Familial ovarian cancer

Pathfinders in oncology from the time the causal relation between tobacco use and lung cancer was established to publication of the first Cancer Staging Manual by the American Joint Committee on Cancer

During the period from 1962 to 1977, several antigens, notably carcinoembryonic antigen and prostate-specific antigen, were discovered and entered clinical use. Ultrasonography, positron emission tomography scanning, and magnetic resonance imaging were introduced, and adjuvant radiation and chemotherapy after limited surgery became routine procedures. Radioimmunoassay and immunohistochemistry techniques were standardized. The announcement in England and the United States that tobacco is a potent lung carcinogen was long delayed, important news. The US Cancer Act of 1971 made it possible to experiment with newly discovered drugs, transfer promising therapeutic agents from the laboratory to the clinic, and finance randomized clinical trials. Oncologists achieved a series of successes with combination chemotherapy in childhood cancers, adult lymphomas, and testis tumors. Clinical trials demonstrated that breast-conserving therapy is as effective as mastectomy. The discovery of retroviruses, reverse transcriptase, and vascular endothelial growth factor was coupled with learning about oncogenes. The 2-hit theory and the reciprocal translocation of chromosomes helped to solve some of the riddles of oncogenesis. The staging classification of cancers by the American Joint Committee on Cancer unified clinical and pathologic handling and prognostication of malignant tumors. The progress made in oncology between 1962 and 1977 came about through the dedicated work of many individuals. However, there were 9 pathfinders (3 medical oncologists, 2 surgeons, 1 medical nuclear physicist, 1 pediatrician geneticist, 1 hematologist geneticist, and 1 virologist) who, despite their diverse backgrounds, personalities, and interest, made extraordinary contributions to oncology.

A note from history: Landmarks in history of cancer, Part 6

In the 3 decades from 1940 to 1970, the United States became the nucleus for research, diagnosis, and treatment of cancer. The discovery of anticancer drugs, and the clinical demonstration that chemotherapy and radiation can cure cancer and have the ability to prevent recurrence of cancer, were incontrovertibly the most remarkable groundbreaking events. Consequently, the trend of less surgery and more multimodality therapy began. The introduction of radioautography, mammography, ultrasonography, computed tomography, Papanicolaou smear, and other novel laboratory tests furthered early detection of cancer and refined accurate diagnosis. The unequivocal linking of lung cancer to cigarette smoking made medical history. The delineation of the potential role of oncogenes adduced new thoughts about oncogenesis and cancer prevention, and pathologists finalized the classification and nosology of tumors. Finally, it is worth noting that although more advances were made in the detection, diagnosis, and treatment of cancers than any other period in history, the overall mortality rate of patients with cancer remained high and unchanged.

Segregation analysis of epithelial ovarian cancer in Finland

Epithelial ovarian cancer is known to aggregate in families. The dominantly inherited ovarian cancer predisposing genes, BRCA1, BRCA2 and genes involved in the hereditary non-polyposis colorectal cancer (HNPCC) syndrome, have recently been identified. However, in the majority of families with more than one case of ovarian cancer, dominant inheritance cannot be recognized. We investigated familial clustering of epithelial ovarian cancer in a population-based sample of 663 Finnish ovarian cancer patients. A segregation analysis with the POINTER software was conducted on the 937 nuclear families from these 663 pedigrees. The major gene model was favoured, and the sporadic and multifactorial models were strongly rejected. In the studied population, the best fitting model was a recessive mode of inheritance, and 8% of ovarian cancer patients were estimated to be homozygous for the deleterious genotype. This evidence for recessively inherited ovarian cancer predisposition should be interpreted cautiously, as the analysis is subject to certain errors, which are discussed in the article. Results of this analysis, however, strongly emphasize the role of genetic factors in all familial aggregation of epithelial ovarian cancer.

The genetics of ovarian cancer: molecular biology and clinical application

Ovarian cancer is the fifth most common malignancy among American women and the fourth leading cause of cancer death. The rapid advances in molecular genetic analysis, presymptomatic detection, and treatment of ovarian cancer are staggering. In this review, both the genetic component and the molecular biology of ovarian cancer are discussed, as well as current recommendations for genetic counseling. It is important for the practicing obstetrician and gynecologist to become familiar with these concepts, for it is he or she who will likely serve as a primary resource of information for these patients.

Cancer incidence in the first-degree relatives of ovarian cancer patients

Cancer incidence was studied among 3072 first-degree relatives of 559 unselected ovarian cancer patients. Among cohort members there were 306 cancer cases. The overall cancer incidence was not increased: the standardised incidence ratio (SIR) in males was 0.9 (95% confidence interval 0.8-1.1) and in females 1.0 (0.8-1.1). The female relatives had a significantly increased risk for ovarian cancer (SIR 2.8, 1.8-4.2). The excess was attributable to sisters only (SIR 3.7, 2.3-5.7). The relative risk for ovarian cancer among sisters decreased both by increasing age of the sister and by increasing age at diagnosis of the index patient: the SIRs were 7.3 (1.5-21.4), 4.5 (1.6-9.8) and 3.1 (1.7-5.4) for sisters of index patients diagnosed in age < 45, 45-54 and 55-75 years respectively. The age dependency of the risk supports the role of genetic factors in familial ovarian cancer. Although the risk of ovarian cancer among sisters from families with breast cancer (SIR 9.2, 3.7-19.0) was significantly higher than among sisters from families with no breast cancer patients (SIR 2.9, 1.6-4.8, rate ratio 3.1, P < 0.05), the excess was not solely attributable to coaggregation of breast and ovarian cancer. Among the 27 families with two or more ovarian cancers, only sisters were affected in 24 families, which might implicate recessive inheritance or shared environmental factors influencing ovarian cancer risk in sisters.

An extended Li-Fraumeni kindred with gastric carcinoma and a codon 175 mutation in TP53

We present an extended family with Li-Fraumeni syndrome characterised by gastric and breast carcinoma, glioma, sarcoma, and leukaemia. This family showed strong evidence of linkage to TP53, and three of four tumours analysed showed loss of the wild type allele. A codon 175 missense mutation was identified in exon 5 in all available affected subjects. Counselling, screening, and issues surrounding presymptomatic testing are discussed.

Familial ovarian cancer. Update and clinical applications

BACKGROUND

Genetics plays a role in all cancers. Evidence exists for the presence of inherited genes associated with the development of ovarian cancer in three familial ovarian cancer syndromes: a site-specific ovarian cancer syndrome, a breast/ovarian cancer syndrome, and an ovarian cancer syndrome associated with hereditary nonpolyposis colorectal cancer.

METHODS AND RESULTS

The authors present an updated summary of recent advances within the field of ovarian cancer genetics and examine the extent to which this genetic information, at both an epidemiologic and molecular level, may be used to identify a subset of women who are likely to be at increased risk of developing ovarian cancer. In addition, the extent to which these data may be used to define methods of prevention or treatment for women at risk is discussed.

CONCLUSION

Women who are members of high risk ovarian cancer families should receive genetic screening and medical follow-up in an effort to reduce their overall chances of morbidity and death associated with the development of ovarian and other cancers. The construction of cancer family registries will help to identify women at risk and facilitate their entry into clinical trials and screening programs for ovarian cancer.

Epidemiology, etiology, and fertility drugs in ovarian epithelial carcinoma: where are we today?

OBJECTIVE

To review studies that have examined the epidemiology and etiology of the development of epithelial carcinoma of the ovary.

DATA IDENTIFICATION

Important published studies related to the topic were identified through a computerized bibliography search.

CONCLUSION

A review of the literature reveals that the etiology of epithelial ovarian cancer is probably multifactorial and that genetic, environmental, hormonal, and viral factors appear to be directly or indirectly related to the development of the disease. An attempt to implicate specific agents has not produced conclusive results. However, based on large epidemiologic studies, it seems that there is a clear trend of decreasing risk with increasing number of pregnancies, deliveries, use of oral contraceptives, and the duration of breast feeding. An increased risk was found to be associated with ovarian dysfunction leading to infertility and exposure to asbestos and talc. The recent observation that infertile women who used fertility drugs might experience an increased risk for the development of epithelial ovarian cancer should be examined very carefully because of the small number of patients in the study, lack of appropriate information about the type of infertility, drugs used, dosage, and duration of treatment. Because there are no screening tests that are consistently accurate enough to detect ovarian cancer at an early stage, translating the current information into disease prevention requires careful clinical evaluation with a routine follow-up of patients at risk.

Familial clustering of malignant germ cell tumors and Langerhans' histiocytosis

Three sisters in a family with seven children whose grandmother had an ovarian embryonal carcinoma experienced development of malignant and a malignant-like situation in childhood. Two were diagnosed as having malignant germ cell tumors of the ovary, and the third was found to have Langerhans' histiocytosis. The two girls with germ cell tumor shared an identical human leukocyte antigen, whereas the sister with histiocytosis shared one identical haplotype with them. All three children have been treated successfully with chemotherapy and are doing well off of treatment.

Patterns of inheritance of ovarian cancer. An analysis from an ovarian cancer screening program

BACKGROUND

A variety of inheritance patterns for familial ovarian cancer have been proposed including an autosomal dominant inheritance, a breast-ovary cancer syndrome and Lynch Cancer Family Syndrome (involving breast, bowel, ovary, and endometrial cancers).

METHODS

Women participating in an ovarian cancer screening study completed a questionnaire concerning their family history of ovarian and other malignancies (in particular breast, bowel, and endometrial cancer). Confirmation of the diagnosis was sought when there was uncertainty.

RESULTS

Two hundred forty women with a first-degree relative with ovarian cancer participated in the study. Nine percent of these women (representing 13 families) gave a definite history of two or more affected first-degree relatives. Two families had a pedigree consistent with an autosomal dominant inheritance. A breast-ovary cancer family and a Lynch cancer family syndrome were suspected in one family each, although 34% of all women gave a history of at least one other first-degree relative with either breast, bowel, or endometrial cancer.

CONCLUSIONS

Only a small number of women with a family history of ovarian cancer fit into the recognized hereditary patterns. Difficulty in recognizing the inheritance patterns and the lack of definitive genetic markers poses problems in providing adequate counseling regarding screening and prophylactic oophorectomy.

Hereditary ovarian cancer. Heterogeneity in age at onset

BACKGROUND

Hereditary ovarian cancer (HOC) is heterogeneous, with at least three distinctive syndromes, namely, hereditary site-specific ovarian cancer, hereditary breast-ovarian cancer (HBOC) syndrome, and Lynch syndrome II. Ovarian cancer, in accord with virtually all varieties of adult onset cancer, displays an increasing incidence with advancing age; however, it shows an earlier age of onset in hereditary settings.

METHODS

Detailed medical and pathology studies were performed on extended ovarian cancer-prone pedigrees, with special attention given to age at ovarian cancer onset.

RESULTS

The age of onset of ovarian cancer is heterogeneous, wherein the average age of onset in HBOC is 52 years, in hereditary site-specific ovarian cancer it is 49 years, and in the Lynch syndrome II it is 45 years, in contrast to its occurrence in the general population, at an average age of 59 years.

CONCLUSIONS

These differences are important for the initiation of surveillance and management strategies. Age of onset of ovarian cancer differences in these several hereditary subsets are less striking than they are in the case of other integral forms of cancer in the respective syndromes, such as the breast in the HBOC syndrome. In addition, the phenomenon of extremely early age of onset of ovarian cancer occurs infrequently in HOC when compared to other forms of cancer, such as the breast in HBOC or the colon in Lynch syndrome II. Knowledge about age of onset heterogeneity in HOC may harbor important clues about etiology, pathogenesis, and cancer control.

Genetic epidemiology of epithelial ovarian cancer

BACKGROUND

Aside from age, family history is the strongest predictor of ovarian cancer risk. Genetic components of risk for ovarian cancer have been evaluated by a number of designs, including case-control studies of family history and other risk factors, segregation and genetic linkage studies, and studies of biomarkers and tumor-specific cytogenetic abnormalities.

METHODS

Data were extracted from all available case-control studies that included family history. Cytogenetic, biomarker, segregation, analytic, and genetic linkage studies were reviewed.

RESULTS

Family history of ovarian cancer confers a 3.6-fold increased risk for this disease. Segregation studies of breast and ovarian cancer in five large families were consistent with dominant inheritance. Low levels of alpha-L-fucosidase confer mildly increased risk for ovarian cancer. Low galactose-1-phosphate uridyl transferase and type A blood group may increase risk for ovarian cancer. Cytogenetic and oncogene studies have identified regions that may be important in tumorigenesis and metastasis, but discriminating between early and late changes is difficult from these studies. Presence of a genetic susceptibility locus for breast and ovarian cancer has been confirmed on chromosome 17q21.

CONCLUSIONS

Family history is an important predictor of ovarian cancer risk. In rare families, a specific dominantly acting gene can be identified, but in the vast majority of familial ovarian cancers the underlying mechanism remains unclear. Specific studies are needed for women with a family history of ovarian cancer because evidence suggests modification of the effects of oral contraceptive use and reproductive patterns in this population of women.

Endometrial carcinoma in the cancer family syndrome

The study group consisted of 26 women with endometrial adenocarcinoma belonging to 19 cancer families. Age at the onset of cancer, the stage and histologic differentiation of the tumor, initial symptoms, other malignancies, 5-year survival, and transmission of cancer to descendants were studied. The focus was on the importance of endometrial carcinoma in the tumor spectrum. The diagnosis of cancer family was delayed in 14 of the 19 families because endometrial carcinoma was not included in the primary diagnostic carcinoma. This delay may have been harmful to 16 family members who had carcinomas later in life. In ten of the 14 women with multiple malignancies, endometrial adenocarcinoma was the primary malignancy diagnosed, thus enabling the suspicion of a gene carrier and screening for subsequent malignancies. The authors concluded that endometrial carcinoma is a significant component of cancer family syndrome and should be included in the main criteria of Lynch syndrome II.

an unusual family cancer syndrome manifested in young siblings

Three siblings whose mother had an ovarian mass excised as a teenager all developed malignancies in late childhood. Two were diagnosed as having malignant germ cell tumors of the ovary, whereas the third was found to have a soft tissue sarcoma. No underlying familial disease or constitutional chromosomal aberration has been detected and no known carcinogenic chemical exposure has been identified. All three children have been successfully treated with chemotherapy and are doing well off treatment. This is the first family cancer syndrome reported to have an association of ovarian germ cell tumors with embryonal sarcoma.

Risk factors as an indicator for breast cancer screening in asymptomatic patients

A review of breast carcinoma risk factors has established that age and sex are dominant variables. Additional epidemiological factors include family history, past medical history, menstrual status, age at birth of first child, demographic factors and reproductive history, which are of established importance as major or minor risk determinants for breast cancer. Taking into account the various epidemiological correlations and the multifactorial aetiology of this type of carcinoma, there is only a small probability that the identification of known risk factors will enable conclusive identification or prevention of the disease. Nevertheless the recognition of known risk factors may enhance screening efforts through surveillance, more selective biopsies and interval xeromammography. Total ductoglandular mastectomy may possibly be considered a beneficial approach to the management of the high-risk patient in whom preinvasive disease is detected. The identification of the high-risk patient is of paramount importance for prophylaxis. Prospective clinical trials using diagnostic approaches may include the study of genetic markers, hormones and steroid metabolites, mammographic parenchymal patterns and the analysis of genetic pedigree or other undetermined risk markers. While screening and detection programmes for breast carcinoma are not cost-effective, these intensive surveillance procedures do allow the early identification of high-risk individuals with the disease. The formulation of screening programmes which incorporate major and minor risk determinants may enhance the effectiveness of efforts to achieve diagnosis at a prognostically favourable stage of disease. Established diagnoses of stage 0 or stage I disease will translate as direct benefits to survival and reductions in economic morbidity.

Hereditary ovarian carcinoma. Biomarker studies

Three ovarian-cancer-prone kindreds were studied, two of which contained identical twin sisters concordant for ovarian carcinoma. In one kindred, both identical twin sisters had daughters with ovarian carcinoma. In another kindred, one of the identical twin sisters had an ovarian-cancer-affected daughter. Ovarian carcinoma showed vertical transmission in all three families in a pattern consonant with an autosomal dominant mode of inheritance. Medical-genetic survey of each family included detailed questionnaires with retrieval of primary medical and pathology documents on cancer of all anatomic sites. Putative biomarker determinations included: (1) in vitro hyperdiploidy in dermal monolayer cultures; and (2) lower serum levels of alpha-L-fucosidase (less than or equal to 275 IU/ml) in all cancer-affected patients and statistically significant lower levels in 50% risk individuals when compared to spouse and published controls (P = 0.04 and P = 0.0002, respectively). These findings are discussed in context with the eventual development of a risk factor profile which, given acceptable sensitivity and specificity, would enable identification of individuals who would be prime candidates for intensive surveillance/management programs.

Ovarian dysplasia. A study of identical twins

The normal, identical twin sisters of patients who had been the subjects of ovarian cancer were subjected to prophylactic oophorectomy after the menopause. The finding of epithelial abnormality suggests a precancerous change similar to other genital epithelial dysplasia.

Familial carcinoma of the ovary. Case report

A patient was successfully treated by surgery, progestogens and chlorambucil for a poorly differentiated cystadenocarcinoma of the ovary. Four of her relatives had died of ovarian cancer; it was ascertained that two of them also had poorly differentiated cystadenocarcinoma.

Familial ovarian carcinoma

Familial aggregation of patients with ovarian carcinoma is unusual. A family with four affected members in three consecutive generations is described. The tumors were all of the serous papillary adenocarcinoma type. The pattern of appearance of the malignant disorder in the present family may be explained as the result of transmission of a dominant mutant autosomal gene. The future long term management of such a family might include prophylactic oophorectomy in certain family members, and possibly selective terminations of pregnancies with female fetuses in high-risk women.

Six families prone to ovarian cancer

Six families are presented with multiple cases of ovarian cancer, mainly serous cystadenocarcinoma. Three families had concomitant aggregation of breast cancer, suggesting genetic determinants common to both tumors. The exceptional cancer risk in these families prompted prophylactic oophorectomy in 14 asymptomatic women from four families. Review of the original microscopic sections from 8 women revealed that 3, representing two families, had abnormalities of ovarian surface epithelium and mesothelial tissue, which may be of etiologic significance and portend neoplastic changes. To enable early detection and prevention of ovarian cancer, new diagnostic techniques and etiologic studies should be applied whenever possible to high-risk families.