CA 125 regression after two completed cycles of chemotherapy: lack of prediction for long-term survival in patients with advanced ovarian cancer

The prognostic influence of CA 125 regression between the time point before surgery and after two completed courses of chemotherapy was studied in 210 patients with advanced ovarian cancer, and was compared to other well established prognostic factors. CA 125 blood samples were collected preoperatively (CA 125 pre) and 3 months after surgery (CA 125 3 mo) (at the beginning of the 3rd cycle of chemotherapy). The parameter CA 125 regression defined as log10 (CA 125 3 mo/CA 125 pre) was used for statistical analysis. In a survival analysis using a Cox proportional hazards model, CA 125 regression (P = 0.0001), residual tumour (P = 0.0001), age (P = 0.0095) and grading (P = 0.044) were independent variables, whereas stage of disease, histology, ascites and type of surgery failed to retain significance. Using log10 (CA 125 3 mo/CA 125 pre) as simple covariate in a Cox model showed a hazard ratio of 1.70 (95% confidence interval 1.32-2.19, P = 0.0001). However, a detailed analysis of the interaction of time with the prognostic factor CA 125 regression on survival revealed a strong time-dependent effect with a hazard ratio of more than 6 immediately after two courses of chemotherapy, whereas within approximately 1 year the hazard ratio for the surviving patients dropped quickly to the neutral level of 1. In summary, CA 125 regression is an independent prognostic factor for survival of women with advanced ovarian cancer and allows an identification of a high-risk population among patients with advanced ovarian cancer. However, the discriminating power of serial CA 125 for long-term survival seems to be temporary and prediction of individual patients outcome is far less precise.

[Therapy studies of the Austrian Breast Cancer Group (ABC)]

The Austrian Breast Cancer Group (ABC) consisting of more than 60 participating centers in Austria has randomized more than 5800 patients in 11 randomized trials since 1984. At present, roughly 30% of all patients with the diagnosis primary breast cancer are accrued in protocols throughout the country. Due to specific activities, the breast conservation rate raised from an initial 20% to more than 60% in the last years. Multicenter trials are not only the basis for progress in medicine but also tools for quality control and quality improvement.

Influence of delayed staging laparotomy after laparoscopic removal of ovarian masses later found malignant

OBJECTIVE

To determine whether delayed laparotomy after attempted laparoscopic excision of an ovarian mass later found to be malignant has an impact on the stage of disease.

METHODS

A questionnaire regarding laparoscopic management of ovarian masses later found to be malignant was mailed to all gynecologic departments in Austria. Of the 70 cases reported, laparotomy was performed after laparoscopy in 48 cases. In 24 of these cases, laparotomy was performed within 17 days of laparoscopy, whereas 24 cases involved a delay of more than 17 days. Twenty-two patients in whom laparotomy was performed immediately after laparoscopy were used as controls.

RESULTS

In patients with borderline tumors who underwent laparotomy more than 17 days after laparoscopy, the odds ratio (OR) for International Federation of Gynecology and Obstetrics (FIGO) stage IIB-IV disease was 5.3 (95% confidence interval [CI] 0.40, infinity), compared with patients undergoing immediate laparotomy (multivariate analysis). Patients with invasive ovarian cancer who underwent laparotomy more than 17 days after laparoscopy had an OR of 9.2 (CI 0.92, 481) for stage IIB-IV disease compared with patients undergoing immediate laparotomy (multivariate analysis). In patients with borderline tumors, multivariate analysis showed that the timing of laparotomy is an independent prognostic factor for the stage of disease. In invasive ovarian cancer, none of the factors evaluated by multivariate analysis was found to be an independent prognostic factor for the distribution of disease stage. A delay between laparoscopy and laparotomy may affect adversely the distribution of disease stage.

CONCLUSION

The timing of subsequent laparotomy was found to be a factor predictive of the distribution of disease stage.

TATI (tumor associated trypsin inhibitor) and cancer antigen 125 (CA 125) in patients with early-stage endometrial cancer

BACKGROUND

In patients with gynecologic malignancies, a 6 kD polypeptide known as the tumor-associated trypsin inhibitor (TATI) is present in high concentrations, both in the urine and the serum. This study attempts to evaluate the usefulness of pretreatment serum levels of TATI (cutoff level 21 ng ml-1) and CA 125 (cutoff levels 35 U ml-1 and 65 U ml-1) in the prediction of early endometrial cancer.

PATIENTS AND METHODS

One hundred twenty-seven patients with stage I and II endometrial carcinomas, 110 healthy women and 258 women with benign pelvic pathologies were evaluated. The data obtained were correlated with the tumor stage and tumor grade.

RESULTS

Overall, TATI showed a sensitivity of 31% and a specificity of 81%. The sensitivity and specificity of CA 125 > 35 U ml-1 was 25% and 86%, respectively. When both serum tumor markers were combined the sensitivity increased to 48% (CA 125 > 35 U ml-1), with a specificity of 71%. A correlation with the depth of myometrial infiltration was found for neither of the tumor markers under investigation. In addition, neither TATI nor CA 125 correlated well with tumor grade. The combination of TATI and CA 125 had a high positive predictive value (84%) when no other gynecologic pathologies were present. Furthermore, if TATI and CA 125 levels are within normal ranges and gynecological examination does not show other abnormalities besides vaginal bleeding, endometrial carcinoma appears to be very unlikely.

CONCLUSION

We concluded that, while TATI and CA 125 may not be recommended as a screening method for the detection of endometrial cancer, the combination of TATI and CA 125 is a valuable additional tool for further evaluation of women with suspected uterine cancer.

Prediction of toxicity but not of clinical course by determining carboplatin exposure in patients with epithelial ovarian cancer treated with a combination of carboplatin and cisplatin

We present the data from 105 patients with primary epithelial ovarian cancer, who received up to 6 cycles of carboplatin (300 mg/m2) and cisplatin (100 mg/m2) as one treatment arm of a prospective randomized trial. Values for first-course carboplatin area-under-the-curve (AUC) were determined retrospectively. WHO grade 3-4 thrombocytopenia was found in 10% of patients with low AUC (AUC <4 mg/ml x min), but in 44.6% of patients with high AUC (AUC 4 mg/ml x min) (chi-square p<0.0001). No single case of ototoxicity was found in the low AUC group but in 12% of patients in the high AUC group (chi-square p=0.003). Determination of carboplatin AUC may prevent ototoxicity and severe thrombocytopenia for the first cycle of combined treatment with carboplatin and cisplatin.

The relationship of pretreatment serum hemoglobin level to the survival of epithelial ovarian carcinoma patients: a prospective review

BACKGROUND

Tumor anemia is a common symptom in cancer patients. This study assessed the prognostic relationship of pretreatment serum hemoglobin levels to survival in a retrospective sample of 206 patients with epithelial ovarian carcinoma.

METHODS

Survival analysis was evaluated by univariate (Kaplan-Meier product limit method and log rank test) and multivariate (Cox proportional hazards model) analysis. Mean values were compared by the Kruskal-Wallis test. Serum hemoglobin levels were determined in each patient 24-48 hours before surgery. Anemia was defined as a serum hemoglobin value below 12 g/dL.

RESULTS

Tumor anemia was present in 32% of the patients before primary surgery. Hemoglobin levels were significantly lower in patients with residual tumor than in those with no detectable residual tumor after initial surgery (P = 0.008). Although statistically not significant, we found a trend toward lower hemoglobin levels with advanced stage of disease. For 5 years, overall survival probability was 38.5% and 52.3% for patients with pretreatment hemoglobin levels P = 0.008). In multivariate analysis, the relative risk of death was significantly associated with decreasing serum hemoglobin levels. No interaction was found between the grade of anemia and chemotherapy or radiation therapy with respect to its influence on overall survival.

CONCLUSIONS

After adjustment for established prognostic factors, tumor anemia was found to have an independent relationship to the overall survival of patients with ovarian carcinoma. Because no significant interaction could be found between the grade of anemia and chemotherapy, marked tumor anemia was considered an indicator of the presence of biologically aggressive tumor cell clones.

[Survival prognosis in ovarian carcinoma Figo stages III and IV: 1980-1985 versus 1986-1993. A comparison of 2 treatment periods]

We examined the survival prognosis of 638 patients who had ovarian carcinoma Figo stages III and IV. We considered two separate time periods, 1980-1985 versus 1986-1993, including the size of the postoperative residual tumor, polychemotherapy with and without platinum, histological grading 1 versus 2 and 3, Figo stage III versus IV, and ascites present versus no ascites. Since 1986, 96% of the patients received platinum-containing polychemotherapy at a dosage of > or = 75 mg/m2, whereas between 1980 and 1985, only 76% of these patients received platinum-containing polychemotherapy at a dosage of 50 mg/m2, and 24% of the patients received polychemotherapy without platinum. The size of residual tumor masses and also the time period of treatment had an independent influence on survival prognosis. Patients treated from 1980 to 1985 had a relative risk to die which was 1.44 times higher than for the patients who were studied from 1986 to 1993.

Unsuspected primary tubal carcinoma during operative laparoscopy

OBJECTIVE

To evaluate the possible risk of dealing with an unsuspected primary carcinoma of the fallopian tube during laparoscopic surgery.

METHODS

We performed a countrywide survey in Austria concerning laparoscopic procedures in cases of primary carcinoma of the tube. The questionnaire consisted of questions regarding the pre-, intra-, and postoperative management.

RESULTS

Of 18,435 laparoscopies in cases of an adnexal mass, 5 cases were reported, when laparoscopy was performed on an unsuspected carcinoma of the tube. Therefore, the risk of detecting this malignancy during laparoscopy after preoperative evaluation is 1 in 3687 cases (0.028%).

CONCLUSION

The risk of encountering an unsuspected primary carcinoma of the fallopian tube during laparoscopy in Austria is an extremely rare situation. In case of a malignancy, a staging or debulking laparotomy should be performed immediately or as soon as possible.

Very low-dose adjuvant chemotherapy in steroid receptor negative stage I breast cancer patients. Austrian Breast Cancer Study Group

A randomised clinical trial was performed to test whether or not low-dose chemotherapy lasting only 35 days improves the outcome of breast cancer patients with stage I disease and negative oestrogen and progesterone receptors (ER-, PgR-). Between 1984 and 1990, 277 stage I breast cancer patients with tumours negative for both oestrogen and progesterone receptors were randomised to receive either low-dose short-term chemotherapy or no chemotherapy. Chemotherapy consisted of one cycle of doxorubicin, vincristin (AV) and one cycle of cyclophosphamide, methotrexate, fluorouracil (CMF). Patients were stratified for tumour stage, type of surgery, menopausal status and participating centre. Results were analysed both by univariate and multivariate statistical. After a median length of follow-up of 84 months, disease-free (DFS) and overall survival (OS) did not differ significantly between patients having received adjuvant chemotherapy and the control group. Uni- and multivariate analysis did not show any significant prognostic or therapy related factor. A low-dose short-term adjuvant chemotherapy is insufficient to improve the prognosis of patients with breast cancer stage I with ER-, PgR-tumours.

Color-coded and spectral Doppler flow in breast carcinomas--relationship with the tumor microvasculature

The phenomenon of tumor angiogenesis is an important aspect of understanding tumor biology. Studies in breast carcinoma have shown microvessel density (MVD) assessed by immunohistochemistry to be of prognostic importance in primary breast cancer. On the other hand, recently developed highly sensitive color-coded Doppler techniques offer a noninvasive method to examine neovascularisation in breast tumors. The purpose of this study was to determine the relationship between Doppler flow parameters and microvessel count assessed by immunohistochemistry. Fifty-three patients with primary breast cancer were examined preoperatively with color-coded Doppler ultrasound. The obtained Doppler frequency spectra were analyzed for peak systolic flow velocity (Vmax). Following surgery, paraffin-embedded microsections were immunohistochemically stained for factor VIII-related antigen. Tumor angiogenesis was assessed by microvessel count under light microscopy. Undifferentiated tumors correlated with high MVD (p=0.009) whereas other clinicopathological parameters were not associated with MVD. Color Doppler signals were detected in 50 out of 53 breast tumors. Evaluation of tumor flow velocity with various clinicopathological parameters showed a significant correlation with tumor size (p=0.0001) and lymph node metastasis (p=0.02). However, there was no significant correlation between MVD and intratumoral blood flow velocity assessed by color-coded Doppler. Our findings showed that Doppler flow measurement did not correlate with the extent of tumor angiogenesis of breast cancer. The present data give circumstantial evidence that microvessel count assessed by immunohistochemistry reflects the microvascular network, whereas tumor vasculature documented by Doppler ultrasound supplies information on the macrovasculature.

Erythropoietin treatment under polychemotherapy in patients with gynecologic malignancies: a prospective, randomized, double-blind placebo-controlled multicenter study

In order to examine the influence of erythropoietin (rHuEPO) on serum hemoglobin levels, transfusion requirements, and quality of life in patients with gynecologic malignancies under polychemotherapy and chronic tumor anemia (hemoglobin <11 g/dl), we performed a prospective, randomized, double-blinded placebo-controlled clinical trial. Between October 1992 and October 1993, 35 patients from 5 gynecologic departments were entered into this trial. Inclusion criteria were hemoglobin level <11 g/dl, ferritin level >29 ng/ml, stool negative for occult blood, and life expectancy for more than 3 months. Patients received either 150 U/kg body wt rHuEPO (Erypo by Cilag-Janssen) sc three times a week for 12 weeks (n = 23) or a placebo (n = 12). If the hemoglobin levels of the 4th, 8th, or 12th week were >2 g/dl above the baseline value and/or >12 g/dl, the patient was classified as a responder. Patients who required blood transfusions (hemoglobin <8 g/dl, erythrocytes <3 x 10(6)/ml, or clinical symptoms of anemia) were classified as nonresponders. A nonvalidated quality of life questionnaire was completed by the patient at the beginning of the treatment and then every fourth week before receiving chemotherapy. In the rHuEPO group 56.6% of the patients responded to the treatment (chi2 = 10.79, P = 0.001) and only 5 patients (21.7%) required blood transfusions, whereas 8 of 12 patients in the placebo group (66.6%) had to be transfused (chi2 = 6.81, P = 0.009). Quality of life did not differ significantly between the rHuEPO group and the placebo group of patients. Within the rHuEPO group those patients that responded showed a significant increase in physical activity after response in comparison to the preresponsive phase (P = 0.02, paired t test). We therefore concluded that rHuEPO significantly increases serum hemoglobin levels and decreases transfusions requirements while maintaining quality of life in patients with gynecological malignancies who are undergoing polychemotherapy.

EGFR and steroid receptors in ovarian carcinoma: comparison with prognostic parameters and outcome of patients

Epidermal growth factor receptor (EGFR), progesterone receptor (PR) and estrogen receptor (ER) status were analyzed in 108 primary ovarian epithelial carcinoma specimens. Receptor concentration was determined with radioligand binding assays. 61% of the carcinomas investigated were positive for EGFR, 29% for PR and 57% for ER. EGFR status was not correlated with histological grading of tumors and no difference in EGFR positivity was found between subgroups of ovarian carcinomas. On the other hand, 50% of the tumors with FIGO stage III and IV and tumors which could not be operated to be free of residual tumor mass were EGFR positive, whereas only 30% were positive within the group of tumors with FIGO stage I and II and no residual tumor mass. The outcome of the carcinoma patients was followed up for a maximum of 100 months. A significant correlation between EGFR positivity and a shorter progressive-free period as well as shorter overall survival was found. For PR and ER status no relation to patient survival became evident. The response to chemotherapy was significantly correlated to EGFR status. After 5 years 63% of the patients with negative versus 25% with positive EGFR were still alive indicating the impaired response of EGFR positive carcinomas to chemotherapy containing platinum compounds.

Taxol as second-line treatment in patients with advanced ovarian cancer after platinum-based first-line chemotherapy

Salvage chemotherapy in platin-resistant patients typically results in low response rates and short survival, therefore new active cytotoxic agents must be found. One of these agents is paclitaxel (Taxol), isolated from the bark of the western yew which acts as an antimicrotubule agent. In our study 28 patients were treated with Taxol, 20 of whom had platinum-resistant tumors. Taxol was administered at a starting dose of 175 mg/m2, infused over 3 hr every 21 days. A total of 145 courses of Taxol was infused. Dexamethasone, diphenhydramine, and ranitidine were given as premedication. The response rate was 25% (3 complete and 4 partial remissions), the median survival duration was 15 months. In contrast to other studies we found a lower response rate in patients resistant to platinum-based therapy: 15% (no complete, 3 partial remissions). The most common severe toxicity was leukopenia, with grade 3 toxicity occurring in 10% of the courses; no grade 4 leukopenia or neutropenia was noted. Neurologic toxicity was a clinically significant adverse effect, with 1% of patients experiencing grade 3, 9% experiencing grade 2, and 3% experiencing grade 1 toxicity. Other adverse effects were less frequent and less severe. We conclude that paclitaxel, which in a prospective randomized trial has been shown to be the most active treatment of advanced ovarian cancer, yields low response rates in platinum-resistant patients. Only a few of them profited from second-line treatment with Taxol. This could be a new aspect in the treatment of platinum-resistant ovarian cancer with Taxol.

Laparoscopic surgery in cases of ovarian malignancies: an Austria-wide survey

The purpose of the study was to determine the frequency of discovering a malignant ovarian mass when laparoscopy is used to manage an adnexal mass. A countrywide survey was undertaken in Austria, comprising questions about ovarian malignancy detected or accidentally treated by laparoscopy. The response rate of 66.7% represented a total of 54,198 laparoscopies, 16,601 laparoscopic surgeries on adnexal masses, and 108 cases of ovarian tumors subsequently found to be malignant (96 well-documented). Twenty patients were treated with laparoscopy alone. In 22 cases, laparoscopy was followed by immediate laparotomy. A delayed laparotomy (3-1415 days) was performed in 54 cases. Staging revealed FIGO classifications from stages Ia to IV. The follow-up time ranges from 2 to 220 months. Four recurrences have been reported. Thirteen patients died of tumor progression. Laparoscopic surgery on ovarian malignancies is a rare situation (0.65% of all endoscopic surgeries on adnexal masses). In cases of malignancy, a laparotomy has to be performed to ensure optimal staging and treatment.

Adjuvant chemotherapy plus tamoxifen compared with tamoxifen alone for postmenopausal breast cancer: meta-analysis of quality-adjusted survival

BACKGROUND

Adjuvant tamoxifen for early breast cancer provides an improvement in relapse-free (RFS) and overall survival (OS), especially for older women. We carried out a meta-analysis to find out whether the benefit of adding chemotherapy to tamoxifen outweighs its costs in terms of toxic effects for postmenopausal patients.

METHODS

The meta-analysis of quality-adjusted survival was based on data from 3920 patients aged 50 years or older with node-positive breast cancer randomly assigned in nine trials that compared combination chemotherapy plus tamoxifen with tamoxifen alone. The nine trials were included in the worldwide overview conducted by the early breast cancer trialists' collaborative group (EBCTCG). The quality-adjusted time without symptoms or toxicity (Q-TWiST) method was used to provide treatment comparisons incorporating differences in quality of life associated with subjective toxic effects of treatment and symptoms of disease relapse.

FINDINGS

Within 7 years of follow-up the modest benefit of increased RFS and OS for patients who received chemotherapy just balanced the costs in terms of acute toxic side-effects. Chemotherapy-treated patients gained an average of 5.4 months of RFS and 2 months of OS (neither statistically significant), but had to receive cytotoxic treatment for between 2 and 24 months to achieve these gains. No values of preference weights for time spent undergoing chemotherapy and time after relapse gave significantly more Q-TWiST with chemotherapy plus tamoxifen than with tamoxifen alone.

INTERPRETATION

Within 7 years of follow-up, adjuvant chemoendocrine therapy did not provide more quality-adjusted survival time than tamoxifen alone for women aged 50 years or older with node-positive breast cancer. Better selection and administration of chemotherapy regimen, different scheduling of chemotherapy and tamoxifen, and appropriate use of patient and tumour characteristics may increase the therapeutic advantage of the combination.

Influence of delayed diagnosis on established prognostic factors in endometrial cancer

To evaluate the influence of delayed diagnosis on prognostic factors in endometrial cancer, we conducted a retrospective chart analysis based on the data of 116 postmenopausal patients with FIGO stage I-IV endometrial carcinoma. The interval from the first episode of post-menopausal vaginal bleeding to definitive, histological diagnosis (bleeding interval) was compared with tumor stage and various histomorphologic features in endometrial cancer. The mean bleeding interval was 12.7 +/- 17.8 weeks in 74 patients with FIGO stage IA, IB endometrial carcinoma and 35.2 +/- 69.3 weeks in 42 patients with stage IC-IV disease (t-test, p: 0.011). FIGO stage IA, IB disease was diagnosed in 23/26 (88%) patients with a bleeding interval <4 weeks, and in 22/34 (64%) and 29/56 (51%) patients with bleeding intervals of 4-8 weeks and >8 weeks, respectively (Chi-square 10.358, p=0.006). The correlation with histologic grade, lymph-node status, vessel invasion and histologic subtypes did not reach statistical significance. Our data confirm the clinical impression that postmenopausal vaginal bleeding is an early symptom in patients with endometrial cancer, and that advanced disease in the majority of cases might come from delayed diagnosis in women with poor compliance.

-CA-125 antigen as a prognostic factor for survival in patients with epithelial ovarian carcinoma of FIGO stage I--preliminary results-

The tumour marker CA 125 has proved useful in monitoring the course of disease and in indicating responsiveness to therapy in patients suffering from epithelial ovarian cancer. Due to its poor sensitivity, however, attempts to improve early detection by screening with this tumour marker have been unsuccessful to date. This study was performed to evaluate whether there was a relation between pre-operative CA 125 levels and the survival of patients with epithelial ovarian cancer FIGO stage I. If such a relation exists, CA 125 may be an effective variable in singling out those subsets of patients with stage I disease for whom adjuvant chemotherapy would bring an additional therapeutic benefit. Our results suggest CA 125 may be a significant prognostic factor. With a 5-year survival of 43%, marker-positive ovarian cancer carries a poor prognosis. Since the question as the whether follow-up treatment is required in this early, potentially curable stage of disease, is contingent upon numerous factors and since an individualised therapeutic regimen may lead to increased survival rates, the prognostic influence of CA 125 and its relationship to other prognostic factors should be evaluated by multivariate analysis.

[Plasminogen activator inhibitor 1 and prognosis in breast carcinoma]

The proteolytic enzyme urokinase-type plasminogen activator (uPA) plays an important role in degrading extracellular matrix. This seems to be an important step in cancer invasion and metastasis. uPA antigen levels correlate significantly with disease recurrence and death in breast cancer. To build up tumour stroma in primary tumours as well as in metastases, inhibition of proteolytic activity is necessary. In this study we investigated the correlation of the Plasminogen Activator Inhibitor 1 (PAI-1), which is the specific inhibitor of uPA and which seems to be important for tumour formation, with prognosis in breast cancer. PAI-1 antigen levels were measured in cytosols of 268 primary breast cancers. In 205 cases we correlated the PAI-1 status (cut-off value: 1 ng/mg) with the clinical outcome. Furthermore we investigated PAI-1 antigen levels in 10 benign breast tumours and 33 metastases. PAI-1 levels were significantly higher in primary carcinomas (median value: 0.62 ng/mg, range: 0 to 30.7) than in benign tumours (median value: 0 ng/mg, range: 0 to 0.1) and metastases showed elevated levels (median value: 1.05 ng/mg, range: 0 to 7.8) in comparison to the primary tumours (Kruskal-Wallis test: p < 0.05). We found that the PAI-1 status correlated significantly with early disease recurrence (Mantel-Test p = 0.0069) and overall survival (Mantel-Test p = 0.0121). After a median follow-up of 32 months (range 2-58), 36% of patients with PAI-1 antigen levels > or = 1 ng/mg (n = 72) showed an early relapse and 24% died, whereas only 19% of patients with PAI-1 antigen levels < 1 ng/mg (n = 133) relapsed and 9% died within the study period. A multivariate analysis revealed that in our study population PAI-1 is not an independent prognostic factor. According to our findings PAI-1 seems to be involved in the formation of extracellular matrix in primary carcinomas and metastases and is related to poor prognosis in breast cancer.

DNA amplification of HER-2/neu and INT-2 oncogenes in epithelial ovarian cancer

OBJECTIVE

Oncogene alterations are thought to be prognostic indices in patients with breast cancer. The present study was carried out to investigate the amplification of the HER-2/neu and INT-2 oncogenes in ovarian cancer.

METHODS

In a retrospective study of 196 patients with epithelial ovarian cancer, the amplification of the oncogenes HER-2/neu and INT-2 in the DNA of paraffin-embedded tumor cells was determined by quantitative PCR. The purpose of this study was to analyze whether the two oncogenes correlated with such predictive factors as FIGO stage, histological grade, ascites, postoperative residual tumor mass, hormone receptor content, and preoperative CA 125 serum levels. The effect of HER-2/neu and INT-2 amplification on patient survival was also studied.

RESULTS

The only correlation found in this study was between INT-2 and preoperative CA 125 levels (P = 0.03). No correlations were demonstrable between HER-2/neu (log-rank test; P = 0.67) and INT-2 (log-rank test; P = 0.75) amplifications and overall survival.

CONCLUSION

Unlike the established prognostic factors, neither HER-2/neu nor INT-2 appears to be predictive for survival in patients with ovarian cancer.

Randomised phase II study of epirubicin-vindesine versus mitoxantrone-vindesine in metastatic breast cancer

The purpose of this study was to compare the activity and toxicity of epirubicin-vindesine (EV) with mitoxantrone-vindesine (MV) in patients with metastatic breast cancer. A total of 295 patients was randomly allocated to treatment with vindesine 3 mg/m2 combined with either epirubicin 40 mg/m2 or mitoxantrone 10 mg/m2. All drugs were given by intravenous push, treatment cycles were repeated at 3-4 week intervals. 255 patients were available for response, and 283 for toxicity. EV and MV yielded similar objective response rates (34 and 26%, respectively), response durations, times to progression and survival. Median time to remission was 1.8 and 3.1 months (P = 0.006) with EV and MV, respectively. In patients with visceral metastases, response rate was higher with EV than MV (40 versus 23%; P = 0.03). Patients receiving MV had less nausea/vomiting (P = 0.007) and alopecia (P = < 0.001) of WHO grade > or = 2. Bone marrow, cardiac and other toxicities were mild with both treatments. The observed differences in activity and toxicity between the two regimens appear to have clinical relevance. EV proved to be more active in visceral disease and to be able to induce remissions more rapidly. Accordingly, patients with visceral metastases or severe tumour-related symptoms may benefit from epirubicin-based treatment. Subjective toxicities, i.e. nausea/vomiting and alopecia, were less frequent and severe with MV. Thus, MV may prove useful in patients with more indolent disease and appears to warrant phase III evaluation in such patients.

The application of fibrin glue after axillary lymphadenectomy in the surgical treatment of human breast cancer

Experimental studies point out that a reduction of lymph flow can be obtained by the local application of fibrin glue following axillary lymphadenectomy in the surgical treatment of breast cancer. In a prospective study the influence of human fibrin glue on postoperative axillary lymph secretion and the period of drainage of the wound cavity were evaluated. In 40 patients, 5 ml of fibrin glue (Tissucol) was applied to the wound cavity by the use of a spray applicator (Tissumat) immediately after axillary dissection of the lymph nodes. For drainage of the wound area Redon suction-drains were used. The daily amount of postoperative lymph secretion was measured and drains were removed at a lymph secretion of less than 20 ml. 40 patients who underwent surgery and axillary lymphadenectomy without subsequent application of fibrin glue sourced as control group. No significant difference concerning the total amount of lymph secretion, the mean period of drainage or the incidence of lymphatic cysts was observed. In our study, the expected occlusion of the wound cavity by the application of fibrin glue after axillary lymphadenectomy did not lead to any advantage when compared with the control group.

The influence of obesity on the disease-free survival in primary breast cancer

Hyper-estrogenism is more common in obese than in non-obese women. Consequently obesity has been shown to increase the risk of hormone department tumors. Some investigators have claimed that obesity at the time of primary treatment may be an independent prognostic factor for breast cancer, but this issue is still controversial. Therefore, we conducted a retrospective analysis to assess the influence of obesity at the time of primary treatment on disease-free survival (DFS). Obesity was defined as an excess of more than 25% of ideal weight according to Broca's index ([Height (cm) -100])-10%). The Cox-model was used for multivariate analysis. Mean follow-up was 61 (range 6-126) months. 295 (62.3%) patients were classified as of normal weight and 178 (37.6%) as obese. Mean excess of ideal weight was 8.9 kilograms (kg) in premenopausal and 13.9 kg in postmenopausal patients (non-parametric t-test p < 0.00001). Patients with tumor size < 20mm, 20-50mm and > 50mm had a means excess of the real weight of 10.6kg, 12.5kg and 16.1kg, respectively (non-parametric t-test p < 0.0001). Percentual excess of real weight compared to ideal weight was 22.4 [+/-21.2] kg in patients without recurrence and 21.5 [+/-21.9] in patients with recurrent disease (nonparametric t-test p = 0.7256). Univariate analysis revealed no significant association between obesity and the DFS. Multivariate analysis identified axillary lymph node involvement as the only statistically significant prognostic factor for disease-free survival (RR 1.55; 95%-confidence interval 1.02-2.36; p:0.0368). Because of the high correlations and node-status, tumor size and histological grading, the other factors failed to be prognostically relevant in this analysis. Obesity was not found to influence DFS of patients with primary breast cancer and is therefore unlikely to constitute an independent prognostic factor. It may, however, contribute to delayed diagnosis, since a significant proportion of obese patients were diagnosed with local advanced disease.

[The prognostic effect of scintigraphy-guided lymphadenectomy in therapy of stage Ib cervix carcinoma]

In a retrospective study the survival rates of 161 patients with stage Ib cervical cancer after radical operation (Latzko, Wertheim-Meigs) including complete or incomplete pelvine lymphadenectomy were compared. To increase radicality of lymphadenectomy, preoperative targeting of pelvic lymph nodes was done in all the patients using 99mTc-Sb2S3 radiocolloid. Intraoperatively, a gamma-camera being integral part of an operating table allowed delineation and scintigraphy-guided resection of pelvic lymph nodes. Dependent on the evidence of remaining pelvine foci of radioactivity at the end of the operation, lymphadenectomy was assessed as complete or incomplete. Mean observation time of completely lymphadenectomised patients (n = 117,72.67%) were 80 months (5-169 months) and 42 months (1-149 months) of the incompletely lymphadenectomised patients (n = 44,27.33%). In 28 (23.93%) completely lymphadenectomised patients against only 5 (11.36%) patients with incomplete lymphadenectomy, lymph node metastases were proved histologically. Five year-survival rate of completely lymphadenectomised patients was 85.47% and 88.64% of incompletely lymphadenectomised patients (not significant, Mantel-Test). Also, selective comparison of lymph node-positive patients did not suggest a divergent trend indicated by 13 (46.43%) deaths of completely and 3 (60.0%) deaths of the incompletely lymphadenectomised patients after an observation of five years. The technique of scintigraphy-guided pelvic lymphadenectomy using 99mTc-Sb2S3 radiocolloid cannot be expected to improve prognosis of patients with cervical cancer stage Ib.

Preoperative CA 125: an independent prognostic factor in patients with stage I epithelial ovarian cancer

OBJECTIVE

To evaluate the prognostic importance of preoperative CA 125 levels in patients with International Federation of Gynecology and Obstetrics (FIGO) stage I epithelial ovarian cancer in comparison with the established prognostic factors: degree of differentiation, FIGO substage, and age.

METHODS

In a retrospective analysis, the traditional prognostic factors and CA125 levels (cutoff value 65 U/mL) were studied in 201 patients who were treated in five centers during 1984-1993. Patients with borderline tumors or non-epithelial ovarian carcinomas were excluded, as were women in whom CA 125 had not been determined preoperatively.

RESULTS

In univariate analysis (Mantel test), overall survival decreased significantly in patients positive for CA 125 (P < .001). Substage (P = .004) and histologic grade (P = .01) also significantly influenced survival prognosis. When the effects of preoperative CA 125 levels were correlated with histologic grade, all three subgroups with CA 125 levels equal to or greater than 65 U/mL were associated with a decreased survival probability (grade 1, P = .04; grade 2, P = .003; grade 3, P = .01). Multivariate analysis (Cox model) identified preoperative CA 125 as the most powerful prognostic factor for survival (P < .001), the risk of dying of disease being 6.37 times higher (95% confidence interval 2.39-16.97) in CA 125-positive patients. Although FIGO substage retained its significant influence on survival (P = .03), histologic grade and age were not prognostically important.

CONCLUSION

Randomized trials investigating the efficacy of adjuvant treatment in patients with FIGO stage I epithelial ovarian cancer should also include stratification by preoperative CA 125 levels.

Microvessel density and vessel invasion in lymph-node-negative breast cancer: effect on recurrence-free survival

Microvessel density (MVD) and blood and lymphatic vessel invasion (BLVI) were investigated with regard to their influence on the disease-free survival (DFS) in node-negative breast cancer patients. Paraffin embedded microsections of 230 patients with T1,2 N0 breast cancer were immunohistochemically stained for factor VIII-related antigen. Every cluster consisting of more than highlighted endothelial cells was considered a countable microvessel. MVD was counted in 4 fields of 0.25 mm2 each. All MVD values are given as value for the sum of 4 fields of 0.25 mm2 each, that is, I mm2. BLVI was considered positive, when at least one tumor cell could be identified in a stained lumen. Out of 230 patients, 49 experienced local or distant recurrence and had a mean MVD of 72.4/mm2, whereas 181 patients who lived without recurrent disease had a mean MVD of 45.3/mm2. BLVI was negative in 6.2% of the cases with and in 93.8% of the cases without recurrent disease. BLVI was positive in 59.4% of the cases without and 40.6% of the cases with recurrent disease. MVD and BLVI remained the only significant prognostic factors of DFS in the Cox-Model. Tumor size, histological grade, and hormonal-receptor status were not prognostically relevant in the Cox-model. 10-year-DFS was 93.3% in BLVI-negative/MVD < or = 40/mm2 patients, 88.1% when MVD was high or BLVI was positive and 48.9% in BLVI positive/MVD < or = 40/mm2 patients. Our present data indicate that MVD and BLVI identify a very-low risk group among node-negative breast cancer patients, who will not benefit from systemic adjuvant therapy. MVD and BLVI should be used as stratification criteria in clinical trails on node-negative breast cancer patients.

HER-2 amplification but not butyrylcholinesterase multability reflects aggressiveness of European-originated ovarian tumors

Tumorigenic roles were variably suggested for HER-2 and INT-2 oncogene amplifications and the "atypical" aspartate to glycine mutability in the butyrylcholinesterase (BCHE) gene in ovarian adenocarcinomas. To examine this notion we searched for correlations between these three phenomena and ovarian tumor classification and aggressiveness, using quantitative polymerase chain reaction (PCR), single-strand conformation polymorphism (SSCP), and direct PCR sequencing. Our findings revealed no alleles carrying the atypical BCHE mutability in 30 European-originated patients with ovarian tumors compared with 11% (2/18) such alleles in Israeli patients with malignant ovarian tumors. This apparently reflected population diversity rather than disease relationship. INT-2 amplification was observed in 14/94 (15%) of the European patients; however, there was no correlation between this phenomenon and clinicopathological indices in the corresponding patients. In contrast, in 94 tumor samples we found that 40% (38/94) of the cases had HER-2 amplification. Moreover, there was a highly significant correlation (P < 0.008) between the over fivefold HER-2 amplification and ovarian tumor severity. These findings demonstrate an informative value for HER-2 amplification tests in tumor DNA, but not for INT-2 amplification or BCHE mutability, for the assessment of treatment.

Pregnancy-related changes of carnitine and acylcarnitine concentrations of plasma and erythrocytes

Total-, free-, and acylcarnitine concentrations were determined in whole blood, plasma, and red blood cells of 88 women during pregnancy. Already in the 12th week of gestation the mean whole blood carnitine level was significantly (p < 0.01) lower than those of the controls. From the 12th gestational week up to parturition there was a further significant (p < 0.01) decrease. This reduction of total carnitine in whole bloods was mainly caused by a significant (p < 0.01) decrease of free carnitine levels, since no marked changes of short chain acylcarnitine values were found throughout pregnancy. The contribution of red blood cell L-carnitine to whole blood carnitine increased significantly (p < 0.05) to 61% at delivery versus 39% (controls). In umbilical cord blood free and total carnitine levels were significantly (p < 0.05) higher than the corresponding maternal levels. The contribution of red blood cell L-carnitine to whole blood carnitine was higher in cord blood than in maternal blood. The results of the present study demonstrate that during pregnancy whole blood and plasma carnitine levels decrease to those levels found in patients with carnitine deficiency. Also the percentage of acylcarnitine on total carnitine, found in the present study, is characteristic for a secondary carnitine deficiency. Thus L-carnitine substitution in pregnant women, especially in risk pregnancies, may be advantageous.

[The future of surgical gynecology: from dogma to science--from science to practice standard]

In the future of gynecologic surgery, there will be a reduction of traditional and an increase of endoscopic surgery. Development, progress, and realization of new technologies have to be based on scientific results, as it has been shown for the surgery of early-stage ovarian cancer. Endoscopy is already part of daily routine surgery in nearly all gynecologic departments, although important questions like the optimal technique, proper indications, and the consequences of these new technologies regarding the course of ovarian cancer are still not answered. Especially gynecological surgery has to turn away from a dogmatic way of thinking to a critical science-oriented practice in the future.

Three-dimensional video-endoscopy: clinical use in gynaecological laparoscopy

We describe a system that displays the abdominal organs in three dimensions during laparoscopy. The system consists of a single-rod-lens endoscope and two integrated microchip cameras. The surgeon has to wear active-liquid-crystal shutter-glasses to obtain a three-dimensional impression during the operation. Improved orientation in the abdominal cavity allows exact handling of surgical instruments. The three-dimensional system permits surgery with more accuracy, speed, dexterity, and safety than conventional two-dimensional systems.

[Tumor vascular invasion in breast carcinoma. Hematoxylin-eosin versus immunohistochemical staining for factor VIII antigen]

Blood vessel invasion was investigated with haematoxylin-eosin (HE) staining and immunohistochemical staining for factor VIII antigen (F VIII) in 106 patients with primary carcinoma of the breast, in order to compare their value in prognosticating the probability of recurrence. Blood vessel invasion was diagnosed in 65 cases (61.9%) by HE, but in only 45 (43.4%) by F VIII staining. Lymph-node status and blood vessel invasion correlated positively on HE (r = 0.73; P = 0.0001), but not so on F VIII staining. Multivariate logistic regression showed blood vessel invasion to be a strongly independent prognostic factor for recurrence-free survival with F VIII staining (odds ratio: = 7.19; P = 0.0001), while HE staining was not independent from other prognostic factors. These preliminary data thus suggest that demonstrating vascular invasion by F VIII staining may identify those patients with a very high risk of recurrence, independent of lymph-node status.

pS2 protein status fails to be an independent prognostic factor in an average breast cancer population

In this study we analysed the cytosolic concentrations of the estrogen-regulated protein pS2 in tumors of 462 breast cancer patients, 16 benign breast tumors and 58 metastases. The median pS2 values were highest in breast cancer, followed by benign tumors and metastases (Kruskal-Wallis Test: p < 0.05). Information on other prognostic factors and clinical outcome was available for 354 patients (median follow-up, 35 months). We found a pS2 value of 2 ng/mg protein to be the best cut-off level to discriminate between pS2+ (63%) and pS2- (37%) tumors with respect to relapse-free survival (RFS) and overall survival (OS). The pS2 status was significantly correlated with age, estrogen receptor (ER) and progesterone receptor (PR) status. pS2 was negatively correlated with grading and was more often positive in invasive lobular than in invasive ductal carcinomas. ER, pS2 and grading were highly significantly correlated with each other. In univariate analysis pS2- patients showed a significantly shorter RFS (p = 0.0001) and OS (p = 0.0005). However, multiple regression analysis revealed that in our series of patients the pS2 status provides no independent prognostic information.

[Conisation in stage Ia cervix cancer]

Between 1975 and 1988, a total of 78 patients suffering from cervical cancer stage Ia were treated by conisation based on a positive smear. According to FIGO, these 78 patients consisted of 53 (67.9%) stage Ia1 and 25 (32.1%) stage Ia2 cases. Complete removal of the tumour by conisation was achieved in 51 patients. In 23 cases (29.5%) the margin of resection was reached by a carcinoma in situ, in 4 cases (5.1%) invasive carcinoma was found. Conisation was not followed by further surgery in 10/51 patients with complete tumour removal. One patient (1/23) with incomplete removal underwent surgery elsewhere. In the other 67/78 patients following hysterectomy, the pathologist diagnosed three cases of cervical cancer, 11 cases of carcinoma in situ and 53 cases (67.9%) without pathological findings. Carcinoma in situ after hysterectomy was found in only 2 cases (4.9%) with primarily free resection margins of the conus. Among the 27 patients with carcinoma in situ or invasive carcinoma reaching the conus margin, 9 cases of carcinoma in situ and 3 invasive carcinomas were diagnosed histologically after hysterectomy and one patient underwent surgery elsewhere. In this study, the value of conisation as single therapy of cervical cancer stage Ia1 and stage Ia2 with good prognosis (depth of infiltration of < 3 mm and no invasion of blood vessels) is discussed and the importance of thorough and exact histological examination is emphasised.

[Tumoral vascular density in breast tumors and their effect on recurrence-free survival]

Angiogenesis quantitation of 106 patients with primary breast cancer and 35 patients with adenofibroma of the breast was compared and examined to its prognostic relevance for five-years disease-free survival in breast cancer patients. Immunocytochemical staining for Factor VIII-related antigen was performed to outline vascular endothelium. We found a significant higher vessel density in breast cancer patients who experienced recurrence (17.4) than in those with no recurrence (9.4) or with adenofibroma (8.7) [p < 0.0001]. The probability of five-years recurrence-free survival for patients with a primary tumor of high vessel density was at 52.3% and 86.4% for tumors of low microvessel density (p < 0.0011). Microvessel density proved to be an independent prognostic factor for breast cancer recurrence in the Cox-Model (relative risk 2.047, p = 0.0002).

[The value of the "vascular invasion" factor for prognosis of breast cancer]

The histological sections of 106 patients, who underwent a primary breast cancer operation in the years 1986 and 1987, were inspected for the presence of tumour vascular invasion. With immunohistochemical methods, tumour vessels were tomographed and the paraffin sections were stained with an antibody, which is sensitive to factor VIII-antigen. A tumour embolus was considered present, if a malignant cell was established within a positively stained lumen. The question of possible influence on the pathogenesis of breast cancer was examined in case of vascular invasion in the histological preparation. In 46 of the 106 patients (43.4%), tumour emboli were found. After an average observation period of 59 months, no tumour progression was seen in 60 patients, 46 patients developed a recurrence of the tumour at the check-up date. The presence of vascular invasion correlates with undifferentiated tumour grading. The probability of relapse- free survival after 5 years was 83.9% within the group without vascular invasion, compared with 47.9% (p = 0.0001) within the group with established vascular invasion. In the multivariate analysis of the factors lymphonodular status, grading and vascular invasion, it was found, that the presence of tumour vascular invasion with a relative risk of 3.68 (95% CI 1.93-7.03) was the strongest statistically significant prognostic factor for relapse-free survival (p = 0.0001).

A comparative analysis of management and prognosis in stage I and II fallopian tube carcinoma and epithelial ovarian cancer

Staging and surgical as well as post-operative treatment of primary Fallopian tube carcinoma (FTC) followed the lines established for primary ovarian cancer (OC). In a nationwide retrospective analysis we were able to find a distinct difference between these two tumours. A total of 262 patients, 68 with FTC and 194 with OC, in stage I and II were included into this study. A univariate as well as a multivariate analysis for survival was performed, including factors such as age, histological type, grading and surgical and adjuvant treatment. A significantly poorer outcome (P = 0.0002) for FTC patients with a 5-year survival of 50.8% compared with 77.5% for OC patients was observed. This finding was persistent and independent of any investigated factor, in univariate as well as multivariate analyses. Therefore, we feel that a more aggressive therapeutic approach to the treatment of FTC even in early stages can be recommended. On the other hand, the retrospective character of our study has to be taken into account.

Prognostic significance of cell DNA content in early-stage ovarian cancer (FIGO stages I and II/A) by means of automatic image cytometry

Paraffin-embedded material from 69 patients with epithelial ovarian cancer FIGO stages I and II/A (including 21 patients with borderline carcinoma) was studied with automatic DNA image cytometry. Univariate analysis indicated a significant difference in survival based on the presence of nuclei with high DNA content (higher than 5 C). A group of patients with less than 0.2% cells with high DNA content had a 6-year survival of 87%, whereas in a group of patients with more than 0.2% of such cells, 6-year survival was 49%. This parameter remained significant when used in a group of stage I/a and I/b patients. Statistical analysis of diploid vs. non-diploid tumors also showed significant difference in survival. Separate analysis of 48 invasive ovarian cancers indicated that ploidy, the percentage of cells with high DNA content and tumor stage (stage I/a + b vs. stages I/c + II/a) reached significance for survival, whereas grading did not. In addition, comparison of clinical stage, grading, ploidy and the percentage of cells exceeding 5 C with a threshold at 0.2% by means of a multivariate analysis (Cox regression model) showed that only the percentage of cells exceeding 5 C remained statistically significant.

Antenatal betamethasone-dose-effects on fetal rat lung morphology and surfactant

Pregnant rats received betamethasone 0.02, 0.05, 0.10, or 0.20 mg/kg body weight/day or saline (controls) for three days before delivery of fetuses at day 19 of gestation. Dose related effects on morphology, dipalmitoyl phosphatidylcholine content, and phosphatidylcholine species composition of the fetal lungs were evaluated. Injection of 0.02 and 0.05 mg/kg body weight betamethasone resulted in cellular differentiation of some cells, but the increase in dipalmitoyl phosphatidylcholine content was not significant. Dosages of either 0.10 or 0.20 mg/kg body weight resulted in markedly accelerated organ differentiation, complete cytodifferentiation of type II cells, and markedly increased numbers of lamellar bodies per alveolar type II cell. Compared to the controls, maternal administration of 0.10 or 0.20 mg/kg betamethasone caused significant increases of both fetal lung dipalmitoyl phosphatidylcholine content, and the fraction of dipalmitoyl phosphatidylcholine of total phosphatidylcholine. None of the parameters differed between the groups that were treated with 0.10 or 0.20 mg/kg body weight betamethasone respectively. Diminution of lung DNA content was significant after treatment with betamethasone in doses of 0.05, 0.10, and 0.20 mg/kg body weight. The results of the present study suggest that maternal treatment with lower doses than those in common usage may be successful in prevention of respiratory distress syndrome, and that higher dosages do not confer any additional advantage.

Etoposide and carboplatin as salvage and first-line therapy in ovarian cancer patients

BACKGROUND

The agents etoposide and carboplatin are active against ovarian cancer and display synergistic anti-tumor activity in animal tumor models. The objective of these two phase II trials was to determine the efficacy and toxicity of the combination of etoposide with carboplatin in previously treated and untreated patients with ovarian cancer.

PATIENTS AND METHODS

Etoposide (100 mg/m2) was administered as a one-hour infusion on three consecutive days and carboplatin (400 mg/m2) as a 30-minute infusion on day 2 of each monthly scheduled cycle. In 20 patients, previously treated with cisplatin-containing regimens, a total of 102 cycles was applied as salvage therapy (ST) and in 27 patients, a total of 168 cycles as first-line therapy (FLT).

RESULTS

ST yielded 2 complete remissions (CR) and one partial remission (PR); in 7 patients, no evidence of disease (NED) and in 6 patients, no change (NC) were observed. The progression-free intervals (PFI) lasted a median 7.0 months (range < 2-14 months). FLT resulted in 7 CR (4 of them pathologically (p) verified), 11 NED (1 pNED), 3 PR (1 pPR) and 6 NC. The objective response rate was 63% (95% confidence interval: 36-89%). PFI lasted a median 8.0 months (range 3-25+ months); median survival had not been reached at the time of evaluation. Thrombocytopenia (WHO grade 4) was the limiting toxicity.

CONCLUSIONS

Although not fulfilling the expectations of synergistic activity as shown in preclinical models, the combination of etoposide with carboplatin is an active and feasible therapy regimen in the out-patient management of ovarian cancer.

[Intravesical administration of estriol in sensory urge incontinence--a prospective study]

Local intravaginal application of oestriol is part of the therapeutical programme of sensory urge-incontinence. The effectiveness of a new method--intravesical administration of 1 mg oestriol versus a placebo--has been proved in a prospective randomised study. 21 patients each were treated over a period of three weeks with oestriol or with the placebo-substance intravesically. The effectiveness of the administered therapy was checked with clinical and urodynamic parameters. The intravesical administration of 1 mg oestriol proved to be efficient and free of side effects in respect of the parameters such as imperative micturition, bladder capacity, of the maximum urethral closure pressure as well as the number of micturitions per diem. The intravesical administration of oestriol may be considered as additional method of therapy for treatment of sensory urge-incontinence.

[Breech presentation in nulliparous women--vaginal delivery or indications for primary section?]

The strategy of primary Caesarean section (I. UFK) was compared to the strategy of conservative vaginal delivery (SFK) in nulliparous women with singleton breech presentation. 160 women of the I. UFK and 178 women of the SFK were entered into this retrospective study. Women with gemini, preterm delivery before 32 completed weeks of amenorrhoea, with intrauterine death and with non-viable malformations were excluded. The Caesarean section rate at the I. UFK was 85% and at the SFK 12.4%. Perinatal mortality was zero in both groups. Only 1 child (33 weeks of gestation, 1350 g) died after vaginal delivery in consequence of a wrong interpretation of a pathological CTG (I. UFK) 3 weeks post partum. In addition to this child, another 3 children (0.8%) showed late morbidity (2 after vaginal delivery, 1 after Caesarean section). Only 1 case of complete brachial palsy, which healed almost completely 4 years after delivery, can be suspected of being connected with the mode of vaginal delivery. As expected, maternal morbidity was significantly increased in the group of Caesarean section in comparison to the group of vaginal delivery in terms of fever, transfusions, and duration of hospitalisation. Life-threatening complications, however, were not seen. In conclusion, our data show, that, if performed by well experienced doctors, a conservative approach for vaginal delivery in nulliparous women with breech presentation is also a safe strategy in comparison to primary Caesarean section.

In vitro and in vivo evaluation of the combination of cisplatin and its analogue carboplatin for platinum dose intensification in ovarian carcinoma

BACKGROUND

Cisplatin and its analogue carboplatin have been shown to cause dose-dependent growth inhibition throughout a wide dose range in the ovarian cancer cell lines OVCAR-3, 2780, HTB-77, and CRL-1572 tested. Cisplatin was 30 times more effective than carboplatin. The combination of both substances led to a less-than-synergistic effect, as was revealed by an isobologram in the OVCAR-3 cell line. Because of the different toxicity pattern, cisplatin and carboplatin theoretically are ideal candidates for combination chemotherapy in platinum-sensitive tumors.

METHODS

In a Phase II study, the efficacy, the toxicity profile, and the feasibility of combining both substances were assessed in 20 previously untreated patients with ovarian cancer. The regimen consisted of carboplatin (300 mg/m2) on day 1, followed by cisplatin (100 mg/m2) on day 2 every 4 weeks.

RESULTS

A total of 81 cycles were administered (median, 4 cycles; range, 1-6 cycles); four patients experienced complete remission and three experienced clinical partial remissions. Limiting toxicities were thrombocytopenia, leukopenia, and ototoxicity. The mean (+/- standard deviation [SD]) carboplatin and cisplatin dose intensities (DI) reached during the first four cycles of therapy were 58 mg/m2/week (+/- 18 mg/m2/week) and 21 mg/m2/week (+/- 7 mg/m2/week), respectively, which corresponded closely to the projected DI of 75 and 25 mg/m2/week, respectively. Based on the equivalence ratio of 4:1, the DI of carboplatin has been converted into the respective cisplatin DI, resulting in a total DI estimate. The overall DI of 37 mg/m2/week (+/- 14 mg/m2/week) was close to the projected one of 44 mg/m2/week.

CONCLUSIONS

Combining cisplatin with carboplatin was found to represent a feasible and efficacious therapeutic strategy for increasing platinum dose intensity.

First experience with FGF-3 (INT-2) amplification in women with epithelial ovarian cancer

Estimation of FGF-3 oncogene amplification in DNA samples extracted from paraffin embedded sections of 136 ovarian cancer samples was carried out by a quantitative PCR method. The aim of this study was to elucidate a possible association of FGF-3 copy numbers with established prognostic factors such as age, histology, FIGO stage, grading, postoperative residual tumour mass, ascites, hormone receptor content and preoperative CA 125 serum levels. In addition, correlation of FGF-3 amplification with overall survival of the patients was assessed. There was a borderline positive correlation between preoperative CA 125 serum levels and the degree of amplification of the FGF-3 gene (P = 0.06). A statistically significant association of FIGO-stage with FGF-3 copy number could be found (P = 0.008). No correlation between FGF-3 amplification and overall survival was noted. The data combine to suggest that FGF-3 is an indicator of aggressiveness of ovarian cancer.