Assessment of the depth of myometrial invasion in stage I endometrioid endometrial cancer using pancytokeratin immunohistochemistry

BACKGROUND

There is a strong correlation between disease mortality and the depth of myometrial invasion in stage I endometrial cancer (EC). Current assessment of the depth of invasion relies on light microscopy. Tumor cells can evade detection by light microscopy if they are vastly outnumbered by myometrial cells. Immunohistochemical (IHC) techniques against pancytokeratins (PCKs) have a great potential in the detection of such isolated cells.

OBJECTIVES

To investigate the application of IHC techniques in the identification of isolated infiltrating tumor cells within myometrium and assess its significance in clinically stage I EC.

METHODS

A single representative tissue block containing the deepest myometrial invasion by the tumor was selected for 90 patients with stage I EC. Sections from each block were immunostained in accordance with established streptavidin-biotin peroxidase method using a mouse monoclonal antikeratin clone AE1/AE3. Myometrium was re-examined to identify deeper myometrial invasion that had escaped detection on hematoxylin and eosin (H&E) section. The clinical records were reviewed, and following data were collected: age, race, parity, presentation, associated medical disorders (obesity, diabetes, and hypertension), use of tamoxifen or hormone replacement therapy, menopausal state, recurrence, and survival.

RESULTS

Of 90 cases, deeper myometrial invasion was detected on IHC sections in seven cases (7.7%). In five of these seven cases, isolated tumor cells surrounded by inflammatory cells were noted 0.2-1.2 mm deeper within the myometrium than that detected by H&E staining. In the remaining two cases, the deeper extension seen was the result of examining serial levels through the tumor block; in these cases, deeper infiltration should have been apparent on H&E sections. Follow-up data was available in 72 of the 90 cases. A trend was noted between the presence of isolated tumor cells deeper within myometrium on IHC and tumor recurrence (P = 0.056). The 2-year recurrence-free survival was 40% for the group with IHC evidence of deeper invasion compared with 89% for the group without (P = 0.005). Similarly, analysis of cause-specific and overall survival revealed significant differences between the two groups (P = 0.038 and P = 0.026, respectively).

CONCLUSIONS

In this study, we have shown that it is possible to identify deeper level of myometrial invasion by tumor cells using an IHC technique. IHC-detected deeper invasion is an uncommon event and may be a feature of more aggressive tumors with greater potential for recurrence and lower survival.

Does Tamoxifen Use Affect Prognosis in Breast Cancer Patients Who Develop Endometrial Cancer?

OBJECTIVE

The use of tamoxifen to prevent breast cancer and decrease recurrence is not controversial. However, the effect that tamoxifen may have in women with a history of breast cancer in whom endometrial cancer develops is unclear. The purpose of this study was to estimate whether a history of tamoxifen use is a prognostic factor for such patients.

METHODS

Between 1990 and 2002, patients seen at The University of Texas M. D. Anderson Cancer Center with a history of breast cancer who developed endometrial cancer were identified. Medical records were reviewed to identify clinical, pathologic, and outcome information.

RESULTS

Eighty-nine patients with a history of breast cancer in whom endometrial carcinoma developed were identified. Fifty-two percent (46/89) had a history of tamoxifen use (median duration 48 months; range 2-120 months). There were no significant differences in the clinical or pathologic features between tamoxifen users and nonusers. A history of tamoxifen use was associated with a shorter interval from breast cancer to endometrial cancer diagnosis (77.2 versus 121.3 months for nonusers; P =.01). There was no significant difference in overall survival between tamoxifen users and nonusers (39.2 months versus 48.3 months, P =.27), and there was no difference in endometrial cancer-specific survival duration between tamoxifen users and nonusers (55.7 versus 51.0 months, P =.92).

CONCLUSION

Among tamoxifen users, the interval from breast cancer to endometrial cancer diagnosis was significantly shorter than that in nonusers. In this cohort, a history of tamoxifen use was not associated with a worse overall or disease-specific survival.

A new prognostic model comprising p53, EGFR, and tumor grade in early stage epithelial ovarian carcinoma and avoiding the problem of inaccurate surgical staging

Epithelial ovarian carcinoma rarely occurs because of a single event. Therefore, no single biological tumor factor will give accurate prognostic information for all ovarian cancer patients. On the other hand, a combination of two or more independent factors may yield an improved overall prognostic index. Because FIGO stage is included in most of the previously presented models, inaccurate surgical staging in patients with apparently early disease has been a problem. In a series of 226 patients with epithelial ovarian carcinomas in FIGO stages IA-IIC, a number of clinicopathological factors (age, FIGO stage, histopathologic type, and tumor grade) were studied in relation to the biological factors p53 and epidermal growth factor receptor (EGFR), important regulators of the apoptosis and mitosis. Immunohistochemical techniques were used. All patients received adjuvant radiotherapy or chemotherapy after the primary surgery. Expression of p53 was significantly associated with the tumor grade and disease-free survival (DFS). EGFR expression was also associated with DFS. In a Cox multivariate analysis, tumor grade, p53 status, and EGFR status were all independent and significant prognostic factors with regard to DFS. A prognostic model was proposed using these factors. A low-risk group, an intermediate-risk group, and a high-risk group were defined. DFS amounted to 89% in the low-risk group (grades 1-2, p53-negative, and EGFR-negative), 66% in the intermediate-risk group (grade 3, p53-negative, and EGFR-negative or grades 1-2, p53-positive or EGFR-positive) and 39% in the high-risk group (grade 3, p53-positive, and EGFR-positive).

Inability of immunohistochemistry to predict clinical outcomes of endometrial cancer patients

INTRODUCTION

Despite optimal surgery, some patients with early endometrial carcinoma develop recurrence and die of disease. A number of immunohistochemical (IHC)-identified cell products (markers) have been proposed as predictors of recurrence. This study characterizes a large series of endometrial carcinomas with previously described markers as well as markers that have not been investigated in endometrial carcinoma.

PATIENTS AND METHODS

Women who had undergone surgery for endometrial carcinoma were identified and specimens accessed. Tissue blocks were evaluated for ten IHC markers. Results were correlated with last known clinical status.

RESULTS

Mean follow-up was 43 months; complete data were available on 117 patients. Two women died of other causes; of the remaining 115, eight died of disease and six were alive with recurrence at last follow-up (12%). Vascular endothelial growth factor staining independently predicted recurrence and death. However, in multivariate analyses, only FIGO stage predicted outcome.

DISCUSSION

Our goal was to identify markers to predict which women with endometrial carcinoma were likely to have disease recurrence. We evaluated cell-cycle regulatory proteins, growth factors, hormone receptors, and angiogenic factors, but did not identify any marker that independently predicted outcome in multivariate analysis. This may reflect the few negative outcomes in our population.

Consolidation treatment of advanced ovarian carcinoma with radiotherapy after induction chemotherapy

In a prospective randomized trial, consolidation treatment with radiotherapy or chemotherapy was compared with no treatment in a series of 172 patients with epithelial ovarian carcinoma, FIGO stage III, with complete surgical remission after primary cytoreductive surgery and induction chemotherapy. In the subgroup with complete pathological remission, progression-free survival (PFS) was significantly (P = 0.032) better in the radiotherapy group (56%) than in the chemotherapy group (36%) and the untreated control group (35%). The number of recurrences was lowest in the radiotherapy group. The overall relapse rate was reduced by 33% and the pelvic recurrences by 43% by consolidation radiotherapy. On the other hand, treatment-related side effects were more frequent in the radiotherapy group.

Interpretation of p53 Immunoreactivity in Endometrial Carcinoma: Establishing a Clinically Relevant Cut-Off Level

There is accumulating evidence that immunohistochemical staining for p53 can identify patients with endometrial carcinoma who have an adverse outcome, but the interpretation of existing data is complicated by differences between studies in the way that p53 immunohistochemistry results have been assessed. In this study, we sought to determine the appropriate cut-off level for stratification of patients with endometrial carcinoma into high- and low-risk groups, based on p53 immunohistochemical staining. A total of 200 cases of endometrial carcinoma treated by hysterectomy were retrieved from the archives of the Department of Pathology, Vancouver General Hospital, from the period 1983 to 1998. Follow-up information was available for all cases. Slides were reviewed and the diagnosis confirmed, tumors graded according to FIGO grading system, and tumor cell type assessed. A tissue microarray consisting of duplicate 0.6-mm cores of tumor was constructed and immunostained for p53. Immunoreactivity for p53 was scored by counting the number of positively stained tumor cell nuclei and expressing this as a percentage of the total number of tumor cell nuclei counted (p53 index). Kaplan-Meier survival curves were constructed and compared by calculation of log-rank statistic, and multivariate analysis was performed by Cox regression modeling. The distribution of p53 index results was bimodal, with most cases having a very low or very high p53 index. The peaks of the bimodal distribution were clearly separated using a p53 index of > or =50%. Immunoreactivity was a significant adverse prognostic indicator of disease-specific survival (p<0.0001 by univariate analysis). Patients with strongly p53 immunoreactive tumors (p53 index >or =50%) had a significantly worse outcome than patients with weakly immunoreactive (p53 index > or =5% and <50%) or p53-negative (p53 index <5%) tumors (p = 0.0001). There was no significant difference between the outcomes for patients in the latter two groups. By multivariate analysis, p53 overexpression was a significant prognostic indicator independent of patient age and tumor stage (p = 0.008) but was not independent when the analysis was extended to include FIGO grade and tumor cell type. p53 immunostaining was of prognostic significance in the subset of patients with endometrioid carcinomas (p = 0.02), but not in patients with clear cell or papillary serous carcinomas. Using a p53 index of > or =50% as a cut-off between positive and negative p53 staining, immunohistochemical staining for p53 is a prognostic indicator in patients with endometrial carcinoma of endometrioid type. p53 immunostaining was not found to be of prognostic significance independent of tumor cell type and grade.

FIGO stage IIIC endometrial carcinoma: resection of macroscopic nodal disease and other determinants of survival

The objective of this study was to evaluate the potential survival benefit of debulking macroscopic adenopathy and other clinical prognostic factors among patients with node-positive endometrial carcinoma. Demographic, operative, pathologic, and follow-up data were abstracted retrospectively for 41 eligible patients with FIGO stage IIIC endometrial cancer. Survival curves were generated using the Kaplan-Meier method and statistical comparisons were performed using the log rank test, logistic regression analysis, and the Cox proportional hazards regression model. All patients had positive pelvic lymph nodes and 20 patients (48.8%) had positive para-aortic lymph nodes. Postoperatively, all patients received whole pelvic radiation therapy, 17 received extended-field radiation therapy, and 15 patients received chemotherapy. The median disease-specific survival (DSS) time for all patients was 30.6 months (median follow-up 34. 0 months). Patients with completely resected macroscopic lymphadenopathy had a significantly longer median DSS time (37.5 months), compared to patients left with gross residual nodal disease (8.8 months, P = 0.006). On multivariate analysis, independent predictors of DSS were gross residual nodal disease (HR 7.96, 95% CI 2.54-24.97, P < 0. 001), age > or = 65 years (HR 6.22, 95% CI 2.05-18.87, P = 0.001), and the administration of adjuvant chemotherapy (HR 0.22, 95% CI 0.07-0.76, P = 0.016). We conclude that in patients with stage IIIC endometrial carcinoma, complete resection of macroscopic nodal disease and the administration of adjuvant chemotherapy, in addition to directed radiation therapy, are associated with improved survival.

The CD44 receptor is a molecular predictor of survival in ovarian cancer

PURPOSE

CD44 is a cell surface receptor implicated in cancer progression and metastases. Malignant tumors may show a loss of CD44 splice control mechanisms. We investigated the role of CD44 splice variant expression in ovarian tumors and metastases, and its association with survival.

EXPERIMENTAL DESIGN

We tested CD44 expression in 142 cases of epithelial carcinoma of the ovary and 265 metastatic sites by immunohistochemistry.

RESULTS

Survival analysis showed that the expression of CD44s, CD44-v4, -v5, -v6, -v9, and -v10 are significant predictors for survival in univariate analysis. After stage, the expression of CD44-v10 in metastases was the strongest predictor of decreased survival in multivariate analysis (p = 0.0009). Conversely, CD44-v10 expression in the primary tumor was an independent predictor of improved survival in multivariate analysis (p = 0.0002). The expression of CD44s in the tumor/stroma interface of the primary tumor was associated with improved survival (p < 0.0001).

CONCLUSIONS

CD44 variant expression is a molecular prognostic maker for epithelial ovarian carcinomas. CD44-v10 expression is an independent prognostic indicator and the site of expression determines a positive or negative influence in survival. Our results also indicate that CD44 may be involved in important tumor/stroma interactions.

Brain Metastases in Patients with Ovarian Carcinoma: Prognostic Factors and Outcome

Between January 1975 and April 2001, 8,225 patients with ovarian cancer were seen at The University of Texas M.D. Anderson Cancer Center. Brain metastases developed in 72 of these patients (0.9%). The medical records of these patients were reviewed to assess the incidence of these metastases and their correlates of survival, as well as to describe the various treatment modalities used against them and their respective outcomes. The mean age of patients at the time of brain metastasis diagnosis was 53.7 years. The median interval between the diagnosis of the primary cancer and brain metastasis was 1.84 years. Neurological deficit, headache, and seizure were the most common symptoms. The brain was the only site of metastasis in 43% of patients. Multiple metastases were seen in 65% of them, although this may be a slight underestimate, as brain metastases in 17% of patients were evaluated prior to the magnetic resonance imaging era. The median survival time after the diagnosis of brain metastases was 6.27 months (95% CI, 4.48-8.06 months). The combination of surgical resection and whole-brain radiation therapy (WBRT) resulted in a longer survival time (median, 23.07 months) than did WBRT alone (median, 5.33 months) or surgery alone (median, 6.90 months) (p < 0.01 in both instances, multivariate Cox proportional hazards model analysis). The prognosis for patients with brain metastases from ovarian cancer appears to be poor. The existence of systemic dissemination at the time of brain metastasis was associated with a worse survival trend. The only significant predictor of survival in our series was the treatment modality. In particular, the resection of brain metastasis from ovarian cancer followed by WBRT appeared to be superior to resection alone or WBRT alone.

Adjuvant treatment for early ovarian cancer: a randomized phase III trial of intraperitoneal 32P or intravenous cyclophosphamide and cisplatin--a gynecologic oncology group study

PURPOSE

To conduct a prospective study of intraperitoneal radioactive chromic phosphate (32P) versus cyclophosphamide-cisplatin (CP) in women with early ovarian cancer at high risk for recurrence (International Federation of Gynecology and Obstetrics stage Ia or Ib grade 3 or Ic or stage II, no macroscopic residual disease) and to compare cumulative incidence of recurrence, overall survival, and relative toxicity.

MATERIALS AND METHODS

A total of 251 patients were randomly assigned to treatment with 32P or CP. Twenty-two (8.7%) were ineligible following centralized pathology review. Of the 229 patients included in the analysis, 110 received 32P, and 119 received CP.

RESULTS

The cumulative incidence of recurrence at 10 years was 35% (95% CI, 27% to 45%) for patients receiving 32P and 28% (95% CI, 21% to 38%) for those receiving CP. Patients receiving CP had a recurrence rate 29% lower than that of those receiving 32P (P =.15, two-tail test). The death rate for patients treated with CP was 17% lower than that for patients treated with 32P (difference not significant). Combining both arms, the 10-year cumulative incidence of recurrence for all stage I patients was 27% (95% CI, 20% to 34%) compared with 44% (95% CI, 32% to 56%) for stage II patients (P =.01). Both regimens were reasonably well tolerated, but problems with inadequate distribution (7%) and small-bowel perforation (3%) make the otherwise less toxic 32P less acceptable.

CONCLUSION

Although there are no statistically significant differences in survival, the lower cumulative recurrence seen with CP and complications of 32P administration make platinum-based combinations the preferred adjuvant therapy for early ovarian cancer patients at high-risk for recurrence.

The prognostic significance of the immunohistochemical expression of p53, bcl-2, c-erb B-2 and cathepsin-D in ovarian cancer patients receiving platinum with cyclophosphamide or paclitaxel chemotherapy

PURPOSE

To evaluate the prognostic significance of the immunohistochemical expression of p53, bcl-2, c-erbB-2 and cathepsin-D in epithelial ovarian cancer (EOC).

METHODS

We analyzed 100 patients with ovarian carcinoma, FIGO Stage IC-IV who underwent primary cytoreductive surgery and received adjuvant chemotherapy with cyclophosphamide and a platinum analogue (CP) (n = 46) or paclitaxel and a platinum analogue (TP) (n = 54). Immunohistochemical expression was studied on paraffin-embedded tissue from the primary tumor.

RESULTS

After a median follow-up of 55 months median progression-free survival (PFS) and overall survival (OS) were 16 and 41 months, respectively. Positive bcl-2 staining and absence of cathepsin-D expression were associated with an increased complete response rate in the CP group (p = 0.011 and p = 0.003) but not in the TP group. PFS and OS were not associated with the expression of any of the markers studied. FIGO stage (p = 0.006) and histology (p = 0.047) were the only independent prognostic factors for survival.

CONCLUSION

Bcl-2 and cathepsin D expression are associated with response to CP but not TP chemotherapy. P53, bcl-2, c-erb B-2 and cathepsin D expression was not correlated with PFS and OS in our study.

First-line intraperitoneal cisplatin-paclitaxel and intravenous ifosfamide in Stage IIIc ovarian epithelial cancer

OBJECTIVES

To determine the feasibility, toxicity and efficacy of a first-line combination of intraperitoneal (i.p.) paclitaxel and cisplatin and intravenous (i.v.) ifosfamide in untreated patients with Stage IIIc ovarian cancer after cytoreduction or biopsies only.

METHODS

Twenty-six patients entered the trial from 1995 to 1999. Twenty underwent initial cytoreduction which was complete, with residual nodules < 0.5 cm or = 0.5 cm in six, five and nine patients, respectively. Six patients underwent biopsies only at initial surgery. Ten cycles of chemotherapy were planned by both routes. Second-look surgery was planned for all patients.

RESULTS

Twenty-one (81%) of the 26 patients were in complete clinical remission (CCR) at the time of second-look surgery. Of the 15 patients who underwent second-look surgery, ten were in CCR including seven in complete remission (CR) confirmed pathologically. Median overall-survival had not been reached at 53 months (range 16-87), and median disease-free survival was 40 months (range 8-85), for a median follow-up of 53 months (range 16-87). Local toxicity consisted mainly of mild abdominal pain. Systemic toxicity was essentially haematological, with eight (31%) grade 3-4 leukopenia.

CONCLUSION

This study has demonstrated the feasibility, moderate toxicity and efficacy of first-line intraperitoneal paclitaxel-cisplatin chemotherapy.

Green tea consumption enhances survival of epithelial ovarian cancer

Our study investigates whether tea consumption can enhance the survival of patients with epithelial ovarian cancer, a prospective cohort study was conducted in Hangzhou, China. The cohort comprised 254 patients recruited during 1999-2000 with histopathologically confirmed epithelial ovarian cancer and was followed up for a minimum of 3 years. Two hundred forty four (96.1%) of the cohort or their close relatives were traced. The variables examined included their survival time and the frequency and quantity of tea consumed post-diagnosis. The actual number of deaths was obtained and Cox proportional hazards models were used to obtain hazard ratios and associated 95% confidence intervals (CI), adjusting for age at diagnosis, locality, BMI, parity, FIGO stage, histologic grade of differentiation, cytology of ascites, residual tumour and chemotherapeutic status. The survival experience was different between tea drinkers and non-drinkers (p < 0.001). There were 81 (77.9%) of 104 tea-drinkers who survived to the time of interview, compared to only 67 women (47.9%) still alive among the 140 non-drinkers. Compared to non-drinkers, the adjusted hazard ratios were 0.55 (95% CI = 0.34-0.90) for tea-drinkers, 0.43 (95% CI = 0.20-0.92) for consuming at least 1 cup of green tea/day, 0.44 (95% CI = 0.22-0.90) for brewing 1 batch or more of green tea/day, 0.40 (95% CI = 0.18-0.90) for consuming more than 500 g of dried tea leaves/year, and 0.38 (95% CI = 0.15-0.97) for consuming at least 2 g of dried tea leaves/batch. The corresponding dose-response relationships were significant (p < 0.05). We conclude that increasing the consumption of green tea post-diagnosis may enhance epithelial ovarian cancer survival.

Uterine serous and grade 3 endometrioid carcinomas

BACKGROUND

Serous components within endometrial carcinoma are reportedly poor prognosticators. However, to the authors' knowledge the percentage of tumors which must be comprised of a serous component in order to affect outcome is unknown. The authors compared overall survival (OS) in women with endometrial carcinomas comprised of various percentages of uterine serous carcinoma (USC) with that of women with International Federation of Gynecology and Obstetrics (FIGO) Grade 3 endometrioid carcinoma (G3EC) to determine whether outcomes varied between these two poorly differentiated histologies.

METHODS

Data concerning women with either G3EC or USC who were diagnosed between January 1990 and November 2000 were collected retrospectively. Cases were reviewed to confirm diagnosis and estimate the fraction of tumor comprised of USC. Variables assessed included patient age and race, tumor stage, and lymphovascular space invasion. Associations between variables were tested using the Fisher exact test. The Kaplan-Meier method was used to evaluate OS with comparisons performed using the log-rank test.

RESULTS

Fifty-two women with G3EC and 87 women with USC were identified. The OS of women with tumors comprised of > 50% USC was found to be significantly worse compared with women with G3EC (hazard ratio [HR] of 2.4; 95% confidence interval [95% CI], 1.2-5.2). Women with USC were more likely to present with extrauterine disease (odds ratio of 2.2; 95% CI, 1.1-4.5). The 5-year survival rate for women with G3EC was 75% compared with 41% for women with tumors that were > 50% USC (P = 0.01). There was a significant trend toward a worse OS in women with even 10% USC compared with women with G3EC.

CONCLUSIONS

USC involving > 50% of an endometrial carcinoma was found to be predictive of worse OS compared with the OS of women with G3EC. In patients with early-stage disease, a trend toward a worse prognosis was found to exist when USC comprised even 10% of a tumor. Investigation into the treatment of endometrial carcinoma should include and document tumors with any percentage comprised of USC.

HSP27 in patients with ovarian carcinoma: still an independent prognostic indicator at 60 months follow-up

OBJECTIVE

Heat shock protein 27 (HSP27) is produced in response to pathophysiologic stress in animal cells. The authors have previously shown that HSP27 is an independent prognostic indicator in patients with ovarian carcinoma. The present study was performed to see whether HSP27 remained an independent prognostic indicator with longer follow-up.

METHODS

One hundred and three consecutive patients with epithelial ovarian carcinoma were studied. Slides were prepared from fresh tissue. HPS27 staining was performed as previously described. Patient records were examined for FIGO stage, grade, histology, level of cytoreduction and survival.

RESULTS

One hundred and three patients were followed for a mean of 60 months. Twenty patients had FIGO Stage I disease, four Stage II, 59 Stage III, and 20 Stage IV. Immunohistochemical (IHC) staining for HSP27 was not related to histologic grade, level of cytoreduction or histologic subtype. A statistically significant decrease in HSP27 staining was found to correlate with increased FIGO stage (p = 0.008). Using cox-regression analysis, HSP27 staining (p = 0.025), stage (p = 0.0012), and level of cytoreduction (p < 0.0001) were independent predictors of survival in these patients.

CONCLUSION

Cox-regression analysis found HSP27 to be an independent indicator of prognosis and survival in patients with ovarian carcinoma who had longer follow-up. Decreased HSP27 staining was related to decreased survival. This study confirms the authors' earlier report on the importance of HSP27 as a prognostic indicator in ovarian carcinoma.

Increase in expression of the copper transporter ATP7A during platinum drug-based treatment is associated with poor survival in ovarian cancer patients

PURPOSE

The Cu efflux transporter ATP7A is overexpressed in some cisplatin-resistant ovarian carcinoma cell lines. We examined the expression of ATP7A in the major normal human organs and in several types of human malignancies and sought to determine whether ATP7A expression changed during treatment of ovarian carcinomas with Pt-containing regimens.

EXPERIMENTAL DESIGN

ATP7A expression was quantified by immunohistochemical staining using microarrays containing normal and malignant tissues, and standard sections of 54 paired tumor samples obtained from ovarian carcinoma patients before and after at least two cycles of platinum-based therapy.

RESULTS

ATP7A was expressed in normal endometrium, prostate, testis, and kidney but was not detected in the other major organs. ATP7A was expressed in some of the most common human malignancies, including prostate (7 of 7), breast (10 of 10), lung (8 of 8), colon (5 of 8), and ovary (6 of 7), as well as in a wide variety of other types of malignancy. ATP7A staining was detected in 28 of 54 ovarian carcinomas before treatment. Patients with increased ATP7A expression after treatment (18 of 54) exhibited poorer actuarial survival (P<0.0057 by log-rank test). Expression of ATP7A either before or after treatment was not associated with other clinical factors.

CONCLUSIONS

Although ATP7A is not detectable in most normal tissues it is expressed in a considerable fraction of many common tumor types. Enrichment of the tumor for ATP7A-expressing cells during platinum drug-based treatment of ovarian cancers is associated with poor survival. These findings are in agreement with results of in vitro studies from this laboratory demonstrating that increased expression of ATP7A renders cells resistant to cisplatin and carboplatin.

Angiogenesis in endometrial carcinoma: correlation with survival and clinicopathologic risk factors

Association among angiogenesis, survival and clinicopathologic parameters in endometrial carcinoma was evaluated. Sixty patients who had been diagnosed as endometrial carcinoma, from 1993 to 1998, were included in the study. All patients had been surgically staged with bilateral pelvic and para-aortic lymph node dissection. All hysterectomy specimens were stained immunohistologically for factor VIII-related antigen. The area with the most intensified microvasculature was determined under low-power (x100) magnification, and the microvessel count of this area under high-power (x200) magnification was determined as the microvessel density (MVD) of the tumor. The mean MVD was 26.2 +/- 13.0 (range 6-68), and it was considered as high (n = 24; 40%), moderate (n = 19; 31.7%) and low (n = 17; 28.3%) when the MVD was >30, between 15-30 and <15, respectively. Statistical analysis included Mann-Whitney, Kruskal-Wallis and Spearman rank correlation tests. The Kaplan-Meier method was used to evaluate the difference between angiogenesis and survival. Multivariate analysis with the Cox regression model was used in MVD values and different clinicopathological parameters. There was positive correlation between MVD increase and surgicopathological stage (p < 0.05). A significant difference was seen between MVD increase and lymph node metastasis (p < 0.05). There were no differences between MVD and age, histological type, grade and lymphovascular invasion. MVD did not change in association with myometrial invasion depth. There was a significant difference in means of survival between the low and high MVD groups (p = 0.01). However, MVD was not an independent prognostic factor in multivariate analysis. Increased angiogenesis was found to be associated with advanced stage and decreased survival in endometrial carcinoma.

Unusual Epithelial and Stromal Changes in Myoinvasive Endometrioid Adenocarcinoma: A Study of Their Frequency, Associated Diagnostic Problems, and Prognostic Significance

The authors have noted that when the myoinvasive glands of endometrioid carcinomas evoke a prominent fibromyxoid stromal reaction, they sometimes undergo distinctive changes. These are characterized by outpouchings from typical neoplastic glands that become detached and often lined by flattened epithelium, sometimes appearing as microcysts. The glands may less often become elongated or undergo fragmentation into small solid clusters or single cells. For this constellation of changes, which in aggregate are distinctive, the authors have coined the acronym MELF (microcystic, elongated, fragmented). The authors evaluated the prognostic significance of these stromal and glandular features and their association with each other and with other histopathologic and clinical prognostic factors by studying 115 unselected myoinvasive endometrial endometrioid carcinomas. The histologic slides and clinical records were reviewed to collect data on age, recurrences or metastases, survival, stromal reaction pattern (fibromyxoid, lymphocytic, or absent), presence of MELF, FIGO grade, depth of myometrial invasion, vascular invasion, squamous differentiation, and presence or absence of necrosis. Factors associated with an unfavorable outcome (recurrence or death) included a fibromyxoid stromal reaction, age older than 70 years, advanced stage, vascular invasion, FIGO grade, depth of myoinvasion, and the presence of tumor necrosis. The presence of a host lymphocytic reaction was associated with a favorable outcome. A multivariate logistic regression model identified stage and age older than 70 years as independent prognostic factors. The MELF changes were associated with the presence of a host stromal reaction (most strongly with a fibromyxoid reaction) and vascular invasion. Within the group associated with a fibromyxoid reaction, patients exhibiting MELF had a better survival. In conclusion, a fibromyxoid reaction in cases of endometrioid carcinoma is associated with a higher frequency of death or recurrence and it is frequently accompanied by distinctive morphologic changes (MELF) in myoinvasive glands as well as lymphatic or blood vessel invasion. MELF is associated with a fibromyxoid reaction but is not independently associated with an adverse effect on prognosis. A lymphocytic stromal reaction is associated with a favorable effect on prognosis and is less often accompanied by the distinctive morphologic changes (MELF) highlighted herein.

Survival and prognostic factors in patients with synchronous ovarian and endometrial cancers and endometrial cancers metastatic to the ovaries

PURPOSE

To compare the survival and prognostic factors of patients with synchronous primary ovarian and endometrial cancers, and endometrial cancers metastatic to the ovaries.

PATIENTS AND METHODS

Fifty-three patients with synchronous primary ovarian and endometrial cancer and 64 patients with endometrial cancer metastatic to the ovaries were evaluated.

RESULTS

Mean follow-up time was 47.2 months (18-170 months). There was no statistical difference in age, gravidity and parity between the two groups. Abnormal vaginal bleeding was the most common symptom in both groups. All patients were subjected to a surgical staging procedure. Overall survival of the synchronous group was significantly higher than that of the metastatic group (98 +/- 12 vs 59 +/- 6 months; p = 0.048). The significant prognostic factors for synchronous cancers after multivariate analysis were age, stage of ovarian cancer, grade of endometrial cancer, and adjuvant therapy status.

CONCLUSION

Patients with synchronous ovarian and endometrial cancers appear to have a good prognosis and should undergo primary surgical staging since the stage of tumors is a significant prognostic factor.

Endometrioid adenocarcinoma of the uterus: surgico-pathological correlations and role of pelvic lymphadenectomy

INTRODUCTION

In 1988, FIGO added lymph node surgery to the staging system for endometrial cancer. This change remains controversial to date. From our study we aim to determine the significance of surgico-pathological parameters of endometrioid carcinoma for pelvic nodal metastases and survival, as well as to study the role of pelvic lymphadenectomy in the surgical treatment of this disease.

MATERIALS AND METHODS

A retrospective study was conducted in 198 women with endometrioid carcinoma who underwent full surgical staging including pelvic lymphadenectomy. The multiple variant regression analysis and the multi-variant logistic regression analysis were applied in the analysis of relationship.

RESULTS

A positive correlation between nodal metastases and grade, myometrial invasion, peritoneal cytology, adnexal involvement, lympho-vascular space involvement and tumour size was found. For survival, significant prognosticators were grade, myometrial invasion, peritoneal cytology, lympho-vascular space involvement, adnexal involvement, associated atypia and pelvic nodal metastases. Thirty-five per cent of the patients had high risk of recurrence based on uterine pathological factors but were node negative. They were spared external beam radiation and its associated morbidities, and were treated with adjuvant vault brachytherapy instead. Six per cent of the patients would have been understaged based on uterine factors alone if pelvic lymphadenectomy had not been done.

CONCLUSION

We infer that routine pelvic lymphadenectomy should be considered for all surgically fit patients with endometrioid carcinoma. The accurate staging will allow individualized adjuvant therapy and prevent understaging and overtreatment.

Long-term prognosis of stage I ovarian carcinoma. Prognostic importance of intraoperative rupture

OBJECTIVE

There are a few long-term follow-up studies of patients with stage I ovarian carcinoma. The objective of this study was to evaluate prognostic factors for long-term survival.

METHODS

Two hundred fourteen stage I ovarian carcinomas (registered by the Tokai Ovarian Tumor Study Group from 1988 to 1999) were analyzed. Staging according to the International Federation of Gynecology and Obstetrics was set without considering the pathologic findings of the lymph nodes. Stage Ic was divided into Ic(b) and other Ic.

RESULTS

Seventy-four patients were stage Ia, 2 were stage Ib, and 138 were stage Ic, consisting of 75 Ic(b) and 63 other Ic patients. The ratios of stage Ic to Ia and stage Ic(b) to Ic were highest in clear-cell adenocarcinoma among histologies analyzed. There were significant differences in disease-free survival curves between each group. In clear cell adenocarcinoma, there was a significant difference in disease- free survival curves between stage Ic(b) and other Ic (p = 0.0373), while this tendency was also observed in other histologies except for mucinous carcinoma. Multivariate analysis demonstrated that substage was a significant prognostic factor of both disease-free and overall survival.

CONCLUSIONS

Stage Ic(b) patients showed poorer survival than stage Ia patients but better than survival in other Ic. Thus, cautious treatment of ovarian tumor during surgery is quite important to avoid rupture.

Pathological findings in early-stage endometrial cancer

OBJECTIVE

The aim of this study was to assess the pathological characteristics of early-stage endometrial cancer, with regard to endometrioid versus serous papillary adenocarcinoma.

METHODS

Sixty-six cases of early-stage endometrial carcinoma were classified into two groups: group I--36 cases of endometrioid endometrial cancer, staged IA-IB and graded G1-G2; group II--30 cases of Stage I serous papillary endometrial cancer. The pathological characteristics compared between the two groups included features such as tumor location in the uterine cavity, tumor focality, lymphovascular invasion, as well as the status of the uninvolved endometrium, adjacent to the tumor. Patient clinical characteristics were obtained from the medical records.

RESULTS

Significantly more patients with endometrioid endometrial cancer were premenopausal (p < 0.0001), obese (p < 0.02), had hypertension (p < 0.00001) and familial cancer (p < 0.0001). On the other hand, significantly more patients with serous papillary cancer had another primary malignancy (p < 0.001). Considering the pathological characteristics, 75% of endometrioid as compared with 6.7% of serous papillary cancer cases were found in the upper uterine segment only (p < 0.0001). Multifocality was observed in 16.7% of endometrioid as compared with 100% of serous papillary cancer cases (p < 0.0001). Lymphovascular space invasion was absent in all cases of endometrioid cancer, while present in 90% of serous papillary cancer cases (p < 0.0001). Seventy-five percent of endometrioid and 100% of serous papillary cancer cases were associated with an atrophic endometrium.

CONCLUSION

The clinical and pathological features of early-stage endometrial cancer differ according to the histological type of the cancer. The majority of endometrioid cancers are probably associated with an atrophic or normally cycling endometrium, and not with endometrial hyperplasia.

An interleukin-6 gene promoter polymorphism influences the biological phenotype of ovarian cancer

Interleukin (IL)-6 is known to be involved in the pathogenesis of ovarian cancer. We investigated a common G/C polymorphism at position -174 of the IL-6 gene (IL6) promoter in 121 patients with ovarian cancer using pyrosequencing. Presence of at least one mutant allele was associated with early tumor stage as well as an expanded length of disease-free (DFS) and overall survival with a dose-dependent effect regarding the carriage of 0, 1, and 2 alleles. In a multivariate Cox regression model incorporating tumor stage and residual tumor mass, presence of the -174 C allele of IL6 was the best predictor of DFS. We conclude that the mutant -174 C allele of IL6 influences the biological phenotype of ovarian cancer because it is associated with early stage and improved DFS and overall survival.

The role of topotecan as second-line therapy in patients with recurrent ovarian cancer

INTRODUCTION

Up to 80% of patients with advanced ovarian cancer will recur following first-line platinum containing chemotherapy. Topotecan has recently been used as a second-line agent in treatment of advanced ovarian disease. The aim of the study was to evaluate the effect of topotecan on response rate and progression-free interval on patients with recurrent ovarian cancer who had been treated with platinum-containing first-line chemotherapy.

METHODS

A retrospective review of all cases of recurrent ovarian cancer treated with topotecan was done. Response was determined using radiologic reports (CT scans, ultrasound scans), CA-125 level and the clinical evaluation. Response type was determined using World Health Organization (WHO) criteria.

RESULTS

Between 1998-2000, a total of 43 patients were treated with topotecan. Median age was 57 (range 41-80), 40/43 patients had stage III and IV, 37/43 patients had Grade 3 tumors. Seventeen of 43 patients (39.5%) demonstrated stable disease and 9/43 (21%) patients demonstrated partial response. Median time to response was eight weeks, median progression-free interval was 31 weeks and median time of follow-up and survival was 48 weeks.

CONCLUSION

Topotecan is considered a reasonable option for treatment of patients with recurrent ovarian cancer that have failed previous treatment with platinum-containing chemotherapy.

Uterine papillary serous carcinoma (pure and mixed type) compared with moderately and poorly differentiated endometrioid carcinoma. A clinicopathologic study

OBJECTIVE

The aim of this study was to investigate the clinicopathologic features and the outcome in patients with pure and mixed type uterine papillary serous carcinoma (UPSC), and to compare these parameters with those observed in patients with moderately and poorly differentiated endometrioid endometrial carcinoma (MPD-EEC).

METHODS

The charts of 34 patients with UPSC and 30 patients with MPD-EEC, operated on between January 1995 and December 2000, were retrospectively reviewed. The UPSC group included ten cases of pure and 24 cases of mixed type UPSC (admixed with endometrioid component). All patients had undergone full surgical staging. Clinical features, surgicopathological findings, recurrence rate and recurrence-free interval were compared between the study groups.

RESULTS

Significantly more patients with MPD-EEC than with UPSC were operated on in FIGO stage I and II (p = 0.001). MPD-EEC patients were significantly older and more obese (p = 0.03 and p = 0.01, respectively) as compared with the UPSC patients. Significantly more patients with MPD-EEC presented with postmenopausal bleeding (p = 0.02), had a second primary cancer in the past (p = 0.03) and had a first degree relative with history of malignant disease (p = 0.0001). Conversely, the rates of positive abdominal cytology and cervical involvement were significantly higher in the group of UPSC (p = 0.02 and p = 0.02, respectively). Significantly more patients with UPSC were treated with adjuvant therapy (p = 0.01). No significant difference between the two study groups was observed comparing the recurrence rate, the recurrence free interval and the 3-year survival. There was also no significant difference between the pure and the mixed type UPSC, considering the clinical features and the follow-up data.

CONCLUSION

The current study presented no significant difference in the outcome of MPD-EEC as compared with the pure and the mixed type UPSC, yet prospective studies are needed to evaluate the role of adjuvant therapy in each study group.

Actual trends in screening, diagnosis and prognosis of endometrial cancer

Endometrial cancer is today the first ranking malignancy of the female genital tract in civilized countries. We stress the importance of screening and an early accurate diagnosis with personalized therapy. Personalized therapy is particularly important considering that there are two main forms of these neoplasms: the endometrioid form, hormonodependent and with a good prognosis, and a serous autonomous form, which has a poor evolution. Studying the cases in the Ist Clinic of Gynecology, Timişoara, we analyzed the incidence of these forms, their particularities and diagnostic possibilities.

P53 and Bcl-2 as prognostic predictors in epithelial ovarian cancer

The study was designed to evaluate the prognostic importance of clinical and pathologic variables with p53 and Bcl-2 in epithelial ovarian cancer using multivariate analysis. Tumor tissues from 90 patients were analyzed immunohistochemically for p53 and Bcl-2 expression. Hazard ratios were calculated in univariate and multivariate survival analyses. Forty-two (47%) were considered positive for p53 expression and 18 (20%) were positive for Bcl-2. Positive expression for p53 was less frequent in patients in FIGO stage I (22%). Positive staining for Bcl-2 correlated significantly with the histologic type (P < 0.01). No direct correlations could be demonstrated between p53 and Bcl-2 expression and age or histologic grade. In univariate analysis, p53 and Bcl-2 expression were not significantly correlated with overall survival, disease-free survival, or progression time. FIGO stage III and IV and residual disease > or =2 cm3 after first surgery were significantly correlated with poor outcome in univariate analysis. FIGO stage retained their independent prognostic value in multivariate analysis. Neither p53 nor Bcl-2 had any significant influence on outcome in multivariate survival analysis. FIGO stage proved to be the only significant independent prognostic factor in epithelial ovarian cancer, although residual disease remains correlated with disease-free survival.

Thymidine phosphorylase expression in tumor-infiltrating macrophages may be correlated with poor prognosis in uterine endometrial cancer

Expression of thymidine phosphorylase (TP), also known as platelet-derived endothelial cell growth factor, in several types of malignant tumors has been associated with angiogenesis and an unfavorable prognosis. We performed a retrospective study on the immunohistochemical expression of TP in patients with uterine endometrial cancer to investigate correlations between the expression of TP and the clinicopathologic features and the prognosis. The immunohistochemical staining for TP, CD68 (macrophage/monocyte-specific antibody), and von Willebrand factor was performed in surgically resected specimens from 101 patients with operable endometrial cancer. A semiquantitative grading system was used to examine the staining pattern for TP. Positive staining for both cancer cell and tumor stromal cell TP was noted in 41% of the cases. Most of tumor stromal cells expressing TP were shown to coexpress CD68. High angiogenesis was also associated with TP overexpression in either cancer cells or tumor stromal cells. When stromal macrophages/fibroblasts exhibited high TP expression, independent of whether cancer cells showed the positive TP expression, a significant decrease in disease-free survival and overall survival was observed, which was found to be an independent prognostic factor. Stromal macrophage/fibroblast TP expression remained significant on multivariate analysis. We conclude that (1) TP is present in both cancer cells and stromal macrophages/fibroblasts, (2) high angiogenesis correlated with TP overexpression, (3) TP produced by neighboring tumor-infiltrating macrophages may play a part in the regulation of the local invasion and distant metastatic behavior, and (4) TP overexpression in stromal macrophages/fibroblasts may be associated with a poor prognosis.

Ovarian and extraovarian endometriosis-associated cancer

OBJECTIVE

To determine clinical characteristics of women with endometriosis-associated intraperitoneal cancers, to assess differences based on the relationship of the cancer to the endometriosis, and to assess factors associated with survival.

METHODS

A search of medical records at The University of Texas M. D. Anderson Cancer Center from 1970 to 1999 identified patients who had synchronous endometriosis and intraperitoneal cancer. Demographic and clinicopathologic characteristics were evaluated for differences based on the relationship of the cancer to the endometriosis and for correlation with survival.

RESULTS

One hundred fifteen patients were identified: 25 patients with ovarian cancer arising in endometriosis, 21 with an extraovarian cancer arising in endometriosis, 33 patients with endometriosis and ovarian cancer in the same location but without a definite transition point, and 36 patients with ovarian cancer and incidental endometriosis. Women with extraovarian cancers arising in endometriosis were more likely to be postmenopausal (P <.001) and use hormone replacement (P <.001). The median age was 47 years, the most common histological tumor types were clear cell and endometrioid (23% each), and the most common stage was stage I (31%). The median survival was 35 months. Univariate survival analysis revealed that gravidity (P <.038), grade (P <.001), stage (P <.001), histology (P <.01), and type of chemotherapy (P <.011) correlated with survival. Multivariable analysis revealed that stage and gravidity independently predicted survival.

CONCLUSION

Women with endometriosis-associated cancers are typically premenopausal, have a high incidence of endometrioid and clear cell histologies, and have early stage disease. Stage and gravidity independently predicted survival.

Is there a difference in outcome between stage I-II endometrial cancer of papillary serous/clear cell and endometrioid FIGO Grade 3 cancer?

PURPOSE

Several reports in the literature have shown that, compared with endometrioid adenocarcinoma, patients with papillary serous (PS) and clear cell (CC) histologic features do worse. However, it is unclear whether the outcome of PS/CC cancer is different from that of poorly differentiated endometrioid cancer. The purpose of this study was to compare the outcome between PS/CC and endometrioid International Federation of Gynecology and Obstetrics (FIGO) Grade 3 cancer and was limited to patients with Stage I-II uterine carcinoma.

METHODS AND MATERIALS

Between November 1987 and September 1999, 83 patients with Stage I endometrial cancer and Stage II occult endometrial cancer were treated with simple hysterectomy and high-dose-rate intravaginal brachytherapy. Forty-one patients (49%) had FIGO Grade 3 endometrioid tumors (Group 1) and 42 (51%) had PS/CC histologic features (Group 2). The mean age was 63 years (range 30-89). Comprehensive surgical staging was done in 23 (28%) of 83 patients. Capillary space-like invasion (CSLI) was seen in 24 (29%) of 83 patients. The median dose of intravaginal brachytherapy when used alone was 21 Gy in 3 fractions. Additional external beam radiotherapy was given to 42 (51%) of 83 patients to 45 Gy. The two groups were balanced with regard to age, race, comprehensive surgical staging, amount of myometrial involvement, CSLI, lower uterine segment involvement, cervical involvement, and use of external beam radiotherapy. The median follow-up was 46 months (range 4-147).

RESULTS

The pattern of relapse was as follows: vagina/pelvis in 5 of 14 patients, lungs in 8 of 15, intra-abdominal in 4 of 12, and supraclavicular lymph nodes in 1 of 14. One of the four intra-abdominal disseminations was in Group 1 and the other three in Group 2 (p = 0.6). The 5-year vaginal/pelvic control, disease-free survival (DFS), and overall survival (OS) rate was 93% (95% confidence interval [CI] 87-99%), 79% (95% CI 69-89%), and 74% (95% CI 64-85%), respectively. No significant difference in outcome was found between Groups 1 and 2. The 5-year vaginal/pelvic control rate was 97% (95% CI 91-100%) in Group 1 compared with 90% (95% CI 81-99%) in Group 2 (p = 0.2). The 5-year DFS rate was 79% (95% CI 64-95%) in Group 1 vs. 78% (95% CI 65-92%) in Group 2 (p = 0.6), and the 5-year OS rate was 71% (95% CI 55-87%) in Group 1 vs. 79% (95% CI 66-92%) in Group 2 (p = 0.3). The influence on outcome of age, race, comprehensive surgical staging, CSLI, amount of myometrial invasion, cervical involvement, lower uterine segment involvement, and presence of pure PS or CC histologic features was evaluated. On multivariate analysis, only CSLI correlated with poor DFS (p = 0.04; relative risk 3, 95% CI 1-9) and OS (p = 0.02; relative risk 3, 95% CI 1-6).

CONCLUSION

On the basis of the results of this study, no significant difference in outcome exists between patients with Stage I-II endometrial cancer with PS/CC histologic features and those with similar stage disease, but with FIGO Grade 3 endometrioid histologic features. CSLI was the only independent predictor of poor DFS and OS.

Expression of survivin is associated with malignant potential in epithelial ovarian carcinoma

Survivin is a new member of the inhibitor of apoptosis family of anti-apoptotic proteins. It has been reported that survivin is expressed during fetal development and in cancer tissues. Because suppression of apoptosis is important for carcinogenesis and tumor growth, we investigated the expression of survivin in human endometrial carcinomas. We analyzed serial frozen sections for survivin protein expression in 26 patients with ovarian epithelial carcinoma and 10 patients with benign cystadenoma of the ovary by fluorescent immunohistochemistry. We analyzed the relationship between the percentages of survivin-stained cells and the characteristics of the patient including histological classification, clinical stage, histological grade, and clinical outcome. Survivin was weakly detected in some benign ovarian cystadenomas (0-12.1%). There was, however, abundant survivin immunoreactivity in the nucleus and/or cytoplasm of the epithelial ovarian carcinoma cells. Scoring on the basis of the percentage of positive cells indicated that survivin expression was significantly associated with PCNA-labeling index, clinical stage, histological grade, clinical outcome, and survival rate (p<0.01, respectively). We conclude that the survivin protein is a defining diagnostic marker for epithelial ovarian carcinomas that may also yield prognostic information.

Intravaginal high-dose-rate brachytherapy for Stage IB (FIGO Grade 1, 2) endometrial cancer

PURPOSE

To evaluate the outcome of patients with Stage IB Grades 1 and 2 endometrial cancer treated with adjuvant high-dose-rate intravaginal brachytherapy.

METHODS AND MATERIALS

Between November 1987 and October 1999, 233 patients with Stage IB FIGO Grades 1 and 2 were treated with postoperative adjuvant high-dose-rate intravaginal brachytherapy. The median dose was 21 Gy in 7 Gy/fraction given at 2-week intervals. The mean age was 60 years. All patients underwent simple hysterectomy. Comprehensive surgical staging, defined as pelvic washing and pelvic and paraaortic lymph nodes sampling, was done in 9% of patients. Patients with FIGO Grade 3, papillary serous cancer, or clear-cell cancer were excluded from this analysis. Complications were assessed in terms of late Radiation Therapy Oncology Group toxicity (Grade > or =3) of the gastrointestinal tract, genitourinary tract, and vagina.

RESULTS

With a median follow-up of 57 months, the 5-year vaginal/pelvic control, disease-free survival, and overall survival rate was 96% (95% confidence interval [CI] 94-99%), 94% (95% CI 91-98%), and 94% (95% CI 91-98%), respectively. The influence on outcome of age, grade (1 vs. 2), depth of invasion (one-third or less or greater than one-third), capillary space-like invasion, lower uterine segment involvement, and comprehensive surgical staging was evaluated. None of these factors significantly affected the rate of vaginal/pelvic control. Only age > or =60 years influenced the outcome for disease-free and overall survival. The 5-year rate for both disease-free and overall survival was 90% (95% CI 84-97%) for patients > or =60 years old compared with 99% (95% CI 96-100%) for those <60 years (p = 0.03 and 0.005, respectively). Of 233 patients, 3 (1%) developed Grade 3 or greater complications, with a 5-year actuarial rate of 2% (95% CI 0-5%). Two patients developed Grade 3 genitourinary toxicity, and 1 Grade 4 vaginal toxicity.

CONCLUSION

On the basis of this retrospective study, adjuvant postoperative high-dose-rate intravaginal brachytherapy provides excellent outcomes and acceptable morbidity. These results compare very favorably with those reported in the literature using surgery alone or with pelvic radiation.

The effect of residual mass size on response to chemotherapy after surgical cytoreduction for advanced ovarian cancer: long-term results

We report an observational study of chemotherapeutic regression of ovarian tumor implants according to decrements in residual mass size after surgical cytoreduction. Cytoreductive operations were attempted on 74 consecutive patients with stages IIIB-IV disease referred for this purpose. Thirty-two patients had received one to four courses of preoperative chemotherapy (22 responses, no progressions). Postoperative chemotherapy followed current protocols at Dana Farber Cancer Institute (n=61) or referring institutions (n=13); 57 regimens contained cisplatin. Postchemotherapy response was assessed clinically or by second-look procedures. Negative findings were considered a complete remission. Masses > 1 cm were excised from 62 patients. Twelve patients were inoperable. Twenty-eight patients had complete remissions and the correlation between these and decrements in residual mass size was highly significant (P < 0.0001). Complete remissions had a uniform effect and were the only outcome predictive of survival. Preoperative treatment greatly facilitated cytoreduction but only masses 0-0.2 cm were sensitive to postoperative chemotherapy. Masses 0.5 cm or less were optimal. They made up 77% of operable patients and supplied 25 (89%) of the complete remissions. Cytoreduction is not always required but even large-volume disease in the upper abdomen can be safely excised. The concept that masses larger than 10 cm indicate general chemoresistance has not been sustained.

Ribosomal DNA methylation in patients with endometrial carcinoma: an independent prognostic marker

BACKGROUND

Surgery is curative for the majority of patients with endometrial carcinoma: Consequently, the use of adjuvant therapy has been controversial. More effective methods to identify patients who are at risk for recurrence and who would benefit from adjuvant therapy are needed. The objective of this study was to investigate the prognostic significance of ribosomal DNA (rDNA) methylation in patients with endometrial carcinoma.

METHODS

rDNA methylation was assessed in 215 endometrial tumors by Southern blot analysis of HpaII-digested DNA using a probe corresponding to the 5.8 and 28S ribosomal subunits. Tumor rDNA methylation status was correlated with patient outcome.

RESULTS

The majority of tumors demonstrated high levels of rDNA methylation (rDNA-high; 74%). Both disease free survival and overall survival were significantly worse for patients with low-level rDNA methylation (rDNA-low; P < 0.0001). African-American patients were more likely to have rDNA-low tumors than Caucasian patients (P = 0.002). Among the subpopulation of patients with endometrial carcinoma for whom the use of adjuvant therapy is most controversial (148 women with Stage I-II endometrioid tumors), survival was significantly worse for the patients with rDNA-low tumors (P < 0.0001); and, using multivariate analyses, tumor rDNA level was the only significant prognostic factor for both disease free survival and overall survival (hazard ratios, 11.0 and 26.3, respectively; P < 0.01 for both).

CONCLUSIONS

rDNA methylation is an independent prognostic indicator for patients with endometrial carcinoma that may serve to identify women with early-stage disease at who are at high risk for recurrence. Racial differences in DNA methylation may explain the historically observed disparity in survival between African-American patients and Caucasian patients.

Heterogeneity of ovarian cancer: relationships among histological group, stage of disease, tumor markers, patient characteristics, and survival

Epidemiological studies have established associations between various reproductive factors and risk of ovarian cancer; it has also been observed that some of these risk factors are only associated with specific histological subgroups. To investigate the correlation of genetic alterations with these risk factors, we examined a consecutive series of 158 ovarian cancer cases treated at the University of Kentucky (1990-96). Common molecular genetic alterations (LOH on chromosome 17, P53 alterations, K-RAS mutations), histological and clinical characteristics of the disease, demographic patient information and survival were evaluated. These latter data were from the Kentucky Cancer Registry. Univariate analysis showed higher frequencies of chromosome 17 loss and P53 mutations in tumors of advanced stage and grade, and in older and post-menopausal women. Non-mucinous tumors were more likely to be classified as late stage, high-grade cancers, and to have chromosome 17 loss and P53 mutations. Survival analysis indicated that stage was the only independent significant variable. When stage was the outcome variable in multiple logistic regression analysis, histology and chromosome 17 loss were significantly associated with poor survival. This case-case study provides evidence that ovarian cancers of mucinous and non-mucinous histology are significantly different with respect to clinical characteristics, survival and molecular alterations. It also lends support to the hypothesis that ovarian cancer is a heterogeneous disease with distinct etiological factors and clinical outcomes, which may require different approaches to treatment.

Treatment of recurrent gynecologic malignancies with iodine-125 permanent interstitial irradiation

PURPOSE

To analyze the outcome of permanent 125I interstitial radiotherapy for unresectable retroperitoneal recurrences of gynecologic malignancies.

METHODS AND MATERIALS

A retrospective review of 20 patients treated between 1979 and 1993 was performed to evaluate survival and morbidity associated with the interstitial 125I technique.

RESULTS

Nineteen tumors were located on the lateral pelvic wall and one in the para-aortic region. Eight patients, not previously irradiated, received external beam radiotherapy (EBRT) along with 125I interstitial implants placed at the time of celiotomy. Nineteen (95%) are dead of disease at 1-69 months of follow-up. The median survival was 7.7 months for patients treated with 125I alone and 25.4 months for those treated with both 125I and EBRT. One patient is alive without evidence of disease 69 months after 125I implantation. Fistulas, bowel obstructions, and fatal complications occurred only among patients previously irradiated.

CONCLUSIONS

When used in a previously irradiated field, 125I interstitial radiotherapy has major morbidity and is unlikely to be associated with cure or long-term survival. In radiotherapy-naive patients with unresectable isolated recurrent gynecologic malignancies, 125I implants and EBRT are feasible and occasionally may contribute to long-term disease-free survival.

Survival of patients with advanced ovarian cancer treated with intermittent chemotherapy following cytoreductive surgery and adjuvant chemotherapy

BACKGROUND

The purpose of this study was to report the duration of the progression-free interval (PFI) in advanced ovarian cancer patients who were treated with intermittent maintenance chemotherapy.

METHODS

Between 1991 and 1998, 25 patients with stage III or IV ovarian cancer were enrolled in a trial of intermittent maintenance chemotherapy. All patients underwent cytoreduction surgery, and received adjuvant chemotherapy, after which they were treated with intermittent maintenance chemotherapy every 3 to 4 months for 2 years.

RESULTS

The median PFI in the 25 women in the intermittent chemotherapy group was 25 months, while in the 32 patients in the control group it was 18 months (P = 0.0124). The median survival of women treated with the intermittent chemotherapy was 34 months, and for the control group patients, it was 35 months (P = 0.0672). Multivariate analysis in the intermittent chemotherapy group revealed that the only factor that correlated significantly with PFI was the status after adjuvant chemotherapy (P = 0.0137). In patients with no evidence of disease after the adjuvant chemotherapy, the median survival was 39 months in the intermittent chemotherapy group, and 35 months in the control group (P = 0.0156). The median PFI was 28 months in the intermittent chemotherapy group, and 18 months in the control group (P = 0.0012).

CONCLUSION

It would be warranted to perform intermittent maintenance chemotherapy for patients with advanced ovarian cancer, if a clinically disease-free status could be achieved after completion of the standard treatment procedure.

Neoadjuvant chemotherapy or primary surgery in advanced epithelial ovarian carcinoma

Neoadjuvant chemotherapy has been proposed as an alternative approach to conventional surgery as initial management of bulky ovarian cancer, with the goal of performing adequate debulking in the interval surgery. Two hundred five consecutive patients with advanced ovarian cancer were divided into two groups. Neoadjuvant chemotherapy followed by interval surgery was performed in 45 of 205 patients. The remaining 158 patients received primary surgery plus adjuvant chemotherapy. Optimal cytoreductive surgery rates were significantly higher in the neoadjuvant CT group (P<0.001). In multivariate analysis, only residual tumor diameter and appendix involvement were found to affect total survival significantly in both groups. Five-year survival and median survival were not statistically different when all patients treated conventionally were compared with all patients treated with neoadjuvant chemotherapy. Primary chemotherapy followed by interval debulking surgery in a selected group of patients does not appear to worsen prognosis, but it permits less aggressive surgery and improves patients' quality of life.

Primary epithelial ovarian carcinoma in Taiwanese women

PURPOSE OF INVESTIGATION

Primary epithelial ovarian carcinoma is common in industrial countries but rare in the Orient. In fact, it is still a rare disease in Taiwan. In this article, we report the general data of Taiwanese patients with primary epithelial ovarian carcinoma.

METHODS

In this retrospective study we used univariate and multivariate analysis models to analyze the prognosis of patients with surgically confirmed primary epithelial ovarian carcinoma. One hundred and ninety-four patients from 1990 to 1996 were identified and enrolled in this study.

RESULTS

The mean follow-up time was 44.7 months with an interval between 15.1 months and 105.9 months. Univariate analysis showed postmenopausal status, advanced stage, presence of lymph node metastasis, poor differentiation, and suboptimal surgery as risk factors for disease recurrence and subsequent deaths. Multivariate analysis demonstrated stage as the most important factor correlated with recurrent disease (risk ratio: 7.303 and 5.409, respectively), followed by optimal surgery (RR: 2.447), and cellular differentiation (RR: 1.677).

CONCLUSIONS

Our data on the Taiwan population were consistent with other reports of different races. Early detection for primary epithelial ovarian cancer is of great importance because stage is still the most important predictor in disease-free survival and disease-related deaths. Application of the most reliable and acceptable methods of screening is our goal in the next century after weighing benefits over costs.

Thrombospondin-1 and -2 messenger RNA expression in epithelial ovarian tumor

BACKGROUND

The role of thrombospondin (TSP) in tumor progression remains controversial. The association of TSP with clinicopathological features regarding prognostic significance was examined in patients with epithelial ovarian tumor.

MATERIALS AND METHODS

Gene expression of TSP-1 and TSP-2 was assessed by reverse transcriptase-polymerase chain reaction in 6 borderline and 29 malignant epithelial ovarian tumors.

RESULTS

TSP-1 mRNA expression was detected in 14 out of the 29 malignant epithelial ovarian tumors (48.3%), whereas TSP-2 mRNA expression was detected in 7 malignant epithelial ovarian tumors (24.1%). In contrast, no specimen from the borderline epithelial ovarian tumors expressed TSP mRNA. TSP-1 expression was significantly higher in tumors with advanced stage, massive ascites, positive peritoneal cytology and high grade. TSP-2 expression was significantly higher in tumors with massive ascites. Patients exhibiting TSP-1 and -2 mRNA expression demonstrated a markedly poorer prognosis than those lacking TSP-1 and -2 mRNA expression.

CONCLUSION

These findings provide evidence that TSP expression may be associated with an aggressive phenotype in this class of neoplasm.

Comparison of endometrial carcinoma coexisting with and without endometrial hyperplasia

OBJECTIVE

It has been reported that endometrial carcinoma has two pathogenic types; one with and the other without endometrial hyperplasia. The present study was done to clarify whether this was true in our series of a large number of Japanese patients.

METHODS

Three hundred and twenty-eight patients with endometrial carcinoma were classified into two groups, one coexisting endometrial hyperplasia (group 1; 182 cases) and the other having normal endometrium without endometrial hyperplasia (group 2; 107 cases). The clinical and pathological observations of the two groups were compared.

RESULTS

The ages of the patients were significantly lower in group 1 (30-83; mean 50.7) than in group 2 (34-81; mean, 57.2). The incidence of the carcinoma with invasion limited to less than 1/3 of the myometrium, with surgical stage I, lower grade endometrioid type and higher levels of progesterone receptor, and without lymph node metastasis were significantly higher in group 1 than in group 2. The cumulative survival rate for stage I was also significantly higher in group 1 patients.

CONCLUSION

A significant difference was found between groups 1 and 2 in age distribution, degree of progress and pathological observations. Stage I patients in the former group had a better prognostic than the latter.

Favorable survival associated with microsatellite instability in endometrioid endometrial cancers

OBJECTIVE

To determine whether microsatellite instability in endometrioid endometrial cancer is associated with favorable survival.

METHODS

Microsatellite instability analysis was performed in 131 patients with endometrioid endometrial cancer using three polymorphic markers in paired cancer and normal DNA. Logistic regression and multivariable analyses calculated the relation between microsatellite instability, clinical features, and survival.

RESULTS

Microsatellite instability was detected in 29 of 131 (22%) endometrioid endometrial cancers. There was no correlation between microsatellite instability and age, race, grade, stage, or depth of myometrial invasion. Microsatellite instability was associated with better survival in univariate and multivariable analyses after controlling for confounding influences (P =.03). The 5-year survival rate of those with microsatellite instability was 77% (95% confidence interval 55%, 90%) compared with only 48% (95% confidence interval 39%, 57%) in other cases. Microsatellite instability was associated with other molecular features that predict favorable outcome including PTEN mutation (P =.002) and the absence of p53 overexpression (P =.01).

CONCLUSION

Microsatellite instability is a molecular alteration associated with favorable outcome in endometrioid endometrial cancers, even when accounting for other prognostic factors. This association might be explained by the finding that the pathway of molecular carcinogenesis characterized by loss of DNA mismatch repair favors alteration of genes that result in a less virulent clinical phenotype.

Expression and mutation of p53 in tumor effusion cells of patients with ovarian carcinoma: response to cisplatin-based chemotherapy

p53 alterations are considered as one of the most important factors responsible for drug resistance in ovarian carcinomas, although the relationship between p53 gene status and response to cisplatin-based chemotherapy in ovarian cancer patients remains unclear. The aim of the study was to evaluate the relationship between p53 protein accumulation, p53 gene mutation and response to cisplatin-based chemotherapy in patients with ovarian carcinoma considering conventional clinicopathological parameters. Tissue sections and corresponding cyst and/or ascitic fluid cells from 79 patients with epithelial ovarian cancer were analyzed immunohistochemically for p53 expression. The PCR-SSCP analysis was performed in 25 cases and the results were compared with immunohistochemical data. It was demonstrated that p53 expression reaching approximately 50% of positive cells in immunostaining was usually associated with PCR-amplified exons showing abnormal migration and suspected for mutation. p53 gene changes were not correlated with histological structure, grade of differentiation or residual tumor after cytoreductive surgery, despite being detected more frequently in III/IV than in II FIGO stages and in patients with residual disease above 2 cm. A significant correlation between p53 accumulation and p53 gene alteration and poor response to cisplatin-based chemotherapy was shown. The overall survival time of patients decreased with an increase in p53 protein expression. A strong p53 expression especially accompanied by p53 changes detectable by PCR-SSCP analysis appears to be a good indicator of the resistance to cisplatin-based chemotherapy. The association between strong p53 overexpression and shorter overall survival time was also revealed.

Prognostic results of cisplatin IP and carboplatin IV with G-CSF in patients with ovarian cancer

We performed a dose-escalation study of carboplatin combined with a fixed dose of intraperitoneal cisplatin and G-CSF in patients with epithelial ovarian cancer, and analyzed the progression-free and overall survival. Six of the patients who entered the study with stage IC and II disease are still alive with no evidence of disease. The five-year survival rate was 61% for the 18 patients with stage III and IV disease; progression-free survival over 5 years was 32%. Our results show this to be an effective treatment regimen for epithelial ovarian cancer. Prognosis is good with this combined carboplatin/cisplatin/G-CSF therapy, especially for those patients with microscopic or no residual disease.

Cell cycle-related phosphatases CDC25A and B expression correlates with survival in ovarian cancer patients

Alterations in cell cycle regulating proteins are common in many cancer types. Recent data suggest a possible link between CDC25 phosphatases overexpression and malignancy. Our objective was to evaluate the expression of the three cell cycle-related phosphatases CDC25A, CDC25B and CDC25C in patients with ovarian cancer. All the patients had a minimal follow up of three years. CDC25A, CDC25B and CDC25C expression were investigated by immunohistochemistry in 106 patients with ovarian cancer. CDC25A and CDC25B were found expressed in almost all the samples analyzed, while CDC25C was undetectable in more than 80% of the patients. The low evaluable data on CDC25C expression, did not allow any association between the expression of this phosphatase and prognosis. The expression of CDC25A and CDC25B showed some evidences of association with a poor prognosis (p = 0.034 and p = 0.058 respectively). This relationship was independent of other factors such as tumor grade, histotype, stage and residual tumor after surgery. In the same patients the examined parameters (residual tumor, grade, stage and histotype) did show the expected relation with survival. The results indicate that high CDC25A and CDC25B expression is related to a worse prognosis in ovarian cancer patients. CDC25 phosphatases expression can be regarded as a possible prognostic factor for ovarian cancer and these proteins should be evaluated as potential molecular targets of novel drugs against this human neoplasm.

Age-specific survival of women with endometrioid adenocarcinoma of the uterus

OBJECTIVE

The purpose of this paper was to evaluate the age-specific survival for women diagnosed with endometrioid adenocarcinoma of the uterus.

METHODS

A retrospective analysis was conducted of 328 patients diagnosed with endometrioid adenocarcinoma of the uterus between January 1990 and December 1997. Patients were followed for 3 to 96 months with a mean of 43 months. The impact of age on survival was assessed using Cox proportional hazard regression and multivariate analysis for age, stage, and grade. Stage and grade were analyzed using log-rank tests, and survival curves were generated by the Kaplan-Meier method.

RESULTS

A total of 328 patients were evaluated. Multivariate analysis revealed age, stage, and grade were all significant independent predictors of survival (P < 0.0001). Age-specific survival varied from a high of 90% at age 40 to a low of 55% at age 80. Interval age-specific survival decreased below 86% at age 50. Subset analysis of patients younger than 50 compared with older patients revealed no difference in surgical stage or grade of tumors among these patients. Patients older than 50, however, were 41% more likely to receive adjuvant radiation therapy.

CONCLUSION

Age is a specific, significant predictor of outcome in endometrioid adenocarcinoma of the uterus. Survival decreases significantly in patients older than 50. This decreased survival associated with age is unrelated to surgical stage or grade of adenocarcinoma. Decreased survival could involve molecular differences in the developing endometrial cancer or an increased risk of death from other non-cancer-related factors.

An intensive follow-up does not change survival of patients with clinical stage I endometrial cancer

BACKGROUND

The clinical benefit of an intensive follow-up protocol in endometrial cancer patients is still uncertain.

MATERIALS AND METHODS

One hundred and thirty-three patients underwent initial abdominal surgery for clinical stage I endometrial cancer between January 1988 and December 1997 and were periodically followed-up until April 1999 or until death. After surgery, 89 patients received postoperative adjuvant treatment. Periodical surveillance included physical examination, vaginal smear and abdominal-pelvic ultrasound every 3-4 months for the first 2 years from surgery, every 6 months for the next 3 years and yearly thereafter. Chest X-ray was performed every 6 months for the first 2 years, every year for the next 3 years and with individually increasing intervals afterwards. An abdominal-pelvic CT scan was carried out yearly for 5 years.

RESULTS

Twenty-four patients (18.0%) developed recurrent disease after a median time of 17.5 months (range, 6-64 months). Five-year actuarial disease-free survival was 81.2% in the whole series, and in detail 94.2% in the subset of patients with FIGO stage Ia grade 1 or 2 endometrioid adenocarcinoma, or stage Ib grade 1 endometrioid adenocarcinoma (low-risk), compared to 76.0 (p = 0.0472) in the subset of patients with stage Ia grade 3 endometrioid adenocarcinoma, stage Ib grade 2 or 3 endometrioid adenocarcinoma, stage equal to or greater than Ic endometrioid adenocarcinoma any grade, and aggressive histologies (high-risk). The site of recurrent disease was local in 6 (25.0%) patients, distant in 17 (70.8%), and local plus distant in 1 (4.2%). Eleven (45.8%) recurrences were symptomatic and 13 (54.2%) were asymptomatic. The median survival after recurrence was 10 months. Survival was longer in patients who relapsed after 17.5 months from initial surgery when compared to those who relapsed earlier (p = 0.02). Conversely, survival after recurrence was not related to patient characteristics at diagnosis, such as FIGO stage, tumor grade, myometrial invasion, histologic type, and lymph node status. It is noteworthy that survival was similar in asymptomatic women, in whom the relapse was occasionally detected by follow-up examinations, and in symptomatic ones.

CONCLUSION

An intensive surveillance protocol seems to have no significant impact on the outcome of patients with clinical stage I endometrial cancer. Simplified follow-up programs tailored for patient subsets with different recurrence risk are required.

Significance of pretreatment serum hemoglobin and survival in epithelial ovarian cancer

Tumor anemia is common in patients with malignant tumors and it was repeatedly demonstrated to be associated with impaired prognosis in patients with malignant tumors. We conducted a retrospective analysis based on 553 patients with histologically proven epithelial ovarian cancer. Blood hemoglobin levels were determined before surgery and patients with values <12 g/dl were considered anemic. Data analysis included univariate and multiple Cox models. Tumor anemia was present in 143 (25.9%) patients before surgery. Tumor anemia was present in 143 (25.9%) patients before surgery. In a multivariate Cox model, pretreatment hemoglobin values proved to be an independent prognostic factor for patients with stage I-II epithelial ovarian cancer (n=203), but failed to attain significance in patients with stage III-IV disease (n=350). Tumor anemia defined as pretreatment hemoglobin values <12 g/dl may indicate patients with stage I and II epithelial ovarian cancer, who are at increased risk of relapse.

Prospective analysis of DNA ploidy, proliferative index and epidermal growth factor receptor as prognostic factors for pretreated uterine cancer

For the purpose of identifying prognostic factors for pretreated uterine cancer, DNA ploidy, proliferative index (P.I.) and epidermal growth factor receptor (EGFR) expression were analyzed in a large prospective series of 76 cervical cancer and 64 endometrial cancer patients observed for 5 years or more (median 76 months). The frequency of aneuploid cells was 62.0% (44/71) in cervical cancer and 16.7% (10/60) in endometrial cancer. There was no association between DNA ploidy and the clinicopathological findings without clinical stage, in which aneuploid cervical and endometrial cancers were significantly more common among advanced tumors (cervical: p<0. 05, endometrial: p<0.01). The P.I. was significantly higher in the patients with aneuploid tumors (cervical: p<0.05, endometrial p<0. 01). EGFR expression was detected in 56.6% (30/53) in cervical cancer and 59.6% (34/57) in endometrial cancer, and the mean EGFR level was 17.8+/-37.7 and 9.5+/-42.5 fmol/mg. protein, respectively. There was no correlation between EGFR expression and DNA ploidy, P.I. and clinicopathological findings analyzed. Five-year survival rate in patients with aneuploid tumors tended to have a worse outcome in cervical cancer cases (p=0.1003, log-rank test), and was significantly worse in endometrial cancer (p=0.0048, log-rank test). No significant relationship was noted between P.I., EGFR expression and 5-year survival. Cox multivariate analysis showed that DNA ploidy, P.I., and EGFR expression are not association with the risk of death. Our data showed neither DNA ploidy, P.I. nor EGFR expression were independent prognostic factors for pretreated uterine cancer.

The outcome of stage I-II clinically and surgically staged papillary serous and clear cell endometrial cancers when compared with endometrioid carcinoma

PURPOSE

The aim of this study was to compare survival and recurrence in clinical and surgical stage I-II papillary serous (PS), clear cell (CC), and endometrioid (EM) cancers of the endometrium and examine the prognostic utility of myometrial invasion.

METHODS

Clinical, surgicopathologic, and survival data were retrospectively collected on 574 clinical stage I-II endometrial cancer patients, including 53 PS and 18 CC (based on postoperative histology), undergoing hysterectomy at Duke University Medical Center between 1967 and 1990. All staging material was available and reexamined prior to this analysis, and FIGO surgical staging was retrospectively assigned. Prognostic variables examined included age, stage, grade, myometrial invasion, lymph-vascular space invasion (LVSI), and histology. PS and CC histologic subtypes were compared as both common category and discrete categories versus EM, EM grade 1 (EM1), EM grade 2 (EM2), and EM grade 3 (EM3). Statistical analyses were performed using chi(2), Fisher's exact, and Wilcoxon rank sum tests, Cox regression analysis, and Kaplan-Meier survival analysis.

RESULTS

PS tumors accounted for 9%, CC for 3%, and EM for 88% of cases. Recurrences were more frequent among PS (38%) and CC (22%) compared with EM (9%) (P < 0.001 and 0.08, respectively), and PS recurred more frequently than EM3 alone (20%) (P = 0.06). Among PS, CC, and EM3 patients with recurrences there were no statistical differences in the proportion that received preoperative or postoperative radiotherapy or chemotherapy. Prognostic factors for shorter survival included age >=60, surgical stage III+IV, presence of LVSI, histology (PS, CC, or EM3), and >=50% myometrial invasion. The estimated 5-year survival of PS+CC patients with <2 mm myometrial invasion is 0.56 compared to 0.93 for EM patients (P < 0. 001). PS + CC tumors confined to the endometrium had a 5-year survival of 0.60 compared to 0.98 and 1.00 for EM and EM3, respectively. The 5-year survival for surgically staged IA patients (0.57) was not different from stages IB and IC combined (0.53) (P = 0.72). The 5-year survival for surgical stage I + II PS + CC patients (0.56) was comparable to that for clinical stage I + II PS + CC patients (0.46) and remained significantly smaller than that for EM patients (0.86) (P < 0.001).

CONCLUSION

Recurrences are more frequent among PS and CC tumors compared with EM and among PS compared with EM3. When controlled for surgical stage I-II tumors, 5-year survival for PS + CC patients remains comparable to that of clinical stage I-II patients and below that of EM. Prognostic factors for survival in PS and CC patients include age, stage, and LVSI. PS, CC, and EM3 subtypes together are predictors of poor survival. Thorough extended surgical staging is indicated in PS and CC tumors, and prospective trials of aggressive adjuvant therapies for surgical stage I-II tumors are needed to improve outcome in PS and CC patients.