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Olatunde OA, Samaila MO, Imam MI, Uchime KE, Dauda SE. Histopathological patterns of endometrial carcinoma in a tertiary hospital in North-West Nigeria. Ecancermedicalscience 2024; 18:1651. [PMID: 38425759 PMCID: PMC10901633 DOI: 10.3332/ecancer.2024.1651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Indexed: 03/02/2024] Open
Abstract
Background There are relatively few studies in Nigeria, and indeed, sub-Saharan Africa that have documented the relative frequencies and histomorphological patterns of endometrial carcinoma. This study aimed to determine the relative frequencies and clinic-epidemiological characteristics of endometrial carcinoma and its histological variants in Kano, North-Western, Nigeria. Method A 10-year retrospective study of all endometrial carcinoma cases in the Department of Pathology, Aminu Kano Teaching Hospital, Kano. All relevant information was retrieved and data was analysed using Statistical Package for Social Sciences version 22. Results Endometrial carcinoma showed an increment in prevalence from 0.5% of all gynaecologic admission in 2008 to 1.0% in 2017. Type I endometrial carcinoma, specifically endometrioid adenocarcinoma accounted for 80% of cases, while endometrial serous carcinoma was the most common type II endometrial carcinoma representing 20% of cases. Over 75% of endometrial carcinomas occurred in postmenopausal women with a mean age of 59 years. Conclusion There is a rise in the prevalence of endometrial carcinoma and endometrioid adenocarcinoma is the most common histologic type.
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Affiliation(s)
- Olaniyi A Olatunde
- Department of Anatomic Pathology and Forensic Medicine, Faculty of Basic Clinical Sciences, College of Medicine, Afe Babalola University, Ado-Ekiti 360231, Ekiti State, Nigeria
- Department of Pathology, Aminu Kano Teaching Hospital, Kano 700233, Kano State, Nigeria
| | - Modupeola O Samaila
- Department of Pathology, Ahmadu Bello University Teaching Hospital, SHIKA, Zaria 810107, Kaduna State, Nigeria
| | - Mohammed I Imam
- Department of Pathology, Aminu Kano Teaching Hospital, Kano 700233, Kano State, Nigeria
| | - Kasiemobi E Uchime
- Department of Anatomic Pathology and Forensic Medicine, Faculty of Basic Clinical Sciences, College of Medicine, Afe Babalola University, Ado-Ekiti 360231, Ekiti State, Nigeria
| | - Suleiman E Dauda
- Department of Histopathology, College of Medical Sciences, Abubakar Tafawa Balewa University, Bauchi 740272, Nigeria
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Cheng WL, Wang RM, Zhao Y, Chen J. A nomogram for predicting cancer-specific survival in patients with uterine clear cell carcinoma: a population-based study. Sci Rep 2023; 13:9231. [PMID: 37286668 DOI: 10.1038/s41598-023-36323-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 06/01/2023] [Indexed: 06/09/2023] Open
Abstract
Uterine clear cell carcinoma (UCCC) is a relatively rare endometrial cancer. There is limited information on its prognosis. This study aimed to develop a predictive model predicting the cancer-specific survival (CSS) of UCCC patients based on data from the Surveillance, Epidemiology, and End Results (SEER) database between 2000 and 2018. A total of 2329 patients initially diagnosed with UCCC were included in this study. Patients were randomized into training and validation cohorts (7:3). Multivariate Cox regression analysis identified that age, tumor size, SEER stage, surgery, number of lymph nodes detected, lymph node metastasis, radiotherapy and chemotherapy were independent prognostic factors for CSS. Based on these factors, a nomogram for predicting the prognosis of UCCC patients was constructed. The nomogram was validated using concordance index (C-index), calibration curves, and decision curve analyses (DCA). The C-index of the nomograms in the training and validation sets are 0.778 and 0.765, respectively. Calibration curves showed good consistency of CSS between actual observations and nomogram predictions, and DCA showed that the nomogram has great clinical utility. In conclusion, a prognostic nomogram was firstly established for predicting the CSS of UCCC patients, which can help clinicians make personalized prognostic predictions and provide accurate treatment recommendations.
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Affiliation(s)
- Wen-Li Cheng
- Department of Outpatient, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Rui-Min Wang
- Department of Outpatient, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yi Zhao
- Department of Outpatient, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Juan Chen
- Department of Outpatient, West China Second University Hospital, Sichuan University, Chengdu, China.
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, West China Second University Hospital, Sichuan University, Chengdu, Sichuan, China.
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Sendo K, Seino M, Ohta T, Nagase S. Impact of the glutathione synthesis pathway on sulfasalazine-treated endometrial cancer. Oncotarget 2022; 13:224-236. [PMID: 35106124 PMCID: PMC8794577 DOI: 10.18632/oncotarget.28185] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 01/10/2022] [Indexed: 01/17/2023] Open
Abstract
Glutathione is an antioxidant that has an important role in chemotherapeutic drug resistance in cancer. Cysteine is synthesized from cystine and is transported into the cell via the xCT antiporter. Another pathway for synthesizing cysteine involves intracellular methionine. We determined whether targeting the xCT represents a promising strategy for the treatment of endometrial cancer and identified factors that predict efficacy of this treatment strategy. In uterine serous carcinoma (USC) cell lines, the combination of cisplatin and the xCT inhibitor, sulfasalazine, significantly inhibited cell growth compared with single-agent cisplatin or sulfasalazine. Sulfasalazine treatment significantly decreased intracellular glutathione levels and induced apoptosis when combined with cisplatin in USC cell lines. On the one hand, the effectiveness of combined cisplatin and sulfasalazine was not evident in endometrioid carcinoma. USC cell lines exhibited increased expression of xCT and decreased expression of cystathionine gamma lyase (CGL), which is an enzyme involved in the synthesis of cysteine from methionine. On the other hand, endometrioid carcinoma cell lines exhibited increased CGL expression or decreased xCT expression. These findings suggest that using a glutathione synthesis pathway-based approach for selecting subjects for sulfasalazine treatment may be an effective strategy for circumventing glutathione-related chemotherapeutic drug resistance in endometrial carcinoma.
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Affiliation(s)
- Kanako Sendo
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Manabu Seino
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Tsuyoshi Ohta
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan
| | - Satoru Nagase
- Department of Obstetrics and Gynecology, Yamagata University Faculty of Medicine, Yamagata, Japan
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Scaletta G, Dinoi G, Capozzi V, Cianci S, Pelligra S, Ergasti R, Fagotti A, Scambia G, Fanfani F. Comparison of minimally invasive surgery with laparotomic approach in the treatment of high risk endometrial cancer: A systematic review. Eur J Surg Oncol 2020; 46:782-788. [DOI: 10.1016/j.ejso.2019.11.519] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 11/24/2019] [Accepted: 11/30/2019] [Indexed: 02/04/2023] Open
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The role of vaginal brachytherapy in stage I endometrial serous cancer: a systematic review. J Contemp Brachytherapy 2020; 12:61-66. [PMID: 32190072 PMCID: PMC7073340 DOI: 10.5114/jcb.2020.92698] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 01/15/2020] [Indexed: 12/25/2022] Open
Abstract
Purpose Serous adenocarcinoma (uterine serous carcinoma – USC) is a rare and aggressive histologic subtype of endometrial cancer, with a high-rate of recurrence and poor prognosis. The adjuvant treatment for stage I patients is unclear. The purpose of this study was to evaluate the outcomes of stage I USC treated exclusively with chemotherapy plus vaginal brachytherapy (VBT). Material and methods A systematic research using PubMed, Scopus, and Cochrane library was conducted to identify full articles evaluating the efficacy of VBT in patients with stage I USC. A search in ClinicalTrials.gov was performed in order to detect ongoing or recently completed trials, and in PROSPERO for searching ongoing or recently completed systematic reviews. Results All studies were retrospective and 364 of evaluated patients were found. The average local control was 97.5% (range, 91-100%), the disease free-survival was 88% (range, 82-94%), the overall survival was 93% (range, 72-100%), the specific cancer survival was 89.4% (range, 84.8-94%), and the G3-G4 toxicity was 0-8%. Conclusions These data support the concept that in adequately selected patients, VBT alone may be a suitable radiotherapy technique in women with stage I USC who underwent surgical staging and received adjuvant chemotherapy.
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6
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Lorphelin H, Rossard L, Rua C, Arbion F, Bougnoux P, Body G, Ouldamer L. Evolution of characteristics of women with endometrial cancer during a 40 years study period. J Gynecol Obstet Hum Reprod 2019; 48:489-494. [DOI: 10.1016/j.jogoh.2019.04.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 04/07/2019] [Accepted: 04/09/2019] [Indexed: 01/08/2023]
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Lokich E, Kole M, Raker C, Quddus MR, Mathews C. Molecular markers in uterine serous cancer: Correlation between endometrial biopsy and hysterectomy specimens. Gynecol Oncol Rep 2019; 29:98-101. [PMID: 31467960 PMCID: PMC6710608 DOI: 10.1016/j.gore.2019.04.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 04/13/2019] [Accepted: 04/17/2019] [Indexed: 01/03/2023] Open
Abstract
Objectives To measure the correlation of molecular biomarkers between biopsy and final pathology specimens in uterine serous cancer (USC) and to establish the overall prevalence of specific biomarkers among subjects with USC. Methods Twenty eight patients with a diagnosis of USC and sufficient biopsy and hysterectomy specimens were identified. IHC was used to measure the biomarker status of EGFR, phospho-AKT, ER, PR, Her2/neu, and PTEN in FFPE tissue. The presence or absence of individual biomarkers was then compared between a given subject's diagnostic biopsy specimen and final hysterectomy specimen. Results In the cohort identified, average age was 72 and average BMI was 29. 75% of patients had full lymphadenectomy performed. The average time from biopsy to surgery was 33 days (range 9–91 days). The distribution of disease was 61% stage I (n = 17), 14% stage II (n = 4), 22% stage III (n = 6) and 4% stage IV (n = 1). Biopsy and hysterectomy specimens agreed 67% of the time for phospho-AKT, 80% for ER, 73% for PR, 83% for EGFR, 100% for Her2/neu and 95% for PTEN loss. Conclusions The measurement of specific biomarkers correlated well between subjects' biopsy and hysterectomy specimens in women with USC as measured by a pathologist using routine clinical techniques. Preoperative diagnostic biopsy may be a useful tool for guiding neoadjuvant targeted therapy in USC. Molecular biomarkers can be measured in endometrial biopsy specimens using routine clinical techniques. There was 100% correlation between biopsy and hysterectomy specimen staining for Her2/neu. Standardization of staining for molecular markers in endometrial cancers has potential to expand treatment options.
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Affiliation(s)
- Elizabeth Lokich
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Women and Infants' Hospital, Alpert Medical School at Brown University, Providence, RI 02905, USA
| | - Martha Kole
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Women and Infants' Hospital, Alpert Medical School at Brown University, Providence, RI 02905, USA
| | - Christina Raker
- Division of Research, Women and Infants' Hospital, Alpert Medical School at Brown University, Providence, RI 02905, USA
| | - M Ruhul Quddus
- Department of Pathology, Women and Infants' Hospital, Alpert Medical School at Brown University, Providence, RI 02905, USA
| | - Cara Mathews
- Program in Women's Oncology, Department of Obstetrics and Gynecology, Women and Infants' Hospital, Alpert Medical School at Brown University, Providence, RI 02905, USA
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Abdulfatah E, Ahmed Q, Alosh B, Bandyopadhyay S, Bluth MH, Ali-Fehmi R. Gynecologic Cancers: Molecular Updates 2018. Clin Lab Med 2019; 38:421-438. [PMID: 29776639 DOI: 10.1016/j.cll.2018.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Ovarian carcinoma continues to be a concern for woman and maintains significant morbidity and mortality. Emerging molecular markers are providing additional opportunities for effective diagnosis and prognosis of disease. An integrated clinicopathologic and molecular classification of gynecologic malignancies has the potential to refine the clinical risk prediction of patients with cancer and to provide more tailored treatment recommendations.
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Affiliation(s)
- Eman Abdulfatah
- Department of Pathology, Detroit Medical Center Harper University Hospital, Wayne State University, 3990 John R Detroit, MI 48201, USA
| | - Quratulain Ahmed
- Michigan Diagnostic pathologists, Providence Hospital, 16001 W Nine Mile Road, Southfield, MI 48075, USA
| | - Baraa Alosh
- Department of Pathology, Detroit Medical Center Harper University Hospital, Wayne State University, 3990 John R Detroit, MI 48201, USA
| | - Sudeshna Bandyopadhyay
- Department of Pathology, Detroit Medical Center Harper University Hospital, Wayne State University, 3990 John R Detroit, MI 48201, USA.
| | - Martin H Bluth
- Department of Pathology, Wayne State University, School of Medicine, 540 East Canfield Street, Detroit, MI 48201, USA; Pathology Laboratories, Michigan Surgical Hospital, 21230 Dequindre Road, Warren, MI 48091, USA
| | - Rouba Ali-Fehmi
- Department of Pathology, Detroit Medical Center Harper University Hospital, Wayne State University, 3990 John R Detroit, MI 48201, USA
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Seino M, Ohta T, Sugiyama A, Sakaki H, Sudo T, Tsutsumi S, Shigeta S, Tokunaga H, Toyoshima M, Yaegashi N, Nagase S. Metabolomic analysis of uterine serous carcinoma with acquired resistance to paclitaxel. Oncotarget 2018; 9:31985-31998. [PMID: 30174791 PMCID: PMC6112827 DOI: 10.18632/oncotarget.25868] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 07/12/2018] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Uterine serous carcinoma (USC) is more aggressive than other subtypes of endometrial carcinoma and is associated with a poor prognosis. We analyzed the metabolomic profile of USC with acquired resistance to paclitaxel. RESULTS Glutathione (GSH) concentration in PTX-1 cells was higher than in USPC-1 cells. In addition, GSH concentration in the USPC-1 cells increased after treatment with paclitaxel but was unchanged in PTX-1 cells. Glucose-6-phosphate (G6P) and ribose-5-phosphate (R5P) concentrations in PTX-1 cells were higher than those in USPC-1 cells. G6P concentration in the USPC-1 cells was unchanged after treatment with paclitaxel, while it decreased in PTX-1 cells. CONCLUSION Our results indicate that increased GSH and glucose metabolism may be related to acquiring resistance to paclitaxel in USC and thus may be targets for anti-USC therapy. MATERIALS AND METHODS We compared metabolic profiles and reactions to paclitaxel in both a wild type USC cell line (USPC-1) and PTX-1, a cell line derived from USPC-1 which acquired paclitaxel resistance, using a capillary electrophoresis CE-MS/MS system.
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Affiliation(s)
- Manabu Seino
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Tsuyoshi Ohta
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Akiko Sugiyama
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Hirotsugu Sakaki
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Takeshi Sudo
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Seiji Tsutsumi
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Shogo Shigeta
- 2 Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Hideki Tokunaga
- 2 Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Masafumi Toyoshima
- 2 Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Nobuo Yaegashi
- 2 Department of Obstetrics and Gynecology, Tohoku University Graduate School of Medicine, Iidanishi, Yamagata 990-9585, Japan
| | - Satoru Nagase
- 1 Department of Obstetrics and Gynecology, Yamagata University School of Medicine, Iidanishi, Yamagata 990-9585, Japan
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Vargas R, Gopal P, Kuzmishin GB, DeBernardo R, Koyfman SA, Jha BK, Mian OY, Scott J, Adams DJ, Peacock CD, Abazeed ME. Case study: patient-derived clear cell adenocarcinoma xenograft model longitudinally predicts treatment response. NPJ Precis Oncol 2018; 2:14. [PMID: 30202792 PMCID: PMC6041303 DOI: 10.1038/s41698-018-0060-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/19/2018] [Accepted: 06/19/2018] [Indexed: 01/06/2023] Open
Abstract
There has been little progress in the use of patient-derived xenografts (PDX) to guide individual therapeutic strategies. In part, this can be attributed to the operational challenges of effecting successful engraftment and testing multiple candidate drugs in a clinically workable timeframe. It also remains unclear whether the ancestral tumor will evolve along similar evolutionary trajectories in its human and rodent hosts in response to similar selective pressures (i.e., drugs). Herein, we combine a metastatic clear cell adenocarcinoma PDX with a timely 3 mouse x 1 drug experimental design, followed by a co-clinical trial to longitudinally guide a patient's care. Using this approach, we accurately predict response to first- and second-line therapies in so far as tumor response in mice correlated with the patient's clinical response to first-line therapy (gemcitabine/nivolumab), development of resistance and response to second-line therapy (paclitaxel/neratinib) before these events were observed in the patient. Treatment resistance to first-line therapy in the PDX is coincident with biologically relevant changes in gene and gene set expression, including upregulation of phase I/II drug metabolism (CYP2C18, UGT2A, and ATP2A1) and DNA interstrand cross-link repair (i.e., XPA, FANCE, FANCG, and FANCL) genes. A total of 5.3% of our engrafted PDX collection is established within 2 weeks of implantation, suggesting our experimental designs can be broadened to other cancers. These findings could have significant implications for PDX-based avatars of aggressive human cancers.
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Affiliation(s)
- Roberto Vargas
- 1Gynecologic Oncology Division, Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue/A8, Cleveland, OH 44195 USA
| | - Priyanka Gopal
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA
| | - Gwendolyn B Kuzmishin
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA
| | - Robert DeBernardo
- 1Gynecologic Oncology Division, Women's Health Institute, Cleveland Clinic, 9500 Euclid Avenue/A8, Cleveland, OH 44195 USA
| | - Shlomo A Koyfman
- 3Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue/CA-60, Cleveland, OH 44195 USA
| | - Babal K Jha
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA
| | - Omar Y Mian
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA.,3Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue/CA-60, Cleveland, OH 44195 USA
| | - Jacob Scott
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA.,3Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue/CA-60, Cleveland, OH 44195 USA
| | - Drew J Adams
- 4Department of Genetics, Case Western Reserve University, 2109 Adelbert Road/BRB, Cleveland, OH 44106 USA
| | - Craig D Peacock
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA
| | - Mohamed E Abazeed
- 2Department of Translational Hematology Oncology Research, Cleveland Clinic, 2111 East 96th St/NE6-258, Cleveland, OH 44195 USA.,3Department of Radiation Oncology, Cleveland Clinic, 9500 Euclid Avenue/CA-60, Cleveland, OH 44195 USA
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Rossi S, Vigani B, Puccio A, Bonferoni MC, Sandri G, Ferrari F. Chitosan Ascorbate Nanoparticles for the Vaginal Delivery of Antibiotic Drugs in Atrophic Vaginitis. Mar Drugs 2017; 15:md15100319. [PMID: 29048359 PMCID: PMC5666427 DOI: 10.3390/md15100319] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 10/10/2017] [Accepted: 10/13/2017] [Indexed: 12/03/2022] Open
Abstract
The aim of the present work was the development of chitosan ascorbate nanoparticles (CSA NPs) loaded into a fast-dissolving matrix for the delivery of antibiotic drugs in the treatment of atrophic vaginitis. CSA NPs loaded with amoxicillin trihydrate (AX) were obtained by ionotropic gelation in the presence of pentasodium tripolyphosphate (TPP). Different CSA:TPP and CSA:AX weight ratios were considered and their influence on the particle size, polydispersion index and production yield were investigated. CSA NPs were characterized for mucoadhesive, wound healing and antimicrobial properties. Subsequently, CSA NPs were loaded in polymeric matrices, whose composition was optimized using a DoE (Design of Experiments) approach (simplex centroid design). Matrices were obtained by freeze-drying aqueous solutions of three hydrophilic excipients, polyvinylpirrolidone, mannitol and glycin. They should possess a mechanical resistance suitable for the administration into the vaginal cavity and should readily dissolve in the vaginal fluid. In addition to antioxidant properties, due to the presence of ascorbic acid, CSA NPs showed in vitro mucoadhesive, wound healing and antimicrobial properties. In particular, nanoparticles were characterized by an improved antimicrobial activity with respect to a chitosan solution, prepared at the same concentration. The optimized matrix was characterized by mechanical resistance and by the fast release in simulated vaginal fluid of nanoparticles characterized by unchanged size.
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Affiliation(s)
- Silvia Rossi
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | - Barbara Vigani
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | - Antonella Puccio
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | | | - Giuseppina Sandri
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | - Franca Ferrari
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
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12
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Mahdi H, Han X, Abdul-Karim F, Vargas R. Racial disparity in survival of patients with uterine serous carcinoma: Changes in clinical characteristics, patterns of care and outcomes over time from 1988 to 2011. Gynecol Oncol 2016; 143:334-345. [PMID: 26948694 DOI: 10.1016/j.ygyno.2016.03.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/29/2016] [Accepted: 03/01/2016] [Indexed: 01/22/2023]
Abstract
OBJECTIVES To determine if the disparities in the outcome between white (W) and African American (AA) patients with uterine serous carcinoma (USC) have changed over time. METHODS Women with USC were identified using the SEER database from 1988 to 2011 (N=7667). Years of the study were divided into three periods (1988-1997, 1998-2004 and 2005-2011). Overall (OS) and disease-specific survivals (DSS) was estimated. RESULTS Over the three time periods, African American patients continued to be younger and less likely to have cancer directed surgery and extensive lymphadenectomy when compared to white patients. In multivariable analysis adjusting for age, race, marital status, stage, cancer-directed surgery, extent of lymphadenectomy, adjuvant radiation, and geographic location, AA was significantly associated with worse DSS and OS in the three time periods compared to white race. African American patients were 29% (95% CI 1.03-1.62, p=0.027) in 1988-1997, 40% in 1998-2004 (95% CI 1.21-1.63, p<0.0001) and 34% in 2005-2011 (95% CI 1.13-1.59, p=0.0008) more likely to die from uterine cancer compared to their white counterparts. A slight improvement in the difference in OS over time was noted comparing African American and white patients. African American patients were 46% (95% CI 1.23-1.73, p<0.0001) in 1988-1997, 39% in 1998-2004 (95% CI 1.23-1.56, p<0.0001) and 26% in 2005-2011 (95% CI 1.10-1.45, p<0.0001) more likely to die from any cause compared to their white counterparts. CONCLUSIONS Significant improvement in outcome was noted in both racial groups over time. However, African American patients continued to have worse outcome than white patients over time.
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Affiliation(s)
- Haider Mahdi
- Gynecologic Oncology Division, Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA.
| | - Xiaozhen Han
- Population Health and Outcomes Research Core, Clinical and Translational Science Collaborative, Cleveland, OH, USA
| | - Fadi Abdul-Karim
- Department of Anatomic Pathology, Cleveland Clinic, Cleveland, OH, USA
| | - Roberto Vargas
- Gynecologic Oncology Division, Ob/Gyn and Women's Health Institute, Cleveland Clinic, Cleveland, OH, USA
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Abstract
OBJECTIVE The objectives of this study were to evaluate the rates of chemotherapy and radiotherapy delivery in the treatment of uterine serous carcinoma in the Medicare population and to compare clinical outcomes in treated and untreated patients. METHODS The linked Surveillance, Epidemiology, and End Results and Medicare databases were queried to identify patients with a diagnosis of uterine serous carcinoma between 1992 and 2009. The impact of chemotherapy on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. RESULTS A total of 2188 patients met study eligibility criteria. Stages I, II, III, and IV diseases accounted for 890 (41%), 174 (8%), 470 (21%), and 654 (30%) of the study population, respectively. Chemotherapy, radiotherapy, both, or none, were administered as adjuvant therapy in 635 (29%), 536 (24%), 308 (14%), and 709 (32%) of the study population, respectively. Use of chemotherapy became more frequent over time. Over the study period, and after adjusting for race, time of diagnosis, SEER registry, marital status, stage, age, surgery, lymph node dissection, socioeconomic status, and comorbidity index, there was an association between receipt of radiotherapy alone (hazard ratio [HR], 1.3; 95% CI, 1.04-1.67) and not receiving any treatment (HR, 1.5; 95% CI, 1.2-2.01) and worst survival. Survival was not improved over time. CONCLUSION Although adjuvant chemotherapy and combination treatment with chemotherapy and radiation were associated with improved survival in our model, there was no significant improvement in survival over time.
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Abstract
ObjectiveUterine papillary serous carcinoma (UPSC) is a rare variant of endometrial carcinoma responsible for up to 40% of endometrial cancer deaths. Controversy remains regarding optimal adjuvant therapy for UPSC, with lack of randomized trials to date. The objective of this retrospective study was to evaluate clinicopathological factors and determine event-free survival and overall survival (OS) in patients with UPSC managed within a single institution.Materials and MethodsMedical and pathological records between 1987 and 2004 were reviewed at the Royal Women’s Hospital, Melbourne, Australia. Cox regression analysis was used to analyze effects of clinical and histopathological variables on patient survival and survival times following adjuvant therapy. Event-free survival and OS were analyzed using the Kaplan-Meier survival curve.ResultsSixty-two patients were included; 96.8% were managed surgically and 56.5% were completely surgically staged. Myoinvasion was present in 72.6% (n = 45) of the patients.In patients with stage I disease, recurrence rate was 41.4% with a 5-year OS of 46%. In stage II, recurrence rate was 20% with a 5-year OS of 67%. In stage III, recurrence rate was 58.8% with a 5-year OS of 34%. In stage IV, recurrence rate was 71.4% with a 5-year OS of 29%.There was no significant difference in survival based on the presence of positive peritoneal cytology, positive lymphovascular space invasion or positive lymph nodes at diagnosis, and no significant difference in survival based on the type of adjuvant therapy administered. Depth of myometrial invasion was a significant determinant of poor prognosis (P = 0.027).ConclusionsUterine papillary serous carcinoma is an aggressive variant of endometrial cancer associated with a high proportion of advanced-stage disease at diagnosis, high recurrence rates, and low OS. In our patients, prognosis was determined by myometrial invasion and International Federation of Gynecology and Obstetrics stage at diagnosis. Randomized trials in this area are required to clarify optimal adjuvant therapy for patients with UPSC.
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Rauh-Hain JA, Diver E, Meyer LA, Clemmer J, Lu KH, Del Carmen MG, Schorge JO. Patterns of care, associations and outcomes of chemotherapy for uterine serous carcinoma: analysis of the National Cancer Database. Gynecol Oncol 2015; 139:77-83. [PMID: 26325526 DOI: 10.1016/j.ygyno.2015.08.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 08/21/2015] [Accepted: 08/23/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Evaluate rates of chemotherapy and radiotherapy delivery in the treatment of uterine serous carcinoma, and compare clinical outcomes of treated and untreated patients. METHODS The National Cancer Database was queried to identify patients diagnosed with uterine serous carcinoma between 2003 and 2011. The impact of chemotherapy on survival was analyzed using the Kaplan-Meier method. Factors predictive of outcome were compared using the Cox proportional hazards model. RESULTS A total of 13,752 patients met the study eligibility criteria. Stage I, II, III, and IV disease accounted for 4355 (31.7%), 1023 (7.4%), 3484 (25.3%), and 2451 (17.8%) of the study population, respectively. 2439 (17.7%) women had unknown stage. Chemotherapy was administered in 4290 (35.4%) patients, radiotherapy to 1673 (12.2%), adjuvant chemo-radiation to 2915 (21.2%), and 4874 (35.4%) of women did not receive adjuvant therapy during the study period. Utilization of chemotherapy became more frequent over time. Over the entire study period, after adjusting for age, period of diagnosis, race, facility location, facility type, insurance provider, socioeconomic status, comorbidity index, lymph node dissection, treatment modality, and stage, there was an association between treatment modality and survival, with the lowest hazard ratio in patients that received chemo-radiation. After adjusting for the same factors in women with stages I and II, chemo-radiation was associated with improved survival compared to patients that received no treatment. Radiotherapy or chemotherapy alone was not associated with improved survival. CONCLUSION Utilization of chemotherapy is increased in this population over the study period from 2003-2012 and more importantly that survival, particularly in advanced stage patients, is improving.
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Affiliation(s)
- J Alejandro Rauh-Hain
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Elisabeth Diver
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, United States
| | - Joel Clemmer
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Karen H Lu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas M. D. Anderson Cancer Center, Houston, TX, United States
| | - Marcela G Del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - John O Schorge
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
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Rudd ML, Mohamed H, Price JC, O'Hara AJ, Le Gallo M, Urick ME, Cruz P, Zhang S, Hansen NF, Godwin AK, Sgroi DC, Wolfsberg TG, Mullikin JC, Merino MJ, Bell DW. Mutational analysis of the tyrosine kinome in serous and clear cell endometrial cancer uncovers rare somatic mutations in TNK2 and DDR1. BMC Cancer 2014; 14:884. [PMID: 25427824 PMCID: PMC4258955 DOI: 10.1186/1471-2407-14-884] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Accepted: 11/13/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Endometrial cancer (EC) is the 8th leading cause of cancer death amongst American women. Most ECs are endometrioid, serous, or clear cell carcinomas, or an admixture of histologies. Serous and clear ECs are clinically aggressive tumors for which alternative therapeutic approaches are needed. The purpose of this study was to search for somatic mutations in the tyrosine kinome of serous and clear cell ECs, because mutated kinases can point to potential therapeutic targets. METHODS In a mutation discovery screen, we PCR amplified and Sanger sequenced the exons encoding the catalytic domains of 86 tyrosine kinases from 24 serous, 11 clear cell, and 5 mixed histology ECs. For somatically mutated genes, we next sequenced the remaining coding exons from the 40 discovery screen tumors and sequenced all coding exons from another 72 ECs (10 clear cell, 21 serous, 41 endometrioid). We assessed the copy number of mutated kinases in this cohort of 112 tumors using quantitative real time PCR, and we used immunoblotting to measure expression of these kinases in endometrial cancer cell lines. RESULTS Overall, we identified somatic mutations in TNK2 (tyrosine kinase non-receptor, 2) and DDR1 (discoidin domain receptor tyrosine kinase 1) in 5.3% (6 of 112) and 2.7% (3 of 112) of ECs. Copy number gains of TNK2 and DDR1 were identified in another 4.5% and 0.9% of 112 cases respectively. Immunoblotting confirmed TNK2 and DDR1 expression in endometrial cancer cell lines. Three of five missense mutations in TNK2 and one of two missense mutations in DDR1 are predicted to impact protein function by two or more in silico algorithms. The TNK2(P761Rfs*72) frameshift mutation was recurrent in EC, and the DDR1(R570Q) missense mutation was recurrent across tumor types. CONCLUSIONS This is the first study to systematically search for mutations in the tyrosine kinome in clear cell endometrial tumors. Our findings indicate that high-frequency somatic mutations in the catalytic domains of the tyrosine kinome are rare in clear cell ECs. We uncovered ten new mutations in TNK2 and DDR1 within serous and endometrioid ECs, thus providing novel insights into the mutation spectrum of each gene in EC.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Daphne W Bell
- Cancer Genetics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda MD 20892, USA.
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Roelofsen T, van Ham MA, de Hullu JA, Massuger LF. Clinical management of uterine papillary serous carcinoma. Expert Rev Anticancer Ther 2014; 11:71-81. [DOI: 10.1586/era.10.199] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
This article reviews the molecular features and pathogenesis of gynecologic malignancies. Understanding the molecular basis of endometrial carcinoma helps to provide an explanation for the prognosis of these tumors and opens up avenues for research into novel therapies that may prove beneficial.
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Affiliation(s)
- Quratulain Ahmed
- Department of Pathology, Wayne State University, 540, E Canfield, Detroit, MI 48201, USA
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del Carmen MG, Birrer M, Schorge JO. Uterine papillary serous cancer: a review of the literature. Gynecol Oncol 2012; 127:651-61. [PMID: 23000148 DOI: 10.1016/j.ygyno.2012.09.012] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 09/09/2012] [Accepted: 09/13/2012] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Uterine papillary serous carcinoma (UPSC) represents a distinct subtype of endometrial cancer. UPSC is less common than endometrioid carcinoma (ECC) but accounts for a disproportionate number of uterine cancer related deaths. This article critically reviews the literature pertinent to the pathology, pathogenesis, diagnosis, management, and outcome of patients with UPSC. METHODS MEDLINE was searched for all research articles published in English between January 1, 1967-January 1, 2012 which reported on patients diagnosed with UPSC. Given the rarity of this tumor, studies were not limited by design or number of reported patients. RESULTS UPSC represents a histologically aggressive subtype of endometrial cancer. It commonly presents with extra uterine disease involvement which can be identified by comprehensive surgical staging. Optimal cytoreduction and systemic platinum/taxane-based adjuvant therapy appear to confer a survival advantage. CONCLUSIONS UPSC is a biologically distinct entity, different from ECC. Future studies should explore the role of targeted therapies in the management of UPSC.
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Affiliation(s)
- Marcela G del Carmen
- Division of Gynecologic Oncology, Vincent Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA.
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Prognostic determinants in patients with stage I uterine papillary serous carcinoma: a 15-year multi-institutional review. Int J Gynecol Cancer 2012; 22:417-24. [PMID: 22237383 DOI: 10.1097/igc.0b013e31823c6e36] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The aim of this retrospective, multi-institutional study was to evaluate the importance of surgical staging for stage I uterine papillary serous carcinomas (UPSCs) to determine optimal management of this rare tumor. METHODS With institutional review board approval from both participating institutions, all patients with 2009 International Federation of Gynecology and Obstetrics stage I mixed serous and UPSC diagnosed between January 1, 1992, and December 31, 2007, were identified at the 2 institutions. Clinical factors were correlated using Spearman correlation coefficients, Kaplan-Meier survival estimates and a Cox proportional hazards model. RESULTS Of the 204 UPSC patients treated during this period, 84 were classified as stage I, with substages as follows: stage IA, n = 71; stage IB, n = 13. Thirty-seven patients (44%) had a history of a second cancer (22 breast tumors, 9 synchronous müllerian cancers). Surgical staging with at least hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and bilateral pelvic lymph node dissection was performed in 60 (71%) of 84 patients. The median survival for all patients was 10 years. Univariate analysis revealed surgical staging (P < 0.001), normal preoperative CA-125 (P < 0.001), and absence of additional cancers (P < 0.01) to be associated with improved survival. Age-adjusted multivariate analysis incorporating these factors revealed that advancing substage (hazard ratio, 4.59; P < 0.05), a second malignancy (hazard ratio, 2.75; P < 0.04), and surgical staging (hazard ratio, 0.18; P < 0.001) were independent factors associated with overall survival. In a subset analysis excluding patients with a second malignancy, substage (hazard ratio, 3.52; P < 0.05), and surgical staging (hazard ratio, 0.16; P < 0.001) were independent factors affecting overall survival. CONCLUSIONS Independent of adjuvant chemotherapy or radiation, stage of disease, comprehensive surgical staging, and the presence of a second malignancy were predictors of overall survival.
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Turan AT, Dündar B, Gündoğdu B, Boztosun A, Ozgül N, Boran N, Tulunay G, Ozfuttu A, Köse MF. The effect of cell type on surgico-pathologic risk factors in endometrial cancer. J Turk Ger Gynecol Assoc 2011; 12:9-14. [PMID: 24591950 DOI: 10.5152/jtgga.2011.03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2010] [Accepted: 02/19/2011] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE In this study the effect of histologic subtype as a surgicopathologic risk factor in endometrial cancer is evaluated. MATERIAL AND METHODS We evaluated 182 patients who underwent systematic lymphadenectomy up to the level of the renal vessels and at least 15 lymph nodes were dissected from the pelvic area and 10 lymph nodes from the para-aortic area. investigation of whether endometrioid and aggressive cell types (serous papillary cell and clear cell) affect the distribution of surgicopathologic risk factors among endometrial cancer cases was carried out. RESULTS Patients in the aggressive cell type group were older and the tumor size was significantly smaller. There was no difference between the two groups for the total number of dissected lymph nodes except for the external iliac area. Although the difference is not statistically significant, the total number of lymph nodes dissected in the aggressive group was less (54.3 vs 62.9, p=0.067) than that of the endometrioid cell type group. While the incidence of pelvic lymph node metastasis in the aggressive group was 59.1% the incidence was 15.6% in the endometrioid cell type group (p>0.001). The possibility of lymph node metastasis for aggressive cell type endometrial carcinoma in the para-aortic area was twice the endometrioid cell type group. It was found that the presence and type (stromal/glandular) of cervical invasion, depth of myometrial invasion and presence of lymphovascular space invasion were not affected by cell type. CONCLUSION Aggressive cell types significantly increase the adnexial and lymph node metastasis in endometrial cancer.
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Affiliation(s)
- Ahmet Taner Turan
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Betül Dündar
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Burcu Gündoğdu
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Abdullah Boztosun
- Department of Gynecology and Obstetrics, Cumhuriyet University, Sivas, Turkey
| | - Nejat Ozgül
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Nurettin Boran
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Gökhan Tulunay
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Ahmet Ozfuttu
- Department of Pathology, Etlik Zübeyde Hanım Women, Ankara, Turkey
| | - Mehmet Faruk Köse
- Department of Gynecologic Oncology, Etlik Zübeyde Hanım Women, Ankara, Turkey
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Rauh-Hain JA, Growdon WB, Schorge JO, Goodman A, Boruta DM, McCann C, Horowitz NS, del Carmen MG. Prognostic determinants in patients with stage IIIC and IV uterine papillary serous carcinoma. Gynecol Oncol 2010; 119:299-304. [DOI: 10.1016/j.ygyno.2010.07.010] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2010] [Revised: 07/07/2010] [Accepted: 07/11/2010] [Indexed: 01/22/2023]
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El-Sahwi K, Bellone S, Cocco E, Casagrande F, Bellone M, Abu-Khalaf M, Buza N, Tavassoli FA, Hui P, Rüttinger D, Silasi DA, Azodi M, Schwartz PE, Rutherford TJ, Pecorelli S, Santin AD. Overexpression of EpCAM in uterine serous papillary carcinoma: implications for EpCAM-specific immunotherapy with human monoclonal antibody adecatumumab (MT201). Mol Cancer Ther 2010; 9:57-66. [PMID: 20053761 DOI: 10.1158/1535-7163.mct-09-0675] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We evaluated the expression of epithelial cell adhesion molecule (EpCAM) and the potential of MT201 (adecatumumab), a human monoclonal antibody against EpCAM, in uterine serous papillary carcinoma (USPC). EpCAM expression was evaluated by real-time PCR and immunohistochemistry in a total of 56 USPC fresh-frozen biopsies and paraffin-embedded tissues. EpCAM surface expression was also evaluated by flow cytometry and immunohistochemistry in six USPC cell lines. Sensitivity to MT201 antibody-dependent cellular cytotoxicity and complement-dependent cytotoxicity was tested against a panel of primary USPC cell lines expressing different levels of EpCAM in standard 5-h (51)Cr release assays. EpCAM transcript was significantly overexpressed in fresh-frozen USPC when compared with normal endometrial cells (NEC). Median (minimum-maximum) copy number was 943.8 (31.5-1568.3) in tumor samples versus 12.9 (1.0-37.0) in NEC (P < 0.001). By immunohistochemistry, EpCAM expression was found in 96% (26 out of 27) of USPC samples with significantly higher expression compared with NECs (P < 0.001). High surface expression of EpCAM was found in 83% (five out of six) of the USPC cell lines tested by flow cytometry. EpCAM-positive cell lines were found highly sensitive to MT201-mediated antibody-dependent cellular cytotoxicity in vitro, whereas primary USPC cell lines were resistant to natural killer cell-dependent cytotoxicity. Human plasma IgG did not significantly inhibit MT201-mediated cytotoxicity against USPC. EpCAM is highly expressed in uterine serous carcinoma at mRNA and protein levels, and primary USPC are highly sensitivity to MT201-mediated cytotoxicity. MT201 might represent a novel therapeutic strategy in patients harboring advanced/recurrent or metastatic USPC refractory to standard treatment modalities.
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Affiliation(s)
- Karim El-Sahwi
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine, New Haven, Connecticut 06520-8063, USA
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ENGELSEN INGEBORGB, AKSLEN LARSA, SALVESEN HELGAB. Biologic markers in endometrial cancer treatment. APMIS 2009; 117:693-707. [DOI: 10.1111/j.1600-0463.2009.02467.x] [Citation(s) in RCA: 61] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Abstract
Endometrial carcinoma is frequently diagnosed at an early stage, at which point it is usually surgically curable. Some less common subtypes of endometrial carcinoma, such as serous and clear cell carcinomas, have a worse prognosis than most endometrioid carcinomas. Patients with advanced or recurrent disease, regardless of histologic subtype, have a poor prognosis. Both single-agent and combination chemotherapy regimens (such as doxorubicin, cisplatin, and paclitaxel) have antitumor activity but are not curative. Recently, adjuvant chemotherapy has been shown to improve outcomes in high-risk nonmetastatic (stage III) disease. Newer agents such as mammalian target of rapamycin (mTOR) inhibitors show promise, and are currently being tested in a clinical trials.
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Affiliation(s)
- Mandira Ray
- Department of Medicine, Section of Hematology/Oncology, University of Chicago, Chicago, IL 60637, USA.
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26
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Olawaiye AB, Rauh-Hain JA, Withiam-Leitch M, Rueda B, Goodman A, del Carmen MG. Utility of pre-operative serum CA-125 in the management of uterine papillary serous carcinoma. Gynecol Oncol 2008; 110:293-8. [DOI: 10.1016/j.ygyno.2008.05.027] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2008] [Revised: 05/26/2008] [Accepted: 05/28/2008] [Indexed: 11/26/2022]
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Horn LC, Meinel A, Handzel R, Einenkel J. Histopathology of endometrial hyperplasia and endometrial carcinoma: an update. Ann Diagn Pathol 2007; 11:297-311. [PMID: 17630117 DOI: 10.1016/j.anndiagpath.2007.05.002] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Endometrial cancer (EC) is the most common malignancy of the female genital tract in the western world. Conceptually, a dualistic model of endometrial carcinogenesis exists for sporadic EC, based on molecular findings with a good correlation to the morphologic phenotype and clinical behavior. Type 1 endometrial carcinoma represents an estrogen-related tumor, which usually arises in the setting of endometrial hyperplasia, has endometrioid histology with low grade, and tends to be biologically indolent. Grade 3 endometrioid cancers, which constitute a minority of EC, also behave aggressively. The type 2 cancers are not estrogen-driven and have a higher grade, various histologies, particularly serous carcinomas and clear-cell carcinomas, and a poorer prognosis. The diagnostic criteria of endometrial hyperplasia, endometrial in situ carcinoma, and of the different histologic types of EC, according to the most recent World Health Organization classification, are given in detail. In addition, the risk of progression of endometrial hyperplasia into endometrioid type EC and their treatment modalities are discussed. Endometrial pathologies in patients with breast cancer, receiving tamoxifen, and women affected by hereditary nonpolyposis colorectal cancer syndrome are described, including their pathogenetic aspects. Finally, a short practical description for the handling of surgical specimens from fractional curetting and hysterctomies is given.
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Affiliation(s)
- Lars-Christian Horn
- Division of Gynecologic Pathology, Institute of Pathology, Leipzig University, D-04103 Leipzig, Germany.
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Affiliation(s)
- Gini F Fleming
- University of Chicago Medical Center, Chicago, IL 60637, USA.
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Santin AD, Bellone S, Marizzoni M, Palmieri M, Siegel ER, McKenney JK, Hennings L, Comper F, Bandiera E, Pecorelli S. Overexpression of claudin-3 and claudin-4 receptors in uterine serous papillary carcinoma: novel targets for a type-specific therapy using Clostridium perfringens enterotoxin (CPE). Cancer 2007; 109:1312-22. [PMID: 17326053 DOI: 10.1002/cncr.22536] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Uterine serous papillary carcinoma (USPC) represents a highly aggressive variant of endometrial cancer. Using gene expression profiling, we recently identified high expression of the claudin-3 and claudin-4 receptors in a limited set of USPC. These tight junction proteins represent the low- and high-affinity receptors, respectively, for the cytotoxic Clostridium perfringens enterotoxin (CPE) and are sufficient to mediate CPE binding and trigger subsequent toxin-mediated cytolysis. The potential for targeting this pathway in the treatment of USPC was explored. METHODS Claudin-3 and claudin-4 receptor expression was analyzed at the mRNA and protein levels in flash-frozen and formalin-fixed, paraffin-embedded tissue from 20 consecutive USPC patients. The potential of recombinant CPE as a novel therapy against primary, metastatic, and chemotherapy-resistant USPC cell lines was also investigated in vitro. Finally, the in vivo therapeutic effect of sublethal doses of CPE was studied in SCID mouse xenografts harboring subcutaneous and intraperitoneal USPC that expressed claudin-3 and claudin-4. RESULTS In all, 100% (20 out of 20) of the primary flash-frozen USPC tested overexpressed 1 or both CPE receptors by quantitative reverse-transcriptase polymerase chain reaction (RT-PCR). Membranous immunoreactivity for claudin-4 protein expression was documented in the majority of USPC specimens tested by immunohistochemistry, whereas only a low level of membranous staining was found in normal endometrial control tissue samples. When primary and metastatic short-term USPC cell lines were incubated with different concentrations of CPE in vitro, a dose-dependent cytotoxic effect was demonstrated. In vivo, intratumoral injections of well-tolerated doses of CPE in large subcutaneous USPC xenografts led to large areas of tumor cell necrosis and tumor disappearance in all the treated animals, whereas sublethal intraperitoneal injections of CPE had a significant inhibitory effect on tumor progression, with extended survival of animals harboring chemotherapy-resistant intra-abdominal USPC carcinomatosis. CONCLUSIONS Claudin-3 and claudin-4 receptors may offer promising targets for the use of CPE as a novel type-specific therapy against this highly aggressive and chemotherapy-resistant variant of endometrial cancer.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Animals
- Claudin-3
- Claudin-4
- Clostridium perfringens
- Cystadenocarcinoma, Papillary/drug therapy
- Cystadenocarcinoma, Papillary/genetics
- Cystadenocarcinoma, Papillary/pathology
- Cystadenocarcinoma, Serous/drug therapy
- Cystadenocarcinoma, Serous/genetics
- Cystadenocarcinoma, Serous/pathology
- Drug Resistance, Neoplasm
- Enterotoxins/therapeutic use
- Female
- Gene Expression
- Humans
- Injections, Intraperitoneal
- Membrane Proteins/genetics
- Mice
- Mice, SCID
- Middle Aged
- RNA, Messenger/metabolism
- Reverse Transcriptase Polymerase Chain Reaction
- Tumor Cells, Cultured
- Up-Regulation
- Uterine Cervical Neoplasms/drug therapy
- Uterine Cervical Neoplasms/genetics
- Uterine Cervical Neoplasms/pathology
- Xenograft Model Antitumor Assays
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Affiliation(s)
- Alessandro D Santin
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA.
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Tam KF, Ng TY, Tsang PCK, Li CF, Ngan HYS. Potential use of the adenosine triphosphate cell viability assay in endometrial cancer. ACTA ACUST UNITED AC 2006; 13:518-22. [PMID: 16979354 DOI: 10.1016/j.jsgi.2006.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Adenosine triphosphate cell viability assay (ATP-CVA) was used previously to evaluate chemotherapy in uterine cancer cell lines. In this study, we have performed the ATP-CVA on endometrial cancer patients to study the feasibility of using ATP-CVA in endometrial cancer to determine the intrinsic chemosensitivity of the cytotoxic drugs. METHODS Thirty-three patients with endometrial adenocarcinoma who presented for a staging operation were recruited. Endometrial cancer samples were obtained at the time of operation. In vitro ATP-CVA and chemosensitivity testing was performed using cisplatin, carboplatin, paclitaxel, etoposide, doxorubicin, 4-epidoxorubicin, and topotecan. RESULTS Thirty-two of the 33 endometrial cancer samples were evaluable for SF50 (survival fraction at 50% of the peak plasma concentration [PPC]) using ATP-CVA. The median SF50 of carboplatin (0.33) was significantly less than the median SF50 of cisplatin (0.71), topotecan (0.93), paclitaxel (0.68), doxorubicin (1.0), etoposide (0.70), or 4-epidoxorubicin (0.88) (Wilcoxon signed rank test, P <.001). CONCLUSION This study showed the feasibility of using the ATP-CVA in endometrial cancer to determine the intrinsic chemosensitivity of cytotoxic drugs.
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Affiliation(s)
- Kar Fai Tam
- Gynaecological Oncology Division, Department of Obstetrics and Gynaecology, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China.
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Santin AD, Diamandis EP, Bellone S, Marizzoni M, Bandiera E, Palmieri M, Papasakelariou C, Katsaros D, Burnett A, Pecorelli S. Overexpression of kallikrein 10 (hK10) in uterine serous papillary carcinomas. Am J Obstet Gynecol 2006; 194:1296-302. [PMID: 16647913 DOI: 10.1016/j.ajog.2005.10.794] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2005] [Revised: 07/27/2005] [Accepted: 10/21/2005] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Kallikrein 10 is a secreted serine protease recently implicated in the growth and invasion of several human tumors. The goal of this study was to investigate the expression and secretion levels in vitro and in vivo of kallikrein 10 in uterine serous papillary carcinoma, a highly aggressive variant of endometrial tumor. STUDY DESIGN Human kallikrein 10 gene expression levels were evaluated in 11 snap-frozen uterine serous papillary carcinoma biopsies and 6 normal endometrial cell biopsies by real-time polymerase chain reaction. Secretion of kallikrein 10 protein by 10 primary tumor cultures including 3 uterine serous papillary carcinomas, 2 endometrioid carcinomas, and 5 ovarian serous papillary tumors was measured using a sensitive ELISA. Finally, kallikrein 10 concentration in 75 serum and plasma samples from 22 healthy women, 20 women with benign diseases, 21 women with endometrioid carcinomas, and 12 uterine serous papillary carcinoma patients was studied. RESULTS Kallikrein 10 gene expression levels were significantly higher in uterine serous papillary carcinoma when compared with normal endometrial cell biopsies (mean copy number by real time polymerase chain reaction = 743 versus 1.4; uterine serous papillary carcinoma versus endometrioid carcinoma: P < .02). In vitro kallikrein 10 secretion was detected in all primary uterine serous papillary carcinoma cell lines tested (mean = 2.7 microg/L), and the secretion levels were not significantly different to those found in primary ovarian serous papillary tumor cultures (mean 4.2 microg/L). In contrast, no kallikrein 10 secretion was detectable in primary endometrioid carcinomas. Kallikrein 10 serum and plasma concentrations (microg/L; mean +/- SEM) among normal healthy females (0.6 +/- 0.04), patients with benign diseases (0.6 +/- 0.06), and patients with endometrioid carcinomas (0.7 +/- 0.06) were not significantly different. In contrast, serum and plasma kallikrein 10 values in uterine serous papillary carcinoma patients (1.2 +/- 0.1) were significantly higher than those in the non-cancer group (P = .002), benign group (P = .002), and endometrioid carcinoma patients (P = .005). CONCLUSION Kallikrein 10 is highly expressed in uterine serous papillary carcinoma, and it is released in the plasma and serum of uterine serous papillary carcinoma patients. Kallikrein 10 may represent a novel biomarker for uterine serous papillary carcinoma.
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Affiliation(s)
- Alessandro D Santin
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
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Abstract
The most common malignant tumour of the uterus is endometrioid endometrial cancer. However, many less common malignant diseases also develop in the uterus, including both carcinomas and sarcomas. Most notable of these tumours are papillary serous carcinomas, clear-cell carcinomas, carcinosarcomas, stromal sarcomas, and leiomyosarcomas. These less common cancers can be aggressive, and account for a greatly disproportionate amount of deaths from uterine cancers. Because they are uncommon, physicians will usually have seen only a few cases, and randomised data to guide treatment often do not exist. This review summarises the epidemiology, clinical characteristics, and prognoses of the less common malignant diseases of the uterus, and presents the information available to guide the clinician about treatment options.
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Zorn KK, Bonome T, Gangi L, Chandramouli GVR, Awtrey CS, Gardner GJ, Barrett JC, Boyd J, Birrer MJ. Gene expression profiles of serous, endometrioid, and clear cell subtypes of ovarian and endometrial cancer. Clin Cancer Res 2005; 11:6422-30. [PMID: 16166416 DOI: 10.1158/1078-0432.ccr-05-0508] [Citation(s) in RCA: 318] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The presence of similar histologic subtypes of epithelial ovarian and endometrial cancers has long been noted, although the relevance of this finding to pathogenesis and clinical management is unclear. Despite similar clinical characteristics, histologic subtypes of cancers of the ovary and endometrium are treated according to organ of origin. This study compares the gene expression profiles of analogous histologic subtypes of cancers of the ovary and endometrium using the same genomic platform to determine the similarities and differences between these tumors. EXPERIMENTAL DESIGN Gene expression profiles of 75 cancers (endometrioid, serous, and clear cell) of the ovary and endometrium, five renal clear cell cancers, and seven normal epithelial brushings were determined using a 11,000-element cDNA array. All images were analyzed using BRB ArrayTools. Validation was done using real-time PCR on select genes and immunohistochemical staining. RESULTS Comparison across endometrial and ovarian cancers and serous and endometrioid tumors showed expression patterns reflecting their organ of origin. Clear cell tumors, however, showed remarkably similar expression patterns regardless of their origin, even when compared with renal clear cell samples. A set of 43 genes was common to comparisons of each of the three histologic subtypes of ovarian cancer with normal ovarian surface epithelium. CONCLUSIONS The comparison of the gene expression profiles of endometrioid and serous subtypes of ovarian and endometrial cancer are largely unique to the combination of a particular subtype in a specific organ. In contrast, clear cell cancers show a remarkable similarity in gene expression profiles across organs (including kidney) and could not be statistically distinguished.
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Santin AD, Diamandis EP, Bellone S, Soosaipillai A, Cane S, Palmieri M, Burnett A, Roman JJ, Pecorelli S. Human kallikrein 6: a new potential serum biomarker for uterine serous papillary cancer. Clin Cancer Res 2005; 11:3320-5. [PMID: 15867230 DOI: 10.1158/1078-0432.ccr-04-2528] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE The discovery of novel biomarkers might greatly contribute to improve clinical management and outcomes in uterine serous papillary carcinoma (USPC), a highly aggressive variant of endometrial cancer. EXPERIMENTAL DESIGN Human kallikrein 6 (hK6) gene expression levels were evaluated in 29 snap-frozen endometrial biopsies, including 13 USPC, 13 endometrioid carcinomas, and 3 normal endometrial cells by real-time PCR. Secretion of hK6 protein by 14 tumor cultures, including 3 USPC, 3 endometrioid carcinoma, 5 ovarian serous papillary carcinoma, and 3 cervical cancers, was measured using a sensitive ELISA. Finally, hK6 concentration in 79 serum and plasma samples from 22 healthy women, 20 women with benign diseases, 20 women with endometrioid carcinoma, and 17 USPC patients was studied. RESULTS hK6 gene expression levels were significantly higher in USPC when compared with endometrioid carcinoma (mean copy number by real-time PCR, 1,927 versus 239, USPC versus endometrioid carcinoma; P < 0.01). In vitro hK6 secretion was detected in all primary USPC cell lines tested (mean, 11.5 microg/L) and the secretion levels were similar to those found in primary ovarian serous papillary carcinoma cultures (mean, 9.6 microg/L). In contrast, no hK6 secretion was detectable in primary endometrioid carcinoma and cervical cancer cultures. hK6 serum and plasma concentrations (mean +/- SE) among normal healthy females (2.7 +/- 0.2 microg/L), patients with benign diseases (2.4 +/- 0.2 microg/L), and patients with endometrioid carcinoma (2.6 +/- 0.2 microg/L) were not significantly different. In contrast, serum and plasma hK6 values in USPC patients (6.1 +/- 1.1) were significantly higher than those in the noncancer group (P = 0.006), benign group (P = 0.003), and endometrioid carcinoma patients (P = 0.005). CONCLUSIONS hK6 is highly expressed in USPC and is released in the plasma and serum of USPC patients. hK6 may represent a novel biomarker for USPC for monitoring early disease recurrence and response to therapy.
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MESH Headings
- Adult
- Aged
- Biomarkers, Tumor/blood
- Biomarkers, Tumor/genetics
- Carcinoma, Endometrioid/blood
- Carcinoma, Endometrioid/genetics
- Carcinoma, Endometrioid/pathology
- Cystadenocarcinoma, Papillary/blood
- Cystadenocarcinoma, Papillary/genetics
- Cystadenocarcinoma, Papillary/pathology
- Cystadenocarcinoma, Serous/blood
- Cystadenocarcinoma, Serous/genetics
- Cystadenocarcinoma, Serous/pathology
- Endometrial Neoplasms/blood
- Endometrial Neoplasms/genetics
- Endometrial Neoplasms/pathology
- Enzyme-Linked Immunosorbent Assay
- Female
- Gene Expression Regulation, Neoplastic
- Humans
- Kallikreins/blood
- Kallikreins/genetics
- Middle Aged
- RNA, Messenger/genetics
- RNA, Messenger/metabolism
- Reverse Transcriptase Polymerase Chain Reaction
- Tumor Cells, Cultured
- Uterine Neoplasms/blood
- Uterine Neoplasms/genetics
- Uterine Neoplasms/pathology
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Affiliation(s)
- Alessandro D Santin
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205-7199, USA.
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Wong E, D'Souza DP, Chen JZ, Lock M, Rodrigues G, Coad T, Trenka K, Mulligan M, Bauman GS. Intensity-modulated arc therapy for treatment of high-risk endometrial malignancies. Int J Radiat Oncol Biol Phys 2005; 61:830-41. [PMID: 15708263 DOI: 10.1016/j.ijrobp.2004.06.253] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2004] [Revised: 06/14/2004] [Accepted: 06/30/2004] [Indexed: 11/18/2022]
Abstract
PURPOSE We developed an intensity-modulated arc therapy (IMAT) technique for the treatment of women with high-risk endometrial malignancies. In the context of multimodality therapy, nodal and tumor bed irradiation was delivered while respecting tolerance doses for critical structures. METHODS AND MATERIALS Five patients were planned and treated with the IMAT technique after hysterectomy. Computed tomographic (CT) scans for treatment planning were acquired with the tumor bed contoured as the clinical target volume (CTV(tumor_bed)) and the iliac and presacral vessels contoured as the gross tumor volume (GTV). In 2 patients the lower para-aortic nodes were included into the GTV. The small bowel, iliac crests, femoral heads, bladder, and rectum were contoured as critical organs. For the nodes, a CTV(nodes) was generated with a 7-10-mm margin around the vessels, and the planning target volume (PTV(nodes)) was generated by a further 5-mm expansion. For the tumor bed, the PTV(tumor_bed) was generated with a margin of 7-10 mm around CTV(tumor_bed). Planning constraints included adequate coverage of the tumor bed (>95% receiving > or =45 Gy) and nodes (> or =95% receiving > or =40 Gy). Arc combinations with different extents were tested, and the final plan was generated based on the balance between complexity (number of arcs), PTV coverage, and critical structure sparing. Conventional and 8-field intensity-modulated radiation therapy (IMRT) plans were generated for each patient for comparison purposes. All patients were treated with IMAT. RESULTS We found that two anterior intensity-modulated arcs (300 degrees to 30 degrees and 330 degrees to 60 degrees ) adequately treated the PTVs. Furthermore, this IMAT technique allowed sparing of small bowel and the iliac crests (marrow space) to a similar degree as the 8-field IMRT. The 8-field IMRT yielded better dose uniformity than IMAT in the target volumes; however, neither technique was as uniform as the conventional plan. In the 5 patients, IMAT treatment was well tolerated and completed as planned. CONCLUSIONS We successfully piloted an optimized intensity-modulated arc technique to treat 5 high-risk endometrial cancer patients undergoing multimodality treatment. This allowed a significant reduction in dose to bone marrow and small bowel compared with conventional techniques and was simpler to deliver than multifield IMRT.
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Affiliation(s)
- Eugene Wong
- Department of Oncology, University of Western Ontario, and London Regional Cancer Centre, 790 Commissioners Road East, London, Ontario N6A 4L6, Canada.
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