Two case studies of cardiac arrest occurring in medically fit patients undergoing radical hysterectomy for cervical cancer

We report case histories of two young women who had an intraoperative cardiac arrest, potentially caused by preoperative emotional stress, while undergoing open radical hysterectomy for cervical cancer. Neither had any history of heart disease or other comorbidities. Takotsubo cardiomyopathy, a form of stress cardiomyopathy characterized by acute reversible ventricular dysfunction that can occur in the perioperative period, was the cause in one patient. A vasovagal episode during the exploration of the abdomen was the cause in the other. Successful resuscitation and stabilisation of both patients made it possible to continue the surgery and successfully complete both procedures. Takotsubo cardiomyopathy should be considered in any patient showing significant preoperative stress who has a cardiac arrest, even if there is no preoperative morbidity. It is difficult to differentiate from a vasovagal episode intraoperatively. Surgical and anaesthetic teams should be aware of importance of countering severe preoperative stress.

Genomic analysis of low-grade serous ovarian carcinoma to identify key drivers and therapeutic vulnerabilities

Low-grade serous ovarian carcinoma (LGSOC) is associated with a poor response to existing chemotherapy, highlighting the need to perform comprehensive genomic analysis and identify new therapeutic vulnerabilities. The data presented here represent the largest genetic study of LGSOCs to date (n = 71), analysing 127 candidate genes derived from whole exome sequencing cohorts to generate mutation and copy-number variation data. Additionally, immunohistochemistry was performed on our LGSOC cohort assessing oestrogen receptor, progesterone receptor, TP53, and CDKN2A status. Targeted sequencing identified 47% of cases with mutations in key RAS/RAF pathway genes (KRAS, BRAF, and NRAS), as well as mutations in putative novel driver genes including USP9X (27%), MACF1 (11%), ARID1A (9%), NF2 (4%), DOT1L (6%), and ASH1L (4%). Immunohistochemistry evaluation revealed frequent oestrogen/progesterone receptor positivity (85%), along with CDKN2A protein loss (10%) and CDKN2A protein overexpression (6%), which were linked to shorter disease outcomes. Indeed, 90% of LGSOC samples harboured at least one potentially actionable alteration, which in 19/71 (27%) cases were predictive of clinical benefit from a standard treatment, either in another cancer's indication or in LGSOC specifically. In addition, we validated ubiquitin-specific protease 9X (USP9X), which is a chromosome X-linked substrate-specific deubiquitinase and tumour suppressor, as a relevant therapeutic target for LGSOC. Our comprehensive genomic study highlighted that there is an addiction to a limited number of unique 'driver' aberrations that could be translated into improved therapeutic paths. © 2020 The Pathological Society of Great Britain and Ireland. Published by John Wiley & Sons, Ltd.

Abstract B28: Optimizing DNA processing and ovarian cancer methylation-specific PCR assays for the detection of early-stage ovarian cancer

Background: Ovarian cancer screening has the potential to greatly reduce mortality by shifting the time of diagnosis to an early stage when the tumor is confined to a single site and can be completely cured by surgical removal. Ovarian cancer DNA is present in blood and has a distinct methylation profile that distinguishes it from healthy blood cells, thus making it a target for ovarian cancer diagnosis via a blood test. However, while the presence of this DNA in the blood of cancer patients is well established, low abundance and DNA fragmentation present a barrier to developing clinical applications that target it.

Methods: We are systematically evaluating and optimizing each step of DNA extraction, processing, and analysis to increase the sensitivity of cancer DNA detection by PCR. At the same time, we are developing PCR assays to detect ovarian cancer specific methylation based on a previous tumor and blood screen that identified 73 methylated candidate biomarker regions.

Results: We have found that inhibitors of the PCR reaction introduced into the sample during DNA extraction and bisulphite treatment limit the total amount of DNA that can be analyzed, and thus the sensitivity of the test. Precipitation of the DNA samples prior to PCR analysis removes the inhibitors and increases useable sample volume and thus sensitivity. We have also developed methylation-specific PCR assays for DNA regions that are methylated in ovarian tumor tissue, and unmethylated in white blood cells.

Conclusions: We are progressing our candidate methylated DNA ovarian cancer biomarkers closer to testing in clinical samples. Our results on sample processing and DNA analysis methods to enable ovarian cancer DNA detection are relevant to all cancer types for which cell-free tumor DNA has clinical applications.

Citation Format: Kristina Warton, Nicole Yuwono, Claire Henry, Neville Hacker, Caroline Ford. Optimizing DNA processing and ovarian cancer methylation-specific PCR assays for the detection of early-stage ovarian cancer [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research; 2019 Sep 13-16, 2019; Atlanta, GA. Philadelphia (PA): AACR; Clin Cancer Res 2020;26(13_Suppl):Abstract nr B28.

Sentinel node biopsy in vulvar cancer: A critical appraisal

Since the incorporation of inguinal-femoral lymphadenectomy into the management of patients with vulvar cancer in the mid-20th century, there have been attempts to modify or eliminate the groin dissection to decrease the risk of lower limb lymphedema. Early attempts were significantly flawed and resulted in much unnecessary loss of life because recurrence in an undissected groin is usually fatal. The best compromise yet to decrease the risk of lymphedema is sentinel node biopsy, but accumulated evidence now suggests that the false-negative rate for this procedure, if used for lesions up to 4 cm in diameter, is between 5% and 10%. Most women, properly informed of risks and benefits, are not prepared to take a 1% risk of dying from recurrent vulvar cancer to avoid lymphedema. This is the risk involved, assuming a false-negative rate of 5% and an incidence of positive nodes of 20%. For this reason, sentinel node biopsy should not be considered to be standard practice for patients with early vulvar cancer.

Silencing ROR1 and ROR2 inhibits invasion and adhesion in an organotypic model of ovarian cancer metastasis

OBJECTIVE

Elevated expression of the ROR1 and ROR2 Wnt receptors has been noted in both the tumour and stromal compartments of ovarian cancer patient tissue samples. In vitro studies have suggested these receptors play a role in ovarian cancer metastasis. However, these previous studies have utilised simple 2D in vitro models to investigate cancer cell growth and migration, which does not allow investigation of stromal involvement in Wnt driven metastasis.

AIM

To investigate targeting ROR1 and ROR2 using a primary co-culture 3D model of epithelial ovarian cancer dissemination to the omentum.

METHODS

Primary fibroblasts (NOF) and mesothelial (HPMC) cells were isolated from fresh samples of omentum collected from women with benign or non-metastatic conditions and cultured with collagen to produce a organotypic 3D model. Stable shRNA knockdown of ROR1, ROR2 and double ROR1/ROR2 in OVCAR4 cells were plated onto the 3D model to measure adhesion, or using a transwell to measure invasion. Gene expression changes in primary cells upon OVCAR4 interaction was evaluated using indirect transwell co-culture.

RESULTS

Double knockdown of ROR1 and ROR2 strongly inhibited cell adhesion (p<0.05) and invasion (P<0.05) to the omentum model. ROR2 was up regulated in primary fibroblasts when cultured with OVCAR4 (P=0.05) and ectopic overexpression of ROR2 in NOFs inhibited cell proliferation (P<0.01) but increased cell migration.

CONCLUSION

The combination of ROR1 and ROR2 signalling influences ovarian cancer dissemination to the omentum, however ROR2 may also play a role in stromal activation during metastasis. Therefore, targeting both ROR1 and ROR2 may be a powerful approach to treating ovarian cancer.

Vulvar cancer in high-income countries: Increasing burden of disease

The aim of this study was to assess trends in the age-specific incidence of vulvar cancer in 13 high-income countries satisfying a priori conditions regarding the availability of cancer registry data over a 20-year period; these were Canada, the United States, nine European countries, Australia and Japan. Five-yearly incidence and population at risk were obtained from the International Agency for Research on Cancer's Cancer Incidence in Five Continents for the years 1988-1992 (Volume 7) to 2003-2007 (Volume 10). The 5-yearly average percent change (AvPC) over the period and standardised rate ratios (SRRs) for 2003-2007 versus 1988-1992 were used to assess changes in the age-standardised incidence rates of vulvar cancer for all ages, and for <60 years and 60+ years. During the study period, the 5-yearly AvPC across the 13 countries increased by 4.6% (p = 0.005) in women of all ages, and 11.6% (p = 0.02) in those <60 years. No change was observed in women aged 60+ years (5-yearly AvPC = 0.1%, p = 0.94). The SRR for 2003-2007 versus 1988-1992 was significantly elevated in women <60 years of age (SRR = 1.38, 95% CI: 1.30-1.46), but not in women of 60+ years (SRR = 1.01, 95% CI: 0.97-1.05). The increase in incidence in women <60 years of age drove a significant increase in the overall SRR in women of all ages (SRR = 1.14, 95% CI: 1.11-1.18). Some differences in the specific findings at the individual country level were observed. The findings are consistent with changing sexual behaviours and increasing levels of exposure to human papillomavirus (HPV) in cohorts born around/after about 1950, but younger cohorts offered HPV vaccination are likely to receive some protection against developing vulvar cancer in the future.

Targeting the ROR1 and ROR2 receptors in epithelial ovarian cancer inhibits cell migration and invasion

AIM

In recent years, the Wnt signalling pathway has been implicated in epithelial ovarian cancer and its members have potential as diagnostic, prognostic and therapeutic targets. Here we investigated the role of two Wnt receptor tyrosine kinases (RTKs), ROR1 and ROR2, and their putative ligand, Wnt5a, in ovarian cancer.

METHODS

Immunohistochemistry for ROR2 was performed in a large patient cohort, including benign controls, borderline tumours and epithelial ovarian cancer. In addition, siRNA was used to silence ROR1, ROR2 and Wnt5a individually, and together, in two ovarian cancer cell lines, and the effects on cell proliferation, adhesion, migration and invasion were measured.

RESULTS

ROR2 expression is significantly increased in ovarian cancer patients compared to patients with benign disease. In vitro assays showed that silencing either receptor inhibits ovarian cancer cell migration and invasion, and concurrently silencing both receptors has an even stronger inhibitory effect on proliferation, migration and invasion.

CONCLUSIONS

ROR2 expression is increased in epithelial ovarian cancer, and silencing ROR2 and its sister receptor ROR1 has a strong inhibitory effect on the ability of ovarian cancer cells to proliferate, migrate and invade through an extracellular matrix.

Direct comparison of regulators of calcification between bone and vessels in humans

Calcification is not only physiologically present in bone but is a main pathophysiological process in vasculature, favouring cardiovascular diseases. Our aim was to investigate changes in the expression of calcification regulators during vascular calcification in bone and vasculature. Levels of gene expression of osteoprotegerin (OPG), receptor activator of NF-κB ligand (RANKL), osteopontin (OPN), matrix gla protein (MGP), bone sialoprotein (BSP), SMAD6, and runt-related transcription factor 2 (RUNX2) were determined in bone, aorta, and external iliac artery tissue samples of transplant donors. Histological stages of atherosclerosis (AS) in vessels are defined as "no changes", "intima thickening", or "intima calcification". Patients' bone samples were subgrouped accordingly. We demonstrate that in vessels BSP and OPN expression significantly increased during intima thickening and decreased during intima calcification, whereas the expression of regulators of calcification did not significantly change in bone during intima thickening and intima calcification. At the stage of intima thickening, MGP, OPG, and SMAD6 expression and at stage of intima calcification only MGP expression was lower in bone than in vessel. The expression of BSP and RANKL was regulated in opposite ways in bone and vessels, whereas the expression of MGP, OC, RUNX2, and OPN was regulated in a tissue-specific manner. Our study is the first direct comparison of gene expression changes during AS progression in bone and vessels. Our results indicate that changes in the expression of regulators of calcification in the vessel wall as well as in bone occur early in the calcification process, even prior to deposition of calcium/phosphate precipitation.

Wnt signalling in gynaecological cancers: A future target for personalised medicine?

The three major gynaecological cancers, ovarian, uterine and cervical, contribute a significant burden to global cancer mortality, and affect women in both developed and developing countries. However, unlike other cancer types that have seen rapid advances and incorporation of targeted treatments in recent years, personalised medicine is not yet a reality in the treatment of gynaecological cancers. Advances in sequencing technology and international collaborations and initiatives such as The Cancer Genome Atlas are now revealing the molecular basis of these cancers, and highlighting key signalling pathways involved. One pathway which plays a role in all three cancer types, is the Wnt signalling pathway. This complex developmental pathway is altered in most human malignancies, and members of this pathway, particularly the recently linked ROR receptor tyrosine kinases may be attractive future therapeutic targets. This review provides an up-to-date summary of research into Wnt signalling and ovarian, uterine and cervical cancers, and discusses the potential of the Wnt pathway as a future target for personalised medicine in gynaecological cancers.

Abstract B23: P1 glycosphingolipid is expressed on ovarian cancer cells recognized by naturally occurring anti-P1 antibodies

Using printed glycan array we have recently demonstrated that natural occurring anti-glycan antibodies to chemically synthesized P1 trisaccharide and Pk are significantly reduced in ovarian cancer patients (1). These findings were successfully validated with two in-house developed independent glycan-based immunoassays (ELISA and suspension array) (2). Both candidates are glycosphingolipids (GSL) and share similar structural motifs. P1 naturally occurs as a pentasaccharide belonging to the neolacto series. Here we aim to a) validate our findings in an independent validation cohort, b) identify the immunoglobulin subtype causing this observation, c) identify the corresponding naturally expressed P1 antigen in cancer cells, and c) purify human anti-P1 antibodies from cancer ascites.

A cohort of 155 blood plasma samples comprising healthy controls and patients with cancer of the ovary, tube and peritoneum was profiled for P1 antibodies using monoplex suspension array. GSL isolated from fresh cancer tissue were PVDF blotted and extracted enzymatically following purification of glycan alditols. Glycan structures were identified by negative-mode LC-ESI-MS. P1-expressing cancer cell lines were detected using flow cytometry. Human anti-P1 antibodies were affinity purified from cancer ascites and studied using glycan-based immunoassays.

Glycan-based immunoassay profiling of validation cohort confirmed our recent findings, reduced anti-P1 antibody levels in cancer patients compared to healthy controls (p=0.0002). We could also demonstrate that this observation was caused by IgM subtypes and not IgG. Corresponding P blood group- related antigens (GSL) including P1 and Pk were identified in cancer tissue samples. Flow cytometry revealed that a serous ovarian cancer cell line is positive for P1 (up to 46%). We further demonstrate that affinity purified anti-P1 antibodies bind naturally expressed P1 GSL on ovarian cancer cell surface. Monoclonal as well as affinity purified anti-P1 antibodies applied to identify P1-expressing cancer cell lines revealed high specificity to P1 shown by inhibition assay and glycan-based immunoassays.

In this study we demonstrated anti-P1 IgM levels are decreased in a significant number of cancer patients and that the GSL P1 is present on ovarian/ peritoneal cancer cells, both in tissue and immortalized cell lines. We can therefore conclude that P1 is an epitope for human circulating anti-glycan antibodies. These results are in concordance with our previous findings and support the presence of a new antigenic tumor-associated GSL in ovarian cancer. The study of the molecular profile leading to the presence of P1 in ovarian cancer cells is presently under investigation.

1. Jacob F, et al. (2012) Serum antiglycan antibody detection of nonmucinous ovarian cancers by using a printed glycan array. International Journal of Cancer 130(1):138-146.

2. Pochechueva T, et al. (2011) Comparison of printed glycan array, suspension array and ELISA in the detection of human anti-glycan antibodies. Glycoconjugate journal 28(8-9):507-517.

Citation Format: Francis Jacob, Merrina Anugraham, Alam Shahidul, Nicolai Bovin, Nicole Packer, Neville Hacker, Viola Heinzelmann-Schwarz. P1 glycosphingolipid is expressed on ovarian cancer cells recognized by naturally occurring anti-P1 antibodies. [abstract]. In: Proceedings of the AACR Special Conference on Advances in Ovarian Cancer Research: From Concept to Clinic; Sep 18-21, 2013; Miami, FL. Philadelphia (PA): AACR; Clin Cancer Res 2013;19(19 Suppl):Abstract nr B23.

Stage at diagnosis and ovarian cancer survival: evidence from the International Cancer Benchmarking Partnership

OBJECTIVE

We investigate what role stage at diagnosis bears in international differences in ovarian cancer survival.

METHODS

Data from population-based cancer registries in Australia, Canada, Denmark, Norway, and the UK were analysed for 20,073 women diagnosed with ovarian cancer during 2004-07. We compare the stage distribution between countries and estimate stage-specific one-year net survival and the excess hazard up to 18 months after diagnosis, using flexible parametric models on the log cumulative excess hazard scale.

RESULTS

One-year survival was 69% in the UK, 72% in Denmark and 74-75% elsewhere. In Denmark, 74% of patients were diagnosed with FIGO stages III-IV disease, compared to 60-70% elsewhere. International differences in survival were evident at each stage of disease; women in the UK had lower survival than in the other four countries for patients with FIGO stages III-IV disease (61.4% vs. 65.8-74.4%). International differences were widest for older women and for those with advanced stage or with no stage data.

CONCLUSION

Differences in stage at diagnosis partly explain international variation in ovarian cancer survival, and a more adverse stage distribution contributes to comparatively low survival in Denmark. This could arise because of differences in tumour biology, staging procedures or diagnostic delay. Differences in survival also exist within each stage, as illustrated by lower survival for advanced disease in the UK, suggesting unequal access to optimal treatment. Population-based data on cancer survival by stage are vital for cancer surveillance, and global consensus is needed to make stage data in cancer registries more consistent.

Comparison of printed glycan array, suspension array and ELISA in the detection of human anti-glycan antibodies

Anti-glycan antibodies represent a vast and yet insufficiently investigated subpopulation of naturally occurring and adaptive antibodies in humans. Recently, a variety of glycan-based microarrays emerged, allowing high-throughput profiling of a large repertoire of antibodies. As there are no direct approaches for comparison and evaluation of multi-glycan assays we compared three glycan-based immunoassays, namely printed glycan array (PGA), fluorescent microsphere-based suspension array (SA) and ELISA for their efficacy and selectivity in profiling anti-glycan antibodies in a cohort of 48 patients with and without ovarian cancer. The ABO blood group glycan antigens were selected as well recognized ligands for sensitivity and specificity assessments. As another ligand we selected P(1), a member of the P blood group system recently identified by PGA as a potential ovarian cancer biomarker. All three glyco-immunoassays reflected the known ABO blood groups with high performance. In contrast, anti-P(1) antibody binding profiles displayed much lower concordance. Whilst anti-P(1) antibody levels between benign controls and ovarian cancer patients were significantly discriminated using PGA (p=0.004), we got only similar results using SA (p=0.03) but not for ELISA. Our findings demonstrate that whilst assays were largely positively correlated, each presents unique characteristic features and should be validated by an independent patient cohort rather than another array technique. The variety between methods presumably reflects the differences in glycan presentation and the antigen/antibody ratio, assay conditions and detection technique. This indicates that the glycan-antibody interaction of interest has to guide the assay selection.

No benefit from combining HE4 and CA125 as ovarian tumor markers in a clinical setting

OBJECTIVE

About 70% of epithelial ovarian cancer patients (EOC) are diagnosed at advanced stage with a five-year survival rate of only 30%. Whilst CA125 detects peritoneally-spread disease, it has limited sensitivity for early cancers, many of which are potentially curable.

METHODS

We compared the new commercially available tumor marker HE4 with CA125 individually, in combination, within the risk of malignancy index (RMI) and the newly defined risk of malignancy algorithm (ROMA). Our prospectively-collected cohort of 160 patients consisted of healthy controls, benign diseases, and borderline tumors/adenocarcinomas of ovarian, tubal, peritoneal and endometrial origin. HE4 and CA125 were measured in serum using standardized ELISA.

RESULTS

Both markers showed similar diagnostic performance in the detection of EOC at clinically defined thresholds (CA125 35U/ml; HE4 70pM) but HE4 was not elevated in endometriosis. Comparison of non-malignant diagnoses (n=71) versus early stage ovarian and tubal cancers (n=19) revealed that HE4 and ROMA displayed the best diagnostic performance (AUC 0.86/0.87, specificity 85.9%/87.3% and sensitivity 78.9%/78.9%, respectively). Whilst RMICA125 detects peritoneal cancer better than all other models (AUC 0.99, specificity 97.2%, sensitivity 80.0%), there is no other detection benefit from RMI compared to HE4 alone or included in ROMA.

CONCLUSIONS

The major advantage of HE4 lies in its specificity and improved detection of borderline tumors and early stage ovarian and tubal cancers. HE4 is superior to CA125 with or without RMI and ROMA indices. However, we see no benefit from combining both markers in clinical practice.

Pathologic audit of 164 consecutive cases of vulvar intraepithelial neoplasia

There are 2 types of vulvar intraepithelial neoplasia (VIN): warty-basaloid and differentiated. Differentiated VIN is uncommon and seldom diagnosed prior to carcinoma and, traditionally, is not graded. There are currently 3 grading systems for warty-basaloid VIN: the World Health Organization (WHO) 3 grade system of VIN 1-3, a 2 grade system of low and high grade vulvar intraepithelial lesions, and the revised International Society for the Study of Vulvovaginal Disease (ISSVD) classification which has no grading of VIN. According to the ISSVD, VIN 1 should be abolished and VIN 2 and 3 combined into a single category, simply termed warty-basaloid VIN. To determine the best system for grading warty-basaloid VIN and learn more about differentiated VIN, we reviewed the pathology of 164 consecutive women with VIN. Of these, 134 (82.3%) had warty-basaloid VIN, 29 (18.2%) had differentiated VIN, and 1 had both. Of warty-basaloid VIN cases, 4 had VIN 1, 13 VIN 2, and 118 VIN 3 when graded according to the WHO. All VIN 1 occurred in condylomata acuminata. VIN 2 and 3 were distinguished only by degree of abnormality. Differentiated VIN was diagnosed before SCC in only 7 cases (26.7%). Because the only VIN 1 cases seen were in condylomata acuminata and because VIN 2 and 3 were difficult to distinguish and there appears little clinical reason to do so, our study supports the ISSVD proposal that VIN 1 be abolished and VIN 2 and 3 be combined. There needs to be more clinical awareness of vulvar conditions, so that differentiated VIN is biopsied before cancer has supervened.

Systematic aortic and pelvic lymphadenectomy versus resection of bulky nodes only in optimally debulked advanced ovarian cancer: a randomized clinical trial

BACKGROUND

The role of systematic aortic and pelvic lymphadenectomy in patients with optimally debulked advanced ovarian cancer is unclear and has not been addressed by randomized studies. We conducted a randomized clinical trial to determine whether systematic aortic and pelvic lymphadenectomy improves progression-free and overall survival compared with resection of bulky nodes only.

METHODS

From January 1991 through May 2003, 427 eligible patients with International Federation of Gynecology and Obstetrics (FIGO) stage IIIB-C and IV epithelial ovarian carcinoma were randomly assigned to undergo systematic pelvic and para-aortic lymphadenectomy (n = 216) or resection of bulky nodes only (n = 211). Progression-free survival and overall survival were analyzed using a log-rank statistic and a Cox multivariable regression analysis. All statistical tests were two-sided.

RESULTS

After a median follow-up of 68.4 months, 292 events (i.e., recurrences or deaths) were observed, and 202 patients had died. Sites of first recurrences were similar in both arms. The adjusted risk for first event was statistically significantly lower in the systematic lymphadenectomy arm (hazard ratio [HR] = .75, 95% confidence interval [CI] = 0.59 to 0.94; P = .01) than in the no-lymphadenectomy arm, corresponding to 5-year progression-free survival rates of 31.2 and 21.6% in the systematic lymphadenectomy and control arms, respectively (difference = 9.6%, 95% CI = 1.5% to 21.6%), and to median progression-free survival of 29.4 and 22.4 months, respectively (difference = 7 months, 95% CI = 1.0 to 14.4 months). The risk of death was similar in both arms (HR = 0.97, 95% CI = 0.74 to 1.29; P = .85), corresponding to 5-year overall survival rates of 48.5 and 47%, respectively (difference = 1.5%, 95% CI = -8.4% to 10.6%), and to median overall survival of 58.7 and 56.3 months, respectively (difference = 2.4 months, 95% CI = -11.8 to 21.0 months). Median operating time was longer, and the percentage of patients requiring blood transfusions was higher in the systematic lymphadenectomy arm than in the no-lymphadenectomy arm (300 versus 210 minutes, P<.001, and 72% versus 59%; P = .006, respectively).

CONCLUSION

Systematic lymphadenectomy improves progression-free but not overall survival in women with optimally debulked advanced ovarian carcinoma.

Post-treatment sexual adjustment following cervical and endometrial cancer: a qualitative insight

There is an increasing number of long-term survivors of cervical and endometrial cancer for whom quality of life is of major importance. We interviewed 20 women (aged 19-64) to explore the dynamics and components of post-treatment sexual adjustment and its impact on quality of life. Stratification by treatment received (surgery alone, surgery plus external-beam radiation, surgery plus brachytherapy, and surgery plus external-beam radiation and brachytherapy) and time since treatment (immediately post treatment, during the next 2 years and thereafter) was undertaken, to ensure representation of all relevant experiences and views, and to allow time for any long-term side effects to appear. The NUD*IST software (Non-numerical Unstructured Data by Indexing, Searching and Theorising) was used to assist with the coding of audio-taped, transcribed interviews and to search for themes and segments. While the data supported findings reported in the literature, important new themes emerged in the course of the qualitative analysis. These included: (a). issues related to being 'feminine', (b). the role of intimacy in post-treatment adjustment and (c). the importance of communication between health professionals, patients and partners. A model is presented that integrates these issues and highlights the need for effective interventions to improve post-treatment outcomes. The provision of information, support and modification of rehabilitation devices is suggested.

Biological markers in pT1 and pT2 ovarian cancer with lymph node metastases

OBJECTIVE

A relatively high incidence of pelvic and paraaortic lymph node metastases is found in patients with pT1 and pT2 ovarian cancer. This paper investigates the clinicomorphological parameters and the expression of various biological markers in these tumors in order to define possible risk factors for lymphatic dissemination.

METHODS

In a retrospective study we identified 51 patients with pT1 and pT2 ovarian cancer. All patients underwent total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, and systemic pelvic +/- paraaortal lymphadenectomy. The incidence of lymph node metastases in these patients and the clinicomorphological parameters of their tumors were examined. Immunohistochemistry was used to determine the expression levels of the cell proliferation marker Ki-67, the cell adhesion molecules CD44s and CD44v6, and the oncoprotein HER2/neu of the tumors and their respective lymph node metastases.

RESULTS

Lymph node involvement was found in 5 of 26 patients with pT1 ovarian cancer and in 6 of 25 patients with pT2 ovarian cancer. Serous adenocarcinoma was associated with a significantly higher incidence of lymph node metastases than other histological types (chi(2) = 4.7, P = 0.03). No correlation was found between tumor grade and the lymph node status. High Ki-67 expression was significantly correlated with spread to the lymph nodes (chi(2) = 4.2, P = 0.04), whereas expression of CD44s, CD44v6, and HER2/neu was not related to the lymph node status. Survival analyses showed no difference in disease-free and overall survival in patients with lymph node metastases compared to those without lymph node metastases. No association was seen among histological type, tumor grade, and immunohistochemically detected Ki-67, CD44s, CD44v6, and HER2/neu expression on the one hand and disease-free and overall survival on the other hand.

CONCLUSIONS

Our data suggest that in early stage ovarian cancer the serous histological type and tumors showing a high Ki-67 expression carry a high risk of lymph node metastases. With respect to prognosis our data showed a minor role for Ki-67, CD44s, CD44v6, and HER2/neu expression and the occurrence of lymph node metastases in pT1 and pT2 ovarian cancer.

Incidence of microsatellite instability in synchronous tumors of the ovary and endometrium

PURPOSE

Families with hereditary nonpolyposis colorectal cancer (HNPCC) have an increased lifetime risk of endometrial (40%) and ovarian (10%) carcinomas. Endometrial and ovarian carcinomas from members of these families frequently display a mutator phenotype as manifest by high levels of microsatellite instability (MSI-H). Microsatellite instability (MSI) occurs in 17-32% of sporadic endometrial carcinomas and 3-17% of sporadic ovarian carcinomas. We hypothesized that there might be a higher rate of MSI in tumors from women with synchronous primary carcinomas of the ovary and endometrium.

EXPERIMENTAL DESIGN

We identified 52 cases of synchronous tumors of the ovary and endometrium from the databases of four gynecological oncology units. Archival material and clinical data were available on 45 of these patients. We examined DNA extracted from ovarian and endometrial tumor tissue for MSI using DNA extracted from normal tissue of that patient as a germ-line DNA control. MSI was assessed using a panel of five standard microsatellite markers: D2S123, D5S346, D17S250, BAT25, and BAT26. MSI-H was defined by more than two markers being positive. Low-level MSI (MSI-L) was defined as one or two markers positive and microsatellite stable (MSS) was defined as no markers positive.

RESULTS

The 45 patients had a median age at diagnosis of 53 years. Of a total of 134 samples analyzed, only three samples (3.3%) were MSI-H. No patient had high levels of MSI in both ovarian and endometrial tumors. One ovarian carcinoma had five of five markers positive with the corresponding endometrial carcinoma being MSI-L. Two endometrial carcinomas were MSI-H, and the corresponding ovarian carcinomas were MSI-L and MSS, respectively. Seven ovarian tumors and seven endometrial tumors were MSI-L. The majority of patients had early-stage ovarian carcinoma [International Federation of Gynecology and Obstetrics (FIGO) stage I, 44.4%; stage II, 26.7%; and stage III, 26.6%]. Eighty-two % of the endometrial primaries were FIGO stage I. Progression-free survival was significantly better for patients with synchronous primaries than those presenting with ovarian carcinoma alone [adjusted hazards ratio, 1.94; P = 0.023; 95% confidence interval, 1.096-3.44].

CONCLUSION

Synchronous primary carcinomas of the ovary and endometrium are unlikely to be part of the HNPCC syndrome unless the family history is in keeping with the modified Amsterdam criteria.

Fertility effects of cancer treatment

BACKGROUND

Cancer sufferers are a subfertile group, and most treatments have the potential to adversely affect gonadal function. As cancer treatment becomes more effective and survival rates improve there are more cancer survivors in the reproductive age group for whom parenting is an important consideration.

OBJECTIVE

This article outlines the effects on fertility of cancer treatments and techniques to minimise the risk of infertility.

DISCUSSION

The overall prospects for younger cancer sufferers to either retain their fertility or have genetic offspring is now better than ever before, due to advances in assisted reproductive technology, the appropriate use of fertility sparing surgery and other techniques to reduce the toxicity of therapy on the reproductive organs. These advances raise new moral and ethical concerns that must be considered before advising cancer sufferers of the options for preserving reproductive capacity.

Reproductive and other factors and risk of epithelial ovarian cancer: an Australian case-control study. Survey of Women's Health Study Group

Of the few factors known to be associated with epithelial ovarian cancer, the most consistently observed relate to women's reproductive function, although even here uncertainties remain. We have undertaken a case-control study involving personal interviews with over 1,600 women, the largest of its kind to date, to investigate further the associations between women's reproductive histories and other factors and the development of ovarian cancer. Cases were drawn from women diagnosed with epithelial ovarian cancer in 3 Australian states, Queensland, New South Wales and Victoria, between August 1990 and December 1993, and controls were drawn at random from the electoral roll, stratified by age and geographic region. Trained interviewers administered standard questionnaires to obtain detailed information about women's reproductive and contraceptive histories and other factors of interest, such as smoking and family history of ovarian or other cancer. Findings were based on data from 824 cases and 860 controls and confirmed the reduced risk of ovarian cancer associated with increasing parity and duration of use of the oral contraceptive pill (OCP), hysterectomy and tubal ligation. The strongest association of all was seen with use of the OCP for 10 years or more. An inverse association between ovarian cancer and age at first birth was observed, but this was not statistically significant. There were no associations between development of ovarian cancer and number of incomplete pregnancies, use of hormone replacement therapy or menstrual history. Among other factors considered, education after leaving school was negatively associated and high body mass index, family history of ovarian cancer, use of talc in the abdominal or perineal region and smoking were positively associated with occurrence of ovarian cancer.

Chronic cutaneous damage after accidental exposure to ionizing radiation: the Chernobyl experience

BACKGROUND

The hazards of acute radiation exposure are well known. Bone marrow failure from total body gamma or neutron irradiation is the most clinically relevant aspect of acute radiation disease. With nonhomogeneous exposure, as is characteristic in accidents, other organ systems, such as the skin, may be more important in determining clinical prognosis. This became obvious in the two worst radiation accidents since 1945, the Chernobyl accident in April 1986 and the Goiania accident in September 1987.

OBJECTIVE

Our purpose was to describe the characteristic chronic sequelae of accidental cutaneous radiation in a group of patients who survived the Chernobyl nuclear power plant accident.

METHODS

Fifteen patients with the delayed type of the cutaneous radiation syndrome were examined between September 1991 and January 1992. All patients had a history of acute radiation disease. The exposure pattern was characterized by partial body exposure with high doses of beta and gamma irradiation from radioactive water, steam, or dust.

RESULTS

Radiation-induced lesions were confined primarily to the legs and distal arms, but sometimes involved up to 50% of the total body surface. In addition to telangiectases, radiation keratoses, and radiation ulcers, hemangiomas, hematolymphangiomas, splinter hemorrhages in the distal nail bed, lentiginous hyperpigmentation, and severe subcutaneous fibrosis were noted. No malignant transformation could be detected. Associated diseases included cataracts, chronic hepatitis, and recalcitrant bacterial and herpesvirus infections.

CONCLUSION

After accidental partial body exposure to high doses of beta and gamma irradiation, the predominant involvement of the skin, described as the cutaneous radiation syndrome, can become the characteristic feature. This causes longlasting, serious diagnostic and therapeutic problems.

Cisplatin-based chemotherapy for ovarian germ cell malignancies: the Australian experience

PURPOSE

This study was performed to evaluate the Australian experience with cisplatin-based treatment of ovarian germ cell tumors (OGCT) with respect to survival and toxicity of treatment.

PATIENTS AND METHODS

A retrospective review was undertaken based on a standardized questionnaire, which was sent to all major gynecologic oncology centers in Australia.

RESULTS

Data on 58 patients were obtained. Overall survival at 5 years for all patients was 87%. There was one death from disease among 14 patients with dysgerminoma, and four deaths from disease among 44 patients with nondysgerminomas. Cisplatin-based chemotherapy was associated with a low incidence of serious complications, with only one treatment-related death (from bleomycin-induced respiratory failure).

CONCLUSION

Our large series demonstrates that cisplatin-based chemotherapy is highly effective for patients with OGCT. Although direct comparisons cannot be made, the survival of our patients with advanced tumors was comparable to that seen in male germ cell tumors, rather than inferior as is commonly believed. Future studies should aim to refine treatment to minimize toxicity, while further increasing curability.

Positive groin lymph nodes in superficial squamous cell vulvar cancer. A Gynecologic Oncology Group Study

The term microinvasive carcinoma is inappropriate when applied to all vulvar cancers less than or equal to 5 mm thick because approximately 50% of vulvar carcinomas are no thicker than 5 mm and 20% of those superficial tumors metastasize to the lymph nodes. The significant predictors of groin node metastases in patients with superficial vulvar cancer are tumor thickness, histologic grade (proportion of undifferentiated tumor pattern), capillary-like space involvement with the tumor, clitoral or perineal location, and clinically suspicious nodes, according to the linear logistic model analysis of clinicopathologic data in 272 women. No lymph node metastases occurred in approximately one fourth of patients with a combination of low-risk factors: no clinically suspicious nodes, negative capillary-like space, and nonmidline vulvar cancers that were either grade 1 and 1 to 5 mm thick or grade 2 and 1 to 2 mm thick. In contrast, all 10 patients with clinically suspicious nodes and grade 4 tumors had positive groin nodes. The risk of lymph node metastases is best determined by simultaneous evaluation of all risk factors rather than a single factor such as tumor thickness.

Phase II trial of piperazinedione in patients with advanced or recurrent uterine sarcoma. A Gynecologic Oncology Group study

Twenty patients with advanced or recurrent uterine sarcoma no longer amenable to control with surgery and/or radiotherapy were entered into study by Gynecologic Oncology Group institutions to receive piperazinedione 9 mg/m2 intravenously every 3 weeks. One patient was deemed to be ineligible for study. Among the 19 evaluable patients, only one response was observed, a partial response in a patient with leiomyosarcoma. Adverse effects consisted primarily of myelosuppression and were tolerable. Piperazinedione at the dose and schedule tested appears to have little activity against uterine sarcomas.

Activation of peritoneal lymphocyte cytotoxicity in patients with ovarian cancer by intraperitoneal treatment with Corynebacterium parvum

Following an intensive course of combination chemotherapy, patients with minimal residual ovarian cancer were treated with increasing concentrations of intraperitoneal Corynebacterium parvum to assess whether or not natural killer (NK) cells could be activated. Immunotherapy was administered every 2 weeks, initially with a dose of 250 micrograms/m2, which was progressively escalated as tolerated. Each treatment induced a peritoneal cellular exudate which consisted primarily of neutrophils 48h after injection and of lymphocytes and macrophages at 7 and 14 days after injection. Peritoneal NK cytotoxicity increased during treatment in six of nine patients tested. NK precursor cells susceptible to in vitro activation with either C. parvum or interferon became detectable during treatment in all five patients tested. In four of these five, precursors were detected prior to the development of enhanced spontaneous NK activity. In four patients serially studied, peripheral blood NK activity increased during therapy. These results indicate that regional intraperitoneal therapy with C. parvum can enhance nonspecific antitumor cytotoxic mechanisms within the peritoneal cavity.

An incremental-dose combined oestrogen-progestogen oral contraceptive: effects on body weight, blood pressure, and biochemical parameters

An evaluation is presented of the effects of an incremental-dose combined oestrogen-progestogen contraceptive (0.05 mg ethinyl oestradiol throughout the cycle plus d-norgestrel 0.05 mg for the first 11 days and 0.125 mg for the subsequent 10 days). The majority of women showed weight changes less than 1.0 kg; a weight gain in excess of 2 kg was observed in 11.4% and a similar loss in 14.3%. The net change in blood pressure after 12 months was a slight reduction; no excessive elevation of pressure was recorded. Although no significant change in glucose tolerance was noted, triglyceride levels became progressively elevated; the increase in cholesterol levels were observed mainly in the second half of the cycle. Changes occurred in some but not all haematologic parameters: a significant increase in plasminogen level and decrease in activated prothrombin time; factors 7, 9 and 10 were progressively increased, whereas factors 5, 8, fibrinogen and antithrombin activity remained unaltered. This new preparation provides effective contraception with satisfactory cycle control and body weight changes. It is particularly useful in women who require additional oestrogen.

Bromocriptine, methyl testosterone and placebo for inhibition of physiological lactation: a controlled study

Lactation occurs when the fully developed breast is released from the inhibitory influence which oestrogen and progesterone exert upon the action of prolactin. The use of oestrogens to suppress lactation depends on a continuation of the peripheral, that is, mammary, inhibition of prolactin. Androgens are also believed to act by inhibition of the action of prolactin on the mammary gland epithelium. Bromocriptine, when compared in a double-blind trial with orally administered methyl testosterone and placebo, gave almost complete relief of breast discomfort and congestion, though a small amount of milk production was seen. Methyl testosterone, in the dosage used in this study, was quite ineffective in suppressing lactation or breast symptoms.