Veliparib with frontline chemotherapy and as maintenance in Japanese women with ovarian cancer: a subanalysis of efficacy, safety, and antiemetic use in the phase 3 VELIA trial

BACKGROUND

The phase 3 VELIA trial evaluated veliparib with carboplatin/paclitaxel and as maintenance in patients with high-grade serous ovarian carcinoma.

METHODS

Patients with previously untreated stage III-IV high-grade serous ovarian carcinoma were randomized 1:1:1 to control (placebo with carboplatin/paclitaxel and placebo maintenance), veliparib-combination-only (veliparib with carboplatin/paclitaxel and placebo maintenance), or veliparib-throughout (veliparib with carboplatin/paclitaxel and veliparib maintenance). Randomization stratification factors included geographic region (Japan versus North America or rest of the world). Primary end point was investigator-assessed median progression-free survival. Efficacy, safety, and pharmacokinetics were evaluated in a subgroup of Japanese patients.

RESULTS

Seventy-eight Japanese patients were randomized to control (n = 23), veliparib-combination-only (n = 30), and veliparib-throughout (n = 25) arms. In the Japanese subgroup, median progression-free survival for veliparib-throughout versus control was 27.4 and 19.1 months (hazard ratio, 0.46; 95% confidence interval, 0.18-1.16; p = 0.1 [not significant]). In the veliparib-throughout arm, grade 3/4 leukopenia, neutropenia, and thrombocytopenia rates were higher for Japanese (32%/88%/32%) versus non-Japanese (17%/56%/28%) patients. Grade 3/4 anemia rates were higher in non-Japanese (65%) versus Japanese (48%) patients. Early introduction of olanzapine during veliparib monotherapy maintenance phase may help prevent premature discontinuation of veliparib, via its potent antiemetic efficacy.

CONCLUSIONS

Median progression-free survival was numerically longer in Japanese patients in the veliparib-throughout versus control arm, consistent with results in the overall study population. Pharmacokinetics were comparable between Japanese and non-Japanese patients. Data for the subgroup of Japanese patients were not powered to show statistical significance but to guide further investigation.

Discrepancies in pathological diagnosis of endometrial stromal sarcoma: a multi-institutional retrospective study from the Japanese Clinical Oncology Group

Endometrial stromal sarcoma (ESS) is a rare uterine malignancy that requires accurate pathological diagnosis for proper treatment. This study aimed to clarify the discrepancies in the pathological diagnosis of ESS and obtain practical clues to improve diagnostic accuracy. Between 2002 and 2015, 148 patients with low-grade ESS (LGESS), high-grade ESS (HGESS), undifferentiated endometrial sarcoma (UES), or undifferentiated uterine sarcoma (UUS) diagnosed at 31 institutions were included. We performed immunohistochemistry, real-time polymerase chain reaction for JAZF1-SUZ12 and YWHAE-NUTM2A/B, and break-apart fluorescent in situ hybridization for JAZF1, PHF1, and YWHAE. Central pathology review (CPR) was performed by six pathologists. After CPR, LGESS, HGESS, UES/UUS, and other diagnoses were confirmed in 72, 25, 16, and 31 cases, respectively. Diagnostic discrepancies were observed in 19.6% (18/92) of LGESS and 34% (18/53) of HGESS or UUS/UES. Adenosarcomas, endometrial carcinomas, carcinosarcomas, and leiomyosarcomas were common diagnostic pitfalls. JAZF1-SUZ12 transcript, PHF1 split signal, and YWHAE-NUTM2A/B transcript were mutually exclusively detected in 23 LGESS, 3 LGESS, and 1 LGESS plus 3 HGESS, respectively. JAZF1-SUZ12 and YWHAE-NUTM2A/B transcripts were detected only in cases with CPR diagnosis of LGESS or HGESS. The CPR diagnosis of LGESS, HGESS, and UUS was a significant prognosticator, and patients with LGESS depicted a favorable prognosis, while those with UUS showed the worst prognosis. Pathological diagnosis of ESS is often challenging and certain tumors should be carefully considered. The accurate pathological diagnosis with the aid of molecular testing is essential for prognostic prediction and treatment selection.

Resolution of large pelvic lymphocele after incidental intracystic hemorrhage caused by percutaneous catheter drainage: Case report

We report the case of a large pelvic lymphocele after an ovarian cancer operation, which incidentally vanished after bleeding resulting from percutaneous catheter drainage. The patient was a 74‐year‐old woman with stage IVB ovarian cancer who underwent surgery including pelvic lymph node dissection. Three months after surgery, computed tomography revealed a large (13‐cm diameter) pelvic lymphocele with associated bilateral hydronephrosis and left femoral vein thrombosis. The lymphocele was repeatedly drained by percutaneous aspiration, and the day after the second procedure, the drainage fluid became bloody. The catheter was clamped for 3 days and then removed. The lymphocele volume gradually decreased, and it was not seen on a computed tomography scan 70 days after drainage. The lymphocele did not recur prior to her death. In this case, the intracystic hemorrhage was considered to have served as a blood patch for lymph leakage.

Prognosis of bulky pTIIB cervical cancer treated by radical hysterectomy comparing adenocarcinoma with squamous cell carcinoma using propensity score matching

OBJECTIVE

To investigate whether radical hysterectomy (RAH) can effectively treat true Stage IIB (pTIIB) cervical adenocarcinoma (AC) because FIGO (clinical) Stage IIB cervical cancer is rarely treated with RAH and radiotherapy has unfavorable effects on AC.

METHODS

We retrospectively analyzed data for 82 patients with Stage pTIIB cervical cancer who underwent RAH at our institution between January 1997 and December 2017. The end points were disease-free survival (DFS) and overall survival (OS) among squamous cell carcinoma (SCC) (n = 60) and AC (n = 22) patients. Kaplan-Meier survival analysis with and without propensity score matching was conducted to identify the impact of RAH.

RESULTS

Para-aortic lymph node metastasis and tumor diameter were significant factors for recurrence, and adjuvant chemotherapy prevented recurrence on multivariate analysis. After propensity score matching, there was no significant difference in DFS and OS between the groups. Five-year DFS and OS of the SCC group were 0.505 (95% confidence interval [CI] 0.268-0.702) and 0.619 (95% CI 0.351-0.803), respectively, and those of the AC group were 0.444 (95% CI 0.232-0.638) and 0.602 (95% CI 0.351-0.782), respectively.

CONCLUSION

Bulky Stage pTIIB cervical cancer is hard to cure, but RAH plus adjuvant therapy might be an option for radio-resistant pTIIB cervical AC.

Diagnostic benefit of cytological and histopathological examinations for recurrent vaginal cancer metastasizing to the duodenum: A case report

This is the first case report of a vaginal squamous cell carcinoma that metastasized to the duodenum. Cytological and histopathological examinations are useful for the diagnosis of a duodenal metastasis.

Reduction in HPV16/18 prevalence among young women with high-grade cervical lesions following the Japanese HPV vaccination program

The Japanese government began a human papillomavirus (HPV) vaccination program for girls aged 12‐16 years in 2010 but withdrew its recommendation in 2013 because of potential adverse effects, leading to drastically reduced vaccination uptake. To evaluate population‐level effects of HPV vaccination, women younger than 40 years of age newly diagnosed with cervical intraepithelial neoplasia grade 1‐3 (CIN1‐3), adenocarcinoma in situ (AIS), or invasive cervical cancer (ICC) have been registered at 21 participating institutes each year since 2012. A total of 7709 women were registered during 2012‐2017, of which 5045 were HPV genotyped. Declining trends in prevalence of vaccine types HPV16 and HPV18 during a 6‐year period were observed in CIN1 (50.0% to 0.0%, P_trend < .0001) and CIN2‐3/AIS (83.3% to 45.0%, P_trend = .07) only among women younger than 25 years of age. Overall, HPV vaccination reduced the proportion of HPV16/18‐attributable CIN2‐3/AIS from 47.7% to 33.0% (P = .003): from 43.5% to 12.5% as routine vaccination (P = .08) and from 47.8% to 36.7% as catch‐up vaccination (P = .04). The HPV16/18 prevalence in CIN2‐3/AIS cases was significantly reduced among female individuals who received their first vaccination at age 20 years or younger (P = .02). We could not evaluate vaccination effects on ICC owing to low incidence of ICC among women aged less than 25 years. We found HPV vaccination to be effective in protecting against HPV16/18‐positive CIN/AIS in Japan; however, our data did not support catch‐up vaccination for women older than 20 years. Older adolescents who skipped routine vaccination due to the government’s suspension of its vaccine recommendation could benefit from receiving catch‐up vaccination before age 20 years.

Serous carcinoma of the uterine cervix: Clinicopathological features differing from serous carcinomas of other female organs

Aim

Serous carcinoma of the uterine cervix (USCC) is a very rare malignant tumor, while this histological subtype is common in the ovary, fallopian tube, uterine corpus and peritoneum. Because of its rarity, details of the clinicopathological features of USCC are largely unknown. We retrospectively analyzed the clinicopathological characteristics of five cases of pure USCC.

Methods

We reviewed the medical records and pathological specimens of five USCC cases who were treated at the Gynecology Service of the National Hospital Organization Kyushu Cancer Center, Japan, between 2000 and 2017. The clinicopathological features were also compared with those of serous carcinomas of the endometrium and ovary who were treated during the same period.

Results

Five patients were treated at our hospital between 2000 and 2017. Three tumors were stage IB1, one was stage IIB, and one was stage IVB. The median follow‐up time was 104 months (range 26–210). Four patients other than stage IVB were treated with radical hysterectomy and have been free of relapse. One patient with stage IVB tumor was treated with platinum‐based combination chemotherapy and is currently on maintenance therapy with bevacizumab and remains free of relapse.

Conclusion

USCC has a distinctive clinicopathological feature that differentiates it from serous carcinomas of other female organs. USCC had been thought to be a poor prognostic disease; however, it could be curable if it is not accompanied by lymph node metastasis or peritoneal dissemination. We might conquer USCC even if it is accompanied by lymph node metastasis with the use of multimodal therapy.

Adjuvant chemotherapy for a primitive neuroectodermal tumor of the uterine corpus: A case report and literature review

A primitive neuroectodermal tumor (PENT) belongs to the category of a Ewing sarcoma. A PENT of the uterus is rare and has been known to be very aggressive by nature. Owing to the rarity of the tumor, there is no optimal treatment at present. In many cases, after hysterectomy, chemotherapy or radiation therapy has been performed. However, an effective chemotherapy regimen was unclear. In the soft tissue sarcoma area, the chemotherapy approach has recently greatly improved. Vincristine, doxorubicin, cyclophosphamide, ifosfamide and etoposide (VDC-IE) therapy has improved the survival rate of patients with Ewing sarcoma/PENT. Thus, VDC-IE therapy may be used for a uterine PENT. Here, we report a case of a uterine PENT in a premenopausal woman successfully treated with multimodality treatment including VDC-IE therapy and discuss the optimal chemotherapy for a uterine PENT through a literature review.

A study of treatments and outcomes in elderly women with cervical cancer

OBJECTIVE

With the population aging, development of safe and effective treatments for elderly patients with cancer is needed. Although old age is considered a poor prognostic factor, this is not only because of the patient's disease condition or response to treatment, but also because of treatment strategy and intensity. The purpose of this study was to clarify the influence of age on treatment and prognosis in patients with cervical cancer.

METHODS

Women with stage Ib-IV cervical cancer treated at our institution between 1997 and 2014 were retrospectively analyzed. Patients were stratified by age into groups for analysis, <65 years and ≥65 years. Categorical variables were compared using chi-squared and Fisher's exact tests. Survival analyses were performed using the Kaplan-Meier method, and comparisons were made using the log-rank test. Subsequently, Cox proportional hazards models were developed to find independent prognostic factors.

RESULTS

Of 959 patients included in our study, 247 were ≥65 and 712 were <65 years of age. Elderly patients tended to be at a more advanced stage than younger patients (p < 0.001). Elderly patients more commonly had comorbidities. More received standard treatment in the younger patient group at any disease stage than in the elderly patient group (p < 0.001). Similar rates of adverse effects caused by surgery or radiotherapy were seen in patients from both groups. Although overall survival was statistically shorter in elderly patients (74.7 vs. 57.1%, p < 0.001), there was no significant difference in disease-specific survival for patients treated only with standard treatment. In multivariate analyses, clinical stage, histological type, treatment intensity, and primary surgery remained independent prognostic factors. Age was not an independent prognostic factor.

CONCLUSIONS

The influence of age on prognosis in patients with cervical cancer was less than we expected. Elderly patients might have better outcomes depending on the type of standard treatment they receive. The appropriate modality and intensity of treatment should be based on the patient's general condition and background.

Renal function and urological complications after radical hysterectomy with postoperative radiotherapy and platinum-based chemotherapy for cervical cancer

Background

We aimed to clarify renal functional changes long term and serious urological complications in women with cervical cancer who undergo radical hysterectomy followed by pelvic radiotherapy and/or platinum-based chemotherapy to treat the initial disease.

Methods

Data on 380 women who underwent radical hysterectomy at the National Kyushu Cancer Center from January 1997 to December 2013 were reviewed. Main outcome measures were the estimated glomerular filtration rate (eGFR) and monitored abnormal urological findings.

Results

Postoperative eGFR was significantly lower than preoperative eGFR in 179 women with surgery alone and in 201 women with additional pelvic radiotherapy and/or chemotherapy (both P < 0.01). Two types of univariate analyses for eGFR reduction in women after treatment showed that older age, advanced stage, pelvic radiotherapy, and platinum-based chemotherapy were significant variables on both analyses. Two types of multivariate analyses showed that platinum-based chemotherapy or pelvic radiotherapy were associated with impaired renal function (odds ratio 1.96, 95% confidence interval 1.08-3.54 and odds ratio 2.85, 95% confidence interval 1.12-7.24, for the respective analyses). There was a higher rate of bladder wall thickening in women with pelvic radiotherapy had than those without it (17.4% vs. 2.7%, P < 0.01). One serious urological complication (intraperitoneal rupture of the bladder) occurred among women who underwent pelvic radiotherapy (0.6% vs. 0%).

Conclusions

Surgeons should be aware that eGFR is reduced after platinum-based chemotherapy and/or postoperative pelvic radiotherapy. Serious and life-threatening urological complications are rare, but surgeons should be aware of the possibility during the long follow-up.

Improvement in the prognosis of ovarian cancer in the era before addition of molecular targeting therapy

Objective

The prognosis of ovarian cancer has improved because of platinum- and taxane-containing chemotherapy. We investigated the 5-year disease-specific overall survival and prognostic factors of patients with advanced ovarian cancer to elucidate the change in clinical course of ovarian cancer with the advance of chemotherapy for patients who developed relapse in the era before the addition of molecular targeting therapy.

Methods

We reviewed the clinical course of 134 patients with advanced ovarian cancer (FIGO Stage III and IV) treated in the past 11 years (1999-2010). We classified the patients into two groups: those who had been diagnosed with ovarian cancer from 1999 to 2005 (Group A) and those who had been diagnosed from 2006 to 2010 (Group B). We compared the 5-year disease-specific overall survival and median survival rates between these two groups. We also investigated the prognostic factors of 104 patients who developed relapse.

Results

The 5-year disease-specific overall survival rate was significantly higher in Group B than A (67.0% vs. 38.6%; P = 0.032). Chemotherapy containing pegylated liposomal doxorubicin hydrochloride, non-clear cell adenocarcinoma and intestinal resection were independent prognostic factors.

Conclusions

The induction of new chemotherapeutic drugs and the increased variation of second- or third-line chemotherapy affected the improvement in overall survival of patients with advanced epithelial ovarian cancer.

Rhabdomyosarcoma Originating From an Ovarian Immature Teratoma

We report a rare case with unique histologic findings in the extra-abdominal metastases from an ovarian immature teratoma in a 33-year-old Japanese woman. The primary ovarian tumor was a grade 2 immature teratoma that contained a small aggregate of recognizable rhabdomyoblasts in addition to other immature and mature teratomatous elements. After three courses of chemotherapy, metastatic tumors were identified in the para-aortic area and a right cervical lymph node. Histologically, the para-aortic tumor was predominantly a typical embryonal rhabdomyosarcoma with minor foci of mature teratoma, whereas the cervical tumor consisted only of mature teratomatous elements without any evident immature elements. Int J Surg Pathol 2(3):245-250, 1995

Immune thrombocytopenia associated with solid cancer

We describe a case of immune thrombocytopenia (ITP) associated with ovarian cancer. At the patient's first visit to hospital, high platelet-associated IgG and low platelet count (74 × 10(9)/L) were noted on blood test. She was diagnosed as having ITP complicated by ovarian cancer. Four days after surgery, the platelet count had increased to within the normal range. This is the first report of a patient with ITP complicated by ovarian cancer in which the platelet count reverted to normal soon after surgery for the ovarian cancer. We also investigated the characteristics of similar solid cancers with ITP at National Kyushu Cancer Center, Fukuoka, Japan.

Early Identification of Asymptomatic Pulmonary Embolism Proximal to the Subsegmental Arteries After Gynecologic Surgery

Few studies have assessed whether cases of asymptomatic pulmonary embolism (PE) in the early postoperative phase are subsegmental versus more proximal. In this study, we investigated whether asymptomatic PE occurring just after gynecologic surgery was subsegmental, and we examined the background characteristics of patients who experienced PE within 2 months postoperatively. All hospital records were reviewed, yielding a total of 2052 women who had undergone surgeries performed by the gynecologic oncology team between 2003 and 2013 in the National Kyushu Cancer Center. Asymptomatic and symptomatic postoperative PE cases diagnosed by multidetector computed tomography angiography or lung scan were identified; after excluding 2 cases of preoperative PE, there were 15 (0.73%) cases of postoperative PE among 2050 women. Of the 15 cases, 9 (60%) were diagnosed on postoperative day 1 or 2. Of the 9 women, 4 had no or minor symptoms/signs other than decreased oxygen saturation as measured by pulse oximetry (Spo 2), and PE was segmental or more proximal in 3 cases. Only 1 of the 9 cases showed dyspnea. The remaining 4 cases showed dizziness or perspiration, suggesting PE. Univariate analysis showed age, operation time, hypertension, and preoperative d-dimer elevation to be associated with postoperative PE. Multivariate analysis demonstrated that a high (≥ 1 µg/mL) preoperative d-dimer level was associated with postoperative PE (odds ratio, 6.331; 95% confidence interval, 1.567-25.589). Most asymptomatic PE cases occurring within 2 days postoperatively were segmental or more proximal. Identification of early, asymptomatic postoperative PE may be clinically significant because most of these emboli are proximal to the subsegmental arteries.

Prognostic significance of the treatment-free interval in patients with recurrent endometrial cancer

OBJECTIVE

To identify prognostic factors of recurrent endometrial cancer, and clarify whether the treatment-free interval (TFI) predicts outcome in a wide spectrum of patients.

STUDY DESIGN

The clinical data of 60 patients treated for recurrent stage I-IV endometrial cancer between 1997 and 2012 were reviewed retrospectively. The Kaplan-Meier method and Cox regression analysis were used to estimate overall survival (OS) following recurrence and determine the factors influencing outcomes.

RESULTS

The median age at initial treatment was 59 (range 38-80) years and the median post-recurrence overall survival time was 40.0 (range 1.8-156.7) months. Multivariate analysis showed lymph node metastasis (hazard ratio (HR) 2.80; 95% confidence interval (95%CI) 1.29-6.09; p=0.009), TFI (HR 0.33; 95% CI 0.15-0.76; p=0.008), and symptomatic recurrence (HR 2.31, 95% CI 1.11-4.83, p=0.0025) were independent prognostic factors. Patients whose tumors recurred after a TFI≥12 months had better response rates than did those with a TFI<12 months (p<0.001).

CONCLUSION

TFI is a significant prognostic factor in recurrent endometrial cancer. Furthermore, the effect of chemotherapy on recurrent endometrial cancer is probably influenced by the duration of TFI.

Potential impact of combined high- and low-risk human papillomavirus infection on the progression of cervical intraepithelial neoplasia 2

AIM

Few studies have examined the effect of combined low-risk human papillomavirus (LR-HPV) and high-risk human papillomavirus (HR-HPV) infection on the progression of cervical intraepithelial neoplasia (CIN)2 to CIN3. This multi-institutional prospective cohort study investigated the risk of progression of CIN2 with various combinations of HR-HPV and LR-HPV infection.

METHODS

Between January 2007 and May 2008, 122 women with CIN2 (aged 20-50 years) from 24 hospitals throughout Japan were enrolled in the study. Ninety-three women were analyzed after a 2-year follow-up with cytology, colposcopy, HR-HPV testing and HPV genotyping. Colposcopy-directed biopsy was performed at entry and the end of this study, or when disease progression was suspected.

RESULTS

Among 93 women with CIN2, 87 (93.5%) had HR-HPV infection. Among these 87 cases, 24 (27.6%) progressed to CIN3 and 49 (56.3%) regressed. None of the six women with CIN2 without HR-HPV infection progressed. The progression rate was significantly lower in women with combined HR-HPV and LR-HPV infection (3/28, 10.7%) than in those with HR-HPV infection only (21/59, 35.6%; P = 0.016). Multivariate analyses showed that CIN2 progression in women with HR-HPV infection was negatively associated with LR-HPV co-infection (hazard ratio = 0.152; 95% confidence interval [CI] = 0.042-0.553). CIN2 regression was positively associated with LR-HPV co-infection (odds ratio = 4.553; 95% CI = 1.378-15.039).

CONCLUSION

The risk of CIN2 progression is low in women with combined infection of HR-HPV and LR-HPV. The finding may be useful for management of women diagnosed with CIN2.

Reassessment of the utility of frozen sections in endometrial cancer surgery using tumor diameter as an additional factor

OBJECTIVE

The purpose of this study was to improve the reliability of frozen section with the use of tumor diameter (TD) as an additional factor and intraoperatively to identify a subgroup of early endometrial cancers that would not require lymphadenectomy.

STUDY DESIGN

Data for 228 patients who underwent surgery with frozen section were analyzed retrospectively. Lymphadenectomy was performed in 86% of patients; the nodes were positive in 8%.

RESULTS

The accuracy of frozen section for myometrial invasion, grade, and low-risk prediction significantly increased with decreasing TD (P = .036) and was 98%, 95%, and 95%, respectively, when the TD was ≤3 cm. Patients with a TD of ≤2 cm and patients with a TD of 2-3 cm who had low-risk predictors had no nodal metastasis; patients with a TD of 2-3 cm who had intermediate-high risk predictors and a TD of >3 cm with any level of risk predictors were at risk of nodal metastases.

CONCLUSION

When the TD was ≤3 cm, the low-risk group that is defined by frozen section can be predicted accurately and safely to remain lymph-node metastasis free.

Postoperative pulmonary embolism including asymptomatic cases in gynecologic oncology

INTRODUCTION

So far, there has been no report addressing the actual rate of asymptomatic pulmonary embolism (PE). The present study was conducted to clarify the incidence and the characteristics of postoperative PE including asymptomatic cases in gynecologic oncology.

METHODS

A total of 2107 gynecologic surgery cases that were performed from January 1996 to December 2006 at the National Kyushu Cancer Center were included. Pulmonary embolism was diagnosed using a lung scan, multi-detector row computed tomography, or pulmonary angiography. The clinical factors, including prophylaxis, were analyzed by univariate and multivariate analyses.

RESULTS

PE was diagnosed in 45 patients (2.14%). Six (13.3%) of the 45 patients had respiratory symptoms or signs, and 16 patients (35.6%) had no symptoms or signs except for a SpO2 level decrease. PE was diagnosed within 4 days after the surgery in 42 patients (93.3%). There were 1 massive, 2 recurrent, and no fatal PEs. A multivariate analysis demonstrated the incidence of PE to be associated with age (odds ratio, 1.957; 95% confidence interval, 1.497-2.559), operation time (1.664; 1.180-2.346), body mass index (2.457; 1.735-3.479), surgical position (2.253; 1.468-3.458), and the use of a perioperative intermittent pneumatic compression device (0.389; 0.229-0.659).

CONCLUSIONS

A substantial number of postoperative PEs were occult, and identification of high-risk patients and routine SpO2 level monitoring would reduce the diagnostic delay of PE after gynecologic surgery. Increasing age, longer operation time, and obesity were risks. The use of a perioperative intermittent pneumatic compression device in multimodal conditions might thus prevent PE.

Endometrial scraping cytology in women with extragenital malignancies

OBJECTIVE

To clarify the usefulness of endometrial scraping smears in women with extragenital malignancies.

STUDY DESIGN

A total of 4,335 endometrial scraping smears were obtained during the 5-year period 1995-1999 at the National Kyushu Cancer Center and were retrospectively analyzed regarding extragenital malignancies.

RESULTS

There were 88 cases of extragenital malignancies. Extragenital malignant cells were detected in endometrial smears in 13 cases. The cases consisted of 4 gastric cancers, 4 breast cancers, 2 lung cancers, 1 rectal cancer, 1 gastrointestinal stromal tumor of the small intestine and 1 case of adenocarcinoma of unknown origin. The patients' average age was 52.5 years. The symptoms and signs included abnormal vaginal bleeding, abdominal and lumbar pain, lower limb edema, abdominal mass and neck lymph node swelling. Both ascites and peritoneal dissemination were found in 8 cases. Ten of the 13 cases were diagnosed as of extrauterine origin based on the characteristic cancer cell appearance, the absence of cellular detritus among the poorly differentiated adenocarcinomas and, above all, the morphologic difference between normal endometrial cells and cancer cells.

CONCLUSION

Endometrial scraping smears are useful for detecting extragenital malignant cells that enter the uterine cavity.

An attempt to generate an antitumor effect in the regional lymph nodes against endometrial cancer cells by inducing antitumor cytokines

Phytohemagglutinin-stimulated regional lymph node cells obtained from gynecological cancer patients exerted a significant antiproliferative activity against an endometrial cancer cell line, RL95-2 on a human tumor clonogenic assay, and released a high amount of tumor necrosis factor alpha (TNF alpha), and interferons. The activity was thought to be partly due to released TNF alpha, because RL95-2 was highly sensitive to recombinant TNF alpha. However, anti-TNF alpha failed to inhibit the activity, which indicated the probability of some as yet unclarified participation of cytokines. Therefore, the regional lymph nodes might be used as sites of endogenous cytokine therapy in endometrial cancer patients.

The promotion of invasion through the basement membrane of cervical carcinoma cells by fibronectin as a chemoattractant

An in vitro migration and invasion assay was used as the model system to study the effect of 3T3 fibroblast conditioned medium (FCM) and purified human fibronectin on the invasion of cervical carcinoma cells. The 3T3 FCM significantly enhanced both the migration and the invasion of a cervical carcinoma cell line, HeLa. This enhancement of migration and invasion was inhibited by anti-fibronectin antibody. Purified fibronectin alone enhanced the invasion in a dose-dependent manner for all cervical carcinoma cell lines, HeLa, CAC-1 and TMCC. The pretreatment of cells with cell binding aminosequences, GRGDSP and/or YIGSR blocked the enhancement of cell invasion. The implication of these findings for the invasion of cervical carcinoma is discussed.

Antiproliferative lymphokine production by human peripheral blood lymphocytes and lymph node lymphocytes detected by a modified double layer soft agarose clonogenic assay

The double layer soft agarose clonogenic assay using colony formation of target cells as an endpoint was adapted for the detection of antiproliferative lymphokine production from peripheral blood lymphocytes (PBL) and lymph node lymphocytes (LNL). The colony formation of cervical cancer cell lines, HeLa, CAC-1, and TMCC, in the upper layers was significantly inhibited by the inclusion of either PBL or LNL pretreated with PHA in the lower layers. Without stimulation by PHA, neither resident PBL nor LNL exhibited antiproliferative activity on the tumor cells in the upper layers. The antiproliferative activity against target cells increased in relation to the density of lymphocytes in the lower layers, and was dependent on protein synthesis by lymphocytes. Since the cell to cell contact between the effector cells and target cells is not possible in this assay, the reduction of colony formation should be attributed to soluble factor(s) that were secreted from the lymphocytes. Additionally, an antibody against IFN-gamma neutralized most of the antiproliferative activity, and equivalent levels of IFN-gamma were found to be present in the supernatant of PBL and LNL lower layers by a radioimmunoassay. The double layer soft agarose assay system should thus serve as a useful method for studying antiproliferative lymphokine production by lymphocytes.

Potential of human lymph node cells for antitumor activity mediated by interferon gamma

The soluble antitumor activity of regional lymph node cells obtained from patients with cervical cancer was investigated by using a human tumor clonogenic assay (HTCA). A significant antiproliferative activity of the lymph node cells (LNCs) against a cervical cancer cell line, HeLa cells, was demonstrated by stimulation with either phytohemagglutinin (PHA) or concanavalin A (Con A), but not with interleukin-2 (IL-2). This antiproliferative activity of LNC was found in nonadherent cells, possibly T-cells. By using neutralizing antibody experiments, this activity was found to be attributed to interferon gamma (IFN gamma), but not to tumor necrosis factor (TNF), although both cytokines were produced from LNC. These results indicate that human LNC was able to exert an antiproliferative activity mediated through the cytokines by appropriate stimulation.

[Clinical application of subrenal capsule assay in ovarian cancer]

The 6-day subrenal capsule assay (SRC) in normal immuno-competent mice was used to test the responsiveness of ovarian cancer to combination chemotherapy and assess the usefulness of SRC in clinical application. A total of 18 different patients in 22 different assays were studied. Twenty-one assays (95%) were evaluable. The predictive sensitivity was 50%, the predictive resistance 75% and the predictive total accuracy 55% respectively. Sensitive drugs in repeated assays in four patients were not changed. Etoposide, cyclophosphamide, cis-platin and adriamycin were sensitive. Etoposide was the most sensitive of four drugs. The response rate was 50% in the patients treated with etoposide as the first line chemotherapy and the second line chemotherapy, respectively. Patients who were treated with sensitive drugs in SRC survived longer than the patients treated with cis-platin combined chemotherapy without etoposide. The median survival time was 19 months and the mean progression free interval was 15 months. In the results of this study, the value of SRC was supported by the results of chemosensitivity tests and etoposide seems useful in chemotherapy in ovarian cancer.

Hyperreactio luteinalis in normal singleton pregnancy

A case of hyperreactio luteinalis in a patient with normal singleton pregnancy is reported. The course of pregnancy had been normal until the 24th week of gestation, when the mother developed lower abdominal pain and signs of virilization. She delivered of a normal female infant at 39 weeks' gestation. The baby did not show any signs of masculinization. Serum testosterone, delta 4-androstene-dione, and 5 alpha-dihydrotestosterone of the mother were markedly elevated. They remained high after the delivery but returned to the normal ranges soon after the partial resection of the enlarged ovaries. Reported causes of hyperreactio luteinalis are reviewed. Their maternal serum androgen levels were compared with cases of luteoma of pregnancy.