Sonographic Diagnosis and Management With Delayed Hysterectomy of Two Cesarean Scar Pregnancies That Developed Into Placenta Percreta: Two Case Reports

Approximately two-thirds of the patients with a cesarean scar pregnancy (CSP) will develop placenta accreta spectrum (PAS). PAS occurs when the placenta attaches too deeply to the uterine wall, and sometimes, the placenta can extend beyond the uterus, invading surrounding organs. PAS is commonly managed with a cesarean hysterectomy, and these deliveries are often complicated by maternal and fetal morbidity and mortality. However, delaying hysterectomy and using chemotherapeutic agents may be a safe and beneficial alternative. We describe the case of a 32 -year-old G3P2002 with a history of two prior cesarean sections (CS) who was referred to our Maternal Fetal Medicine department due to the concern of a gestational sac embedded in the anterior uterine wall in the cesarean scar. Magnetic resonance imaging (MRI) findings at 33 weeks confirmed that the patient had developed placenta percreta extending into the sigmoid colon. We also describe the case of a 30-year-old G6P4104 with a history of four prior CS who was referred to our department for concern of a pregnancy complicated by CSP. This patient had an MRI performed at 23 weeks that showed placenta percreta invading the bladder. Patients one and two were managed with a staged procedure, with CS followed by a delayed laparoscopic and abdominal hysterectomy, respectively, to minimize bowel and bladder injury. After the CS, the patients subsequently received a five-day course of intravenous (IV) etoposide 100mg/m2, and at six weeks postpartum, the patients had a hysterectomy, both showing resolution of the placenta invasion into the surrounding organs on postpartum MRI and confirmed by tissue pathology reports. Our cases present the challenge in diagnosis and management of the most severe presentation of PAS that varies from the generally accepted management recommendations. Delayed hysterectomy with chemotherapy can be a reasonable, conservative surgical approach in the most severe types of PAS. As in our cases, this management could improve maternal and fetal morbidity and mortality.

Ornithine decarboxylase as a therapeutic target for endometrial cancer

Ornithine Decarboxylase (ODC) a key enzyme in polyamine biosynthesis is often overexpressed in cancers and contributes to polyamine-induced cell proliferation. We noted ubiquitous expression of ODC1 in our published endometrial cancer gene array data and confirmed this in the cancer genome atlas (TCGA) with highest expression in non-endometrioid, high grade, and copy number high cancers, which have the worst clinical outcomes. ODC1 expression was associated with worse overall survival and increased recurrence in three endometrial cancer gene expression datasets. Importantly, we confirmed these findings using quantitative real-time polymerase chain reaction (qRT-PCR) in a validation cohort of 60 endometrial cancers and found that endometrial cancers with elevated ODC1 had significantly shorter recurrence-free intervals (KM log-rank p = 0.0312, Wald test p = 5.59e-05). Difluoromethylornithine (DFMO) a specific inhibitor of ODC significantly reduced cell proliferation, cell viability, and colony formation in cell line models derived from undifferentiated, endometrioid, serous, carcinosarcoma (mixed mesodermal tumor; MMT) and clear cell endometrial cancers. DFMO also significantly reduced human endometrial cancer ACI-98 tumor burden in mice compared to controls (p = 0.0023). ODC-regulated polyamines (putrescine [Put] and/or spermidine [Spd]) known activators of cell proliferation were strongly decreased in response to DFMO, in both tumor tissue ([Put] (p = 0.0006), [Spd] (p<0.0001)) and blood plasma ([Put] (p<0.0001), [Spd] (p = 0.0049)) of treated mice. Our study indicates that some endometrial cancers appear particularly sensitive to DFMO and that the polyamine pathway in endometrial cancers in general and specifically those most likely to suffer adverse clinical outcomes could be targeted for effective treatment, chemoprevention or chemoprevention of recurrence.

Abstract 4816: OVA1: An in vitro diagnostic multivariate index assay for preoperative assessment of ovarian tumors

Objectives: We describe the development and validation of OVA1, an in vitro diagnostic multivariate index assay (IVDMIA) that has been recently approved by the FDA for preoperative assessment of the risk of ovarian cancer in women with ovarian tumors to help in deciding who should be referred to a gynecologic oncologist for surgery.

Methods: The OVA1 test combines five immunoassays into a single numerical result, including CA125 II, transthyretin (prealbumin), apolipoprotein A1, beta 2microglobulin, and transferrin. The OVA1 algorithm was derived using prospectively collected samples from women with a pelvic mass who were surgically evaluated for ovarian cancer. OVA1 was then validated in women scheduled for surgery for a known ovarian tumor in a prospective, multi-institutional trial involving 27 primary care and specialty sites throughout the United States. Over half of the patients (52%) were enrolled by non-GO surgeons. The OVA1 results were correlated with the physician assessment (assigned by the enrolling physician after considering all available clinical information) and surgical pathology. Subjects were excluded from analysis if surgery was not performed, pathology report was not available, or the blood specimen was unusable.

Results: The training sample set consisted of 274 samples from the University of Kentucky (including 63 epithelial ovarian cancer (EOC), 27 tumors of low malignant potential (LMP), 3 other ovarian malignancies, and 12 other cancers) and 125 samples from another multiple institution study (including 33 ovarian cancer). The independent validation study enrolled 590 women and 516 were evaluable with a pre-surgical assessment. There were 151 ovarian malignancies (29.3%), including: 96 EOC, 9 non-EOC, 28 LMP, and 18 malignancies metastatic to the ovary (met). The 235 premenopausal women enrolled (45.5%) accounted for 42 ovarian malignancies. The OVA1 test had a sensitivity of 92.5% and a specificity of 42.8% with corresponding PPV at 42.3% and NPV at 92.7%. OVA1 significantly improved the clinician's pre-surgical assessment for both non-GO and GO physicians. Sensitivity improved from 72.2% to 91.7% (95% CI: 83.0-96.1) for non-GO, and 77.5% to 98.9% (95% CI: 93.9-99.8) for GO. The NPV improved from 89.1% to 93.2% (95% CI: 85.9-96.8) for non-GO, and 85.5% to 97.6% (95% CI: 87.7-99.6) for GO. OVA1 correctly identified 70% (non-GO) and 95% (GO) of malignancies missed by the preoperative physician assessment alone. The OVA1 sensitivity by histologic subtype was: EOC 99.0% (95/96), non-EOC 77.8% (7/9), LMP 75.0% (21/28), and met 94.4% (17/18).

Conclusions: In the prospective, multi-institutional trial, the IDVMIA OVA1 correctly identified the majority of patients with ovarian malignancies that were missed by preoperative physician assessment alone, supporting the use of OVA1 to assist in surgical planning and decisions about referral to a gynecologic oncologist before surgery.

Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 101st Annual Meeting of the American Association for Cancer Research; 2010 Apr 17-21; Washington, DC. Philadelphia (PA): AACR; Cancer Res 2010;70(8 Suppl):Abstract nr 4816.

Abstract A46: Ablack raspberry extract inhibits the proliferation of cervical cancer cells partially through proapoptotic effects

A46

Cervical carcinoma, the second most common female cancer worldwide, is the seventh leading cause of cancer death in women. Although pap smears to screen abnormal cervical cytology have helped reduce mortality rates, it remains a challenge to manage preinvasive and invasive cervical lesions. The long latency of cervical cancer allows preventive and therapeutic interventions before progressing onto invasive disease. Thus, phytochemical-based cancer chemoprevention and the role of bioactive food components have attracted significant interest in current cancer-fighting interventions. We have previously shown that lyophilized black raspberries (LBR, Rubus occidentalis) inhibit the cell proliferation of human oral squamous cell carcinoma cells in vitro as well as oral tumorigenesis in vivo. Given the similar epidemiologic basis of oral and cervical cancers, we evaluated whether an LBR extract had anti-proliferative effects in cervical cancer cells in vitro and began to elucidate the possible regulatory molecular mechanisms. We found that LBR inhibited the proliferation of three human cervical cancer cell lines, HeLa (HPV16−/HPV18+) SiHa (HPV16+/HPV18−) and C-33A (HPV18−/HPV16−), in a dose-dependent manner (at 25, 50, 100 or 200µg/ml for 1, 3 and 5 days, respectively) to a maximum of 44%, 53% and 45% respectively (P&lt;0.005). While exogenous hydrogen peroxide (H2O2, 100µM), a common reactive oxygen species (ROS) intermediate and inhibitor of cell growth, inhibited C-33A proliferation, HeLa and SiHa cells were not significantly affected. The anti-proliferative effects of either LBR or LBR+catalase were similar in all cell lines as shown by WST1 (tetrazolium salt cleavage) and crystal violet assays, which supporting the hypothesis that decreased proliferation is specific to LBR bioactive components and independent in vitro peroxide generation. Flow cytometric analysis of propidium iodide and Annexin V staining showed that LBR induced apoptotic markers in all three cells lines, and did not change cell cycle progression. LBR treatment induced hypercondensation and volume contracted nuclei in Hela cells as demonstrated by fluorescence microscopy analysis of Hoechst 33342 staining. In conclusion, an extract of lyophilized black raspberries demonstrated significant anti-proliferative and pro-apoptotic activities in human cervical cancer cells in vitro. Therefore, black raspberries and their bioactive components may represent promising candidates for the phytochemical-based chemoprevention of cervical cancer and warrant further investigation.

Citation Information: Cancer Prev Res 2008;1(7 Suppl):A46.