to determine the role of lymphadenectomy in advanced epithelial ovarian cancer. The data were obtained from the Surveillance, Epidemiology and End Results (SEER) program reported between 1988 and 2001. Kaplan–Meier estimates and Cox proportional hazards regression models were used for analysis. Of 13 918 women with stage III–IV epithelial ovarian cancer (median age: 64 years), 87.9% were Caucasian, 5.6% African Americans, and 4.4% Asians. A total of 4260 (30.6%) underwent lymph node dissections with a median number of six nodes reported. For all patients, a more extensive lymph node dissection (0, 1, 2–5, 6–10, 11–20, and >20 nodes) was associated with an improved 5-year disease-specific survival of 26.1, 35.2, 42.6, 48.4, 47.5, and 47.8%, respectively (P<0.001). Of the stage IIIC patients with nodal metastases, the extent of nodal resection (1, 2–5, 6–10, 11–20, and >20 nodes) was associated with improved survivals of 36.9, 45.0, 47.8, 48.7, and 51.1%, respectively (P=0.023). On multivariate analysis, the extent of lymph node dissection and number of positive nodes were significant independent prognosticators after adjusting for age, year at diagnosis, stage, and grade of disease. The extent of lymphadenectomy is associated with an improved disease-specific survival of women with advanced epithelial ovarian cancer.

Ovarian cancer in younger vs older women: a population-based analysis

To compare the clinico-pathologic prognostic factors and survival of younger vs older women diagnosed with epithelial ovarian cancer. Demographic, clinico-pathologic, treatment, and surgery information were obtained from patients with ovarian cancer from the Surveillance, Epidemiology, and End Results Program from 1988 to 2001 and analysed using Kaplan–Meier estimates. Of 28 165 patients, 400 were <30 years (very young), 11 601 were 30–60 (young), and 16 164 were >60 (older) years of age. Of the very young, young, and older patients, 261 (65.3%), 4664 (40.2%), and 3643 (22.5%) had stage I–II disease, respectively (P<0.001). Across all stages, very young women had a significant survival advantage over the young and older groups with 5-year disease-specific survival estimates at 78.8% vs 58.8 and 35.3%, respectively (P<0.001). This survival difference between the age groups persists even after adjusting for race, stage, grade, and surgical treatment. Reproductive age (16–40 years) women with stage I–II epithelial ovarian cancer who received uterine-sparing procedures had similar survivals compared to those who underwent standard surgery (93.3% vs 91.5%, P=0.26). Younger women with epithelial ovarian cancer have a survival advantage compared to older patients.

The role of extensive lymphadenectomy in stage I ovarian cancer

5069

Background: To determine if extent of lymphadenectomy affects the survival of women with stage I ovarian cancer. Methods: Demographic and clinico-pathologic information were obtained from the Surveillance, Epidemiology and End Results Program from 1988–2001 and analyzed using Kaplan-Meier methods and Cox proportional hazards regression. Results: Of the 6,686 women diagnosed with stage I ovarian cancer, 4,092 (61.2%) had stage IA, 392 (5.9%) had stage IB, 1,840 (27.5%) had stage IC, and 362 (5.4%) had unspecified stage I disease. The median age was 53 (range: 1–99). 5,625 (84.1%) were White, 388 (5.8%) Black, 488 (7.3%) Asian, and 185 (2.8%) were Other. All patients underwent primary surgery; of which, 3,824 women had no nodes, 1,533 had <10 nodes, and 1,329 had ≥10 nodes resected. Of the patients who underwent a lymphadenectomy, the median number of nodes resected was 9 (range: 1–84). The extent of lymphadenectomy (0, <10, and ≥10 nodes) increased the survival of patients with stage IC disease from 72.8%, 86.7%, to 90.1% (p < 0.0001), but not in those with stage IA (p = 0.07) or stage IB (p = 0.04) disease. In patients with non-clear cell epithelial carcinoma, the extent of lymphadenectomy was associated with improved 5-year disease-specific survivals of 85.6%, 93.3%, and 93.5%, respectively (p < 0.0001). However, the benefit associated with an extensive lymphadenectomy was not evident in clear cell (p = 0.09), sarcoma (p = 0.33), germ cell (p = 0.55), or sex cord stromal tumors of the ovary (p = 0.99). Similarly, patients with grade 3 disease had an improved survival associated with the extent of lymph node resection, 74.4%, 87.5%, to 90.5% (p < 0.0001), but not in those with grade 1 (p = 0.18) or grade 2 (p = 0.27) disease. In multivariate analysis, a more extensive lymphadenectomy remained significant as an independent prognostic factor for improved survival after adjusting for all other independent prognostic factors including age, surgery, histology, stage, and grade. Conclusions: Our findings suggest that the extent of lymphadenectomy was associated with an improvement in the survival of women with stage IC ovarian cancer.

No significant financial relationships to disclose.

A preclinical study of cellular immunotherapy redirected by bispecific antibodies in uterine cell lines and primary cancer cells

15044

Background: Cytokine induced killer cells (CIKs) are ex-vivo activated and expanded CD8+ natural killer T cells that have been shown to have cytotoxic activity against cancers in randomized clinical trials. We determined the cytotoxic activity of CIK cells against endometrioid and serous papillary (UPSC) uterine cancer cell lines and evaluated the ability of Trastuzumab and Her2xCD3 bispecific antibodies to enhance CIK-mediated cytotoxicity in Her2/neu expressing uterine cancer cells. Methods: The cytotoxicity of CIKs was quantified by 4-hour 51Cr release assays against uterine cell lines HEC-1A (endometrioid) and SPEC-2 (UPSC). Bispecific antibodies against Her2/neu (BSAbHer2) were designed using chemical conjugation methods. Results: Using FACS analysis, we found that the population of CD3+ CD8+ T cells increased from 24% to 56% over 21 days, while the CD3+ CD56+ T cells increased from 7% to 14%. Immunofluorescence microscopy revealed that both cell lines overexpressed Her2/neu. Cytotoxicity assays were performed at effector to target (E:T) ratios of 10:1, 20:1, 40:1 and 100:1 with increasing E:T ratio correlating directly with mean percent specific lysis. At the 100:1 E:T ratio, the mean percent lysis of CIKs against HEC-1A and SPEC-2 cells was 38.8% (±0.21) and 35% (±3.4), respectively. Trastuzumab did not affect the cytotoxic activity of CIKs. However, BSAbHer2 redirection significantly enhanced the cytotoxicity of CIKs against HEC-1A and SPEC-2 cells with a mean percent lysis of 66.3% (±1.0) and 50% (±2.7), respectively. Anti-NKG2D antibodies significantly reduced CIK activity by 49% and 47% in HEC-1A and SPEC-2 cells, respectively. The effects of CIK on advanced uterine cancers were demonstrated using our in vivo bioluminescence imaging system. Conclusion: CIK cells have cytotoxic activity both endometriod and UPSC cell lines. Redirection by BSAbHer2 significantly increased CIK-cell mediated cytotoxicity against Her2/neu expressing cell lines. The mechanism of CIK cytotoxicity appears to be partly mediated by the NKG2D receptor.

No significant financial relationships to disclose.

The importance of age as a prognostic factor in corpus cancer

15005

Background: To determine the prognostic factors that influence the survival of younger women diagnosed with uterine cancers. Methods: Patients with a diagnosis of uterine cancer were isolated from the Surveillance, Epidemiology, and End Results (SEER) cancer database from 1988–2001 and demographic and clinico-pathologic data were collected. Patients in the database were stratified by age at diagnosis into two age groups: ≤40and >40 years old. Disease specific survival was calculated using Kaplan-Meier estimates. Results: Of the 51,471 women diagnosed with uterine cancer in the study period, 2076 patients were ≤40 and 49,395 were >40 years old. The mean age in the younger group was 35.6 and that of the older group was 65.2. The overall distribution by stage was Stage I-76%, II-8%, III-7% and IV-9%. Younger patients were more likely to be non-white (30% vs 18%, p < 0.05), have earlier stage disease (79% vs 75%, p < 0.05), grade 1 lesions (48% vs 36%, p <0.05) and sarcomas (16% vs 8%) compared to their older counterparts. The overall disease specific 5-year survival demonstrated that younger patients (≤40 years old) had a significantly improved survival prognosis in comparison to older women (93% versus 86%; p < 0.0001). This survival difference remains significant after adjusting for stage, race, surgical treatment, and radiation treatment. Subgroup analysis revealed no statistical difference in outcome between the two age groups for patients with clear cell histology. There also was no statistical significance in survival for patients with grade 2 or 3 lesions and advanced stage disease. Conclusions: Our large population based study demonstrates that younger patients (≤40) have an overall survival advantage compared to women >40 years. This difference remains significant when adjusted for stage, race, surgical treatment, and radiation treatment. Women with clear cell cancers of the uterus appear to have a poor prognosis independent of age.

No significant financial relationships to disclose.

Cellular immunotherapy redirected by bispecific antibodies in primary ovarian cancer cells: A preclinical study

2518

Background: Cytokine induced killer cells (CIKs) are ex-vivo activated and expanded CD8+ natural killer T cells that have been shown to have cytotoxic activity against cancers in randomized clinical trials. This preclinical study demonstrates the enhanced effect of CIK killing in primary ovarian carcinoma using bispecific antibodies (BSAbs) and the potential of translating our findings to a clinical trial. Methods: Primary ovarian cancer cells and autologous CIKs were collected and cultured under IRB approval. Cytotoxicity enhancing BSAbs against CA125 (BSAbxCA125) and Her2/neu (BSAbxHer2) were designed using chemical conjugation methods. Tumor cell lysis of ovarian primary ovarian cancer cells was quantified using 51Cr release assays. Anti-NKG2D monoclonal antibodies were used in antibody blocking assays. Using a SCID mouse model of minimal residual disease, tumor progression was monitored using the bioluminescence imaging (BLI) system. Three-color immunofluorescence analysis was performed on pathologic specimens to localize CIK migration to tumor cells. Results: The mean percent lysis with an Effector:Target (E:T) ratio at 100:1 was 22.2% (±2.0) in primary cells in 4-hour killing assays. Redirection with BSAbxCA125 significantly enhanced cytolysis to 65.7% (±0.6). Adding BSAbxHer2 significantly enhanced cytolysis of cell lines to 89.4% (±1.3). Anti-NKG2D antibodies significantly attenuated the CIK activity by 54%. In vivo BLI studies in SCID mice showed that CIK treatment at a 10:1 E:T ratio was well-tolerated and effective in reducing tumor burden by 80% after 21 days post-treatment compared to untreated mice (p<0.0001). Immunofluorescence staining clearly depicted the in vivo infiltration of CIK (CD8+NKG2D+) cells into Her2-expressing tumor targets. Conclusions: Bispecific antibodies effectively enhanced the cytotoxicity of autologous CIK cells against fresh ovarian tumors. Our in vivo studies suggest that CIK cells may ultimately prove to be efficacious immunotheraputic modality in the treatment of resistant ovarian cancer.

No significant financial relationships to disclose.

The number of lymph nodes with metastatic disease portends for a poorer prognosis in women with stage IIIC-IV endometrioid uterine cancer

5039

Background: To determine the prognosis of women with IIIC-IV endometrioid uterine cancer based on the number lymph nodes with metastatic disease Methods: Demographic and clinico-pathologic information were obtained from the Surveillance, Epidemiology and End Results Program from 1988–2001 and analyzed using Kaplan-Meier methods and Cox proportional hazards regression. Results: Of the 1,222 women diagnosed with stage IIIC-IV endometrioid uterine cancer with nodal disease, the median age was 64 (range: 28–93). All patients underwent surgical staging including a lymph node assessment and were found to have nodal metastases. 639 (52.3%) had stage IIIC, 24 (2.0%) IVA, and 559 (45.7%) IVB disease. The study cohort was divided in three subgroups based on the number of positive nodal metastases: 1, 2–5, and >5. The 5-year overall disease-specific survivals of women with 1, 2–5, and >5 positive nodes were 68.1%, 55.1% and 46.4%, respectively (p < 0.0001). The increasing number of positive nodes was associated with a worsening survival in stage IIIC (77.1%, 60.9%, 69.1%; p = 0.003) and stage IV (50.9%, 49.8%, 38.9%; p = 0.09) diseases. It appears that the extent of benign nodal resection attenuates the increase in the mortality associated with a higher number of positive nodes (see table ). Women with higher number of positive nodes received significantly less adjuvant radiotherapy at 76.8%, 59.5%, and 56.7% respectively. On multivariate analysis, age, stage, grade, number of positive lymph nodes and extent of lymph node resection were significant independent prognostic factors for survival. However, adjuvant radiation was not an important independent prognostic factor in multivariate analysis. Conclusion: Women with node positive endometrioid uterine cancers have a decreased survival associated with increasing number of positive nodes. Our data suggests that the extent of lymph node resection improves the survival of patients with node-positive uterine cancer.

[Table: see text]

No significant financial relationships to disclose.

The role of surgical staging in grade 1 endometrioid corpus cancer

5009

Background: To evaluate the role of surgical staging of patients with grade 1 endometrioid uterine cancer. Methods: Data including stage, histology, grade, lymph nodes involvement and disease-specific survival were extracted from Surveillance, Epidemiology, and End Results Program from 1988 to 2001. Kaplan-Meier and Cox proportional hazards analyses were used to determine the predictors for survival. Results: 12,712 women were diagnosed with endometrioid carcinoma which included 3,867 (30.4%) with grade 1, 5,285 (41.6%) with grade 2, and 3,560 (28%) with grade 3 disease. The 5-year disease specific survival of patients with grade 1, 2, and 3 disease was 97.78% ± 0.29, 92.14% ± 0.45, and 78.04% ± 0.82, respectively. Of all the patients with nodal involvement, 10% had grade 1, 39% had grade 2 and 51% had grade 3 disease (p < 0.001). Positive nodes were found in 3% of grade 1, 9% of grade 2 and 18% in grade 3 tumors (p < 0.001). Of the 3,867 patients with grade 1 disease, 3,281 (84.9%) had stage I, 317 (8.2%) had stage II, 166 (4.3%) had stage III, and 103 (2.7%) had stage IV disease. Fifteen percent of the patients with grade 1 disease had extra-uterine spread, including 8% to the cervix, 4% to the pelvis and 3% to the upper abdomen or distant metastases. Conclusions: Grade 1 uterine cancers have a risk of extra-uterine spread. Given that the information obtained from a thorough staging procedure clearly influences adjuvant treatment decisions, complete surgical staging is recommended.

No significant financial relationships to disclose.

The significance of the ratio of metastatic to examined lymph nodes in endometrioid uterine cancer

15043

Background: To determine the impact benign to positive lymph node ratio (LNR) on the disease-specific survival of women with advanced endometrioid corpus cancer. Methods: Demographic and clinico-pathologic information were obtained from the Surveillance, Epidemiology and End Results Program from 1988–2001 and analyzed using Kaplan-Meier methods and Cox proportional hazards regression. Results: Of the 1,222 women diagnosed with stage IIIC-IV endometrioid uterine cancer with nodal disease, the median age was 64 (range: 28–93). 1,025 (83.9%) were White, 75 (6.1%) Black, 91 (7.5%) were Asian and 31 (2.5%) were Other. All patients underwent surgical staging including a lymph node assessment and were found to have nodal metastases. 639 (52.3%) had stage IIIC, 24 (2.0%) IVA, and 559 (45.7%) IVB disease. Furthermore, 123 (10.1%), 466 (38.1%), and 581 (47.6%) women had grade 1, 2, and 3 disease, respectively. Grade information was unavailable for 51 (4.2%) patients. The benign to positive lymph node ratios (LNR) were divided in four subgroups: ≤5%, >5% to ≤10%, >10% to ≤20%, and >20% to determine impact of LNR on disease-specific survival. Increasing LNR (≤5%, >5% to ≤10%, >10% to ≤20%, and >20%) was associated with a decrease in disease-specific survival at 83.8%, 73.2%, 62.4%, and 50.8%, respectively (p < 0.0001). More specifically, LNR was an important factor only in patients with 11–20 and >20 lymph nodes removed but not for those with less than 10 nodes resected. Women with higher (LNR) received significantly more adjuvant radiotherapy at 72.0%, 69.7%, 61.1%, and 52.6%, respectively. On multivariate analysis, age, stage, grade, and lymph node ratio were significant independent prognostic factors for survival. Adjuvant radiation was not an important independent prognostic factor in multivariate analysis. Conclusion: The ratio of metastatic to examined lymph nodes in endometrioid uterine cancer is an important prognostic factor. Clinical trials on adjuvant therapy should be designed with consideration of this significant prognosticator.

No significant financial relationships to disclose.

The therapeutic benefit of extensive lymphadenectomy in advanced stage ovarian cancer

15010

Background: To determine if extent of lymphadenectomy affects the disease-specific survival of women with advanced-stage ovarian cancer. Methods: Demographic and clinico-pathologic information were obtained from the Surveillance, Epidemiology and End Results Program from 1988–2001 and analyzed using Kaplan-Meier methods and Cox proportional hazards regression. Results: Of the 15,320 women with stage IIIB-IV disease, 763 (5.0%) had stage IIIB, 5,266 (34.4%) stage IIIC, and 9,291 (60.7%) had stage IV disease. The median age was 66 (range: 1–101). 13,251 (86.5%) were White, 1,049 (6.9%) Black, 716 (4.7%) Asian, and 304 (1.9%) were Other. Of the patients who underwent a lymphadenectomy, the median number of nodes resected was 6 (range: 1–90). We divided our study group 3 groups based on the extent of lymphadenectomy (0, <10, 10–20, and >20). In the overall study group, the extent of lymphadenectomy improved the survival from 21.1%, 40.5%, 45.1% to 46.0%, respectively (p < 0.001). Patients with stage IIIB, IIIC, and IV disease had an improvement in survival associated with lymphadenectomy (see table ). In patients with non-clear cell epithelial carcinoma, the extent of lymphadenectomy was associated with improved survivals 20.9%, 39.8%, 45.4%, and 45.9%, respectively (p < 0.0001). Moreover, those with clear cell cancers (p = 0.0001), germ cell (p = 0.001) and sarcomas of the ovary (p = 0.02) also had a survival benefit; however no benefit was demonstrated in sex cord stromal tumors (p = 0.99). In multivariate analysis, a more extensive lymphadenectomy remained significant as an independent prognostic factor for improved survival after adjusting for all other independent prognostic factors including age, year of diagnosis, surgery, histology, stage, and grade. Conclusions: Our findings suggest that the extent of lymphadenectomy improves the disease-specific survival of women with stage IIIB-IV ovarian cancer. This benefit was demonstrated in epithelial, germ cell, and sarcomas of the ovary.

[Table: see text]

No significant financial relationships to disclose.

The impact of lymphadenectomy in women with endometrioid uterine cancer: A study of 39,396 women

5000

Background: To determine the potential benefit of lymphadenectomy (LNX) during surgical staging procedure in women with early and advanced endometrioid uterine cancers. Methods: Demographic and clinico-pathologic information were obtained from the Surveillance, Epidemiology and End Results program from 1988 to 2001. Data were analyzed by using Kaplan-Meier methods and Cox proportional hazards regression. Results: Of 39,396 women (median age: 65; range 19–102) with endometrioid uterine cancers, 12,333 (31.3%) underwent a surgical staging procedure with LNX. The remainder received a hysterectomy and bilateral salpingo-oophorectomy only. 34,871 (88.5%) were Caucasian, 1,742 (4.4%) were African-American, 1,841 (4.7%) were Asian and 942 (2.4%) were other. The 5-year disease-specific survivals (DSS) were 93.3%, 85.4%, 69.3%, and 38.3% in patients with FIGO stage I-IV diseases, respectively. The 5-year DSS of stage I-IV women who underwent LNX were 95.5%, 90.4%, 73.0%, and 53.3% compared to 96.6%, 82.3%, 61.2%, and 28.2% in those without LNX. Those with stage II (p < 0.001), III (p < 0.001), and IV (p < 0.001) diseases after LNX had significantly better survival; however, the benefit of LNX was not demonstrated in stage I disease. The proportion of stage I patients with grade I histology or tumors limited to the endometrium was significantly higher in those who did not receive LNX compared to those who did (54.8% vs. 34.7%; p < 0.001 for grade I disease; 26.6% vs. 15.9%; p < 0.001 for non-myometrial invasion). In stage I grade 3 endometrioid uterine cancer, patients with LNX had a better 5-year DSS than those without LNX (90.0% vs. 84.97%; p = 0.0001); however, these findings were not seen in grade I (p = 0.26) and grade II (p = 0.14) diseases. In the subset of patients with stage IC grade 3 disease, there was a trend toward an improvement in survival associated with LNX (81.7% vs. 76.5%; p = 0.07). In the overall study group, younger age, African-American race, advanced stage disease, grade 3 histology, and lymphadenectomy. Conclusions: Our data suggest that lymphadenectomy improves the survival of women with stage I grade 3, stage II-IV endometrioid uterine cancers.

No significant financial relationships to disclose.

Uterine papillary serous and clear cell carcinomas predict for poorer survival compared to grade 3 endometrioid corpus cancers

To compare the survival of women with uterine papillary serous carcinoma (UPSC) and clear cell carcinoma (CC) to those with grade 3 endometrioid uterine carcinoma (G3EC). Demographic, pathologic, treatment, and survival information were obtained from the Surveillance, Epidemiology, and End Results Program from 1988 to 2001. Data were analysed using Kaplan–Meier and Cox proportional hazards regression methods. Of 4180 women, 1473 had UPSC, 391 had CC, and 2316 had G3EC cancers. Uterine papillary serous carcinoma and CC patients were older (median age: 70 years and 68 vs 66 years, respectively; P<0.0001) and more likely to be black compared to G3EC (15 and 12% vs 7%; P<0.0001). A higher proportion of UPSC and CC patients had stage III–IV disease compared to G3EC patients (52 and 36% vs 29%; P<0.0001). Uterine papillary serous carcinoma, CC and G3EC patients represent 10, 3, and 15% of endometrial cancers but account for 39, 8, and 27% of cancer deaths, respectively. The 5-year disease-specific survivals for women with UPSC, CC and G3EC were 55, 68, and 77%, respectively (P<0.0001). The survival differences between UPSC, CC and G3EC persist after controlling for stage I–II (74, 82, and 86%; P<0.0001) and stage III–IV disease (33, 40, and 54; P<0.0001). On multivariate analysis, more favourable histology (G3EC), younger age, and earlier stage were independent predictors of improved survival. Women with UPSC and CC of the uterus have a significantly poorer prognosis compared to those with G3EC. These findings should be considered in the counselling, treating and designing of future trials for these high-risk patients.

A method of drusen measurement based on reconstruction of fundus background reflectance

BACKGROUND

The hallmarks of age related macular degeneration (AMD) are the subretinal deposits known as drusen. Current manual methods of drusen segmentation and quantification are laborious and subjective. The authors introduced a digital method and tested it for accuracy and reliability.

METHODS

Fourteen eyes with drusen were selected. The authors digitally reconstructed the macular background using normal background areas ("dots") fitted to quadratic polynomials in two zones. The model was used to level the reflectance for the purpose of segmenting drusen by a global threshold. Measurements of drusen areas were compared with those of a semi-automated background levelling technique and manual drawings from stereo pairs.

RESULTS

Intraobserver reproducibility had standard deviations from 0.1% to 4.1%. Interobserver reproducibility yielded 95% limits of agreement of -2.7% to 6.3%. The dots method compared with manual drawings and with the semi-automated method had 95% limits of agreement of -8.3% to 2.8% and -7.1% to 4.8%, respectively.

CONCLUSIONS

The dots method was reproducible and accurate with respect to validated methods. It provided less total operating time and greater precision than that of standard fundus photo grading. With implementation of commercial software, this technique for macular image analysis has potential for use in clinical research.

HPV infection and number of lifetime sexual partners are strong predictors for 'natural' regression of CIN 2 and 3

The aim of this paper was to evaluate the factors that predict regression of untreated CIN 2 and 3. A total of 93 patients with colposcopic persistent CIN 2 and 3 lesions after biopsy were followed for 6 months. Human papillomavirus (HPV) types were determined by polymerase chain reaction at enrolment. We analysed the biologic and demographic predictors of natural regression using univariate and multivariate methods. The overall regression rate was 52% (48 out of 93), including 58% (22 out of 38) of CIN 2 and 47% (26 out of 55) of CIN 3 lesions (P=0.31 for difference). Human papillomavirus was detected in 84% (78 out of 93) of patients. In univariate analysis, 80% (12 out of 15) of lesions without HPV regressed compared to 46% (36 out of 78) of lesions with HPV infection (P=0.016). Women without HPV and those who had a resolution of HPV had a four-fold higher chance of regression than those with persistent HPV (relative odds=3.5, 95% CI=1.4-8.6). Women with five or fewer lifetime sexual partners had higher rates of regression than women with more than five partners (P=0.003). In multivariate analysis, HPV status and number of sexual partners remained as significant independent predictors of regression. In conclusion, HPV status and number of lifetime sexual partners were strongly predictive of regression of untreated CIN 2 and 3.