Role of surgical staging and adjuvant treatment in uterine serous carcinoma

PURPOSE OF INVESTIGATION

This study evaluates the association of clinical and pathologic characteristics of patients with uterine serous carcinoma (USC) with disease recurrence.

MATERIALS AND METHODS

Surgically-staged patients with USC at a single institution were identified and clinical and pathologic variables were compared.

RESULTS

Of the 51 patients included in this analysis, 75% percent received adjuvant chemotherapy, 51% received radiation therapy, and 47% received both. After a median follow-up of 33 months, 42% of patients had disease recurrence. On multivariable analysis, positive pelvic lymph nodes were associated with a shorter interval between surgery and recurrence: 13.6 months progression-free survival (PFS) with positive vs 17.2 months with negative lymph nodes (p = 0.05). Patients with early-stage disease who did not receive any adjuvant treatments had a significantly greater risk of disease recurrence (44.4% vs 7.70%, p = 0.043).

CONCLUSION

In this population of surgically-staged patients with USC, pelvic lymph node metastases were predictive of a shorter PFS.

Oxaliplatin plus paclitaxel for recurrent and metastatic cervical cancer (CC): New York Cancer Consortium Trial P5840

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Background: Although cisplatin (cis) is an effective radiosensitizer, its activity in patients (pts) with advanced and recurrent CC is disappointing. Oxaliplatin (O) might exhibit greater activity and be suitable for combination with paclitaxel (P). Methods: Pts with advanced and recurrent CC who had not received prior chemotherapy except radiosensitizing cis were treated with P 175 mg/m2 IV and O 130 mg/m2 IV every 21 d. Response (R), as determined by RECIST criteria and confirmed at 9 weeks (wk), and toxicity were primary outcomes. If R in = 8 patients (pts) of 18, accrual to 46 could ensue. Results: Of 17 pts enrolled, 16 were treated. Histology: 7 adeno/10 squamous.The median age was 57 (range 33–78) and 13 had had prior radiation (10 with cis). Median cycles: 3 (0–8). One CR and 4 PRs were achieved for an overall response rate of 29% (95% confidence interval: 10.3%, 56.0%). Additionally, 4 had stable disease, but this was not confirmed at 15wk. Time to progression in those responding was 21 wk (range 11–51). 7 pts are alive. 6 pts experienced grade (gr) 3/4 hematologic toxicity. Neuropathy occurred following cycle 3 in 2 pts (gr3). Additonal gr 3/4 toxicities were gastrointestinal (GI)/metabolic in 6, thrombotic in 1 and hypersensitivity in 1. There were no treatment-related deaths. Conclusions: In the stage I of our Phase II trial, O and P demonstrate a 29% response rate when used to treat advanced and recurrent CC. Toxicities of this regimen are hematologic, gastrointestinal, and neurologic. Supported by N01-CM-62204.

No significant financial relationships to disclose.

Dietary antioxidants, supplements, and risk of epithelial ovarian cancer

Several studies of dietary and serum antioxidant micronutrients (vitamins A, C, and E and beta-carotene) suggest that higher levels may be protective for ovarian cancer. None of these has examined supplements. We used a food frequency questionnaire and additional questions on supplements to study 168 histologically confirmed epithelial ovarian cancer cases, 159 community controls, and 92 hospital-based controls. Antioxidant consumption from diet or supplements was calculated in milligrams or international units per day. In multivariate analyses using only community controls, the highest levels of intake of vitamins C and E from supplements were protective: odds ratio (OR) = 0.40 [95% confidence interval (CI) = 0.21-0.78] and OR = 0.33 (95% CI = 0.18-0.60), respectively. Consumption of antioxidants from diet was unrelated to risk. In analyses combining antioxidant intake from diet and supplements, vitamins C (> 363 mg/day) and E (> 75 mg/day) were associated with reduced risks: OR = 0.45 (95% CI = 0.22-0.91) and OR = 0.44 (95% CI = 0.21-0.94), respectively. Results were similar, with some attenuation toward the null, in analyses combining both control groups. The levels of vitamins C and E associated with the protective effect were well above the current US Recommended Dietary Allowances. These findings support the hypothesis that antioxidant vitamins C and E from supplements are related to a reduced risk of ovarian cancer.

Symptoms of ovarian cancer

OBJECTIVE

To examine the symptoms of ovarian cancer in patients compared with symptoms experienced by healthy women using a case-control design.

METHODS

Cases (n = 168) were women with ovarian cancer diagnosed at two hospitals in New York between 1994 and 1997 who were interviewed shortly after diagnosis. They were compared with healthy women (n = 251 controls) from the community. Women were asked about the prevalence, duration, and constancy of eight symptoms and about use of three types of medications in the 6 to 12 months before diagnosis (cases) or interview (controls).

RESULTS

Nearly all the cases (93%) reported at least one symptom, compared with 42% of controls. The most common symptoms among cases were: unusual bloating, fullness, and pressure in the abdomen (71%); unusual abdominal pain or lower back pain (52%); and lack of energy (43%). The proportions of controls reporting these symptoms were 9, 15, and 16%, respectively, resulting in odds ratios and 95% confidence intervals of 25.3 (15.6, 40.9), 6.2 (4.0, 9.6), and 3.9 (2.5, 6.1), respectively, for these symptoms. Bloating, fullness, and pressure was of more recent onset among cases than controls (4.9 months compared with 7.6 months, P =.01). There were only minor differences in reported symptoms between cases with early and later stage disease.

CONCLUSION

Unusual bloating, fullness, and pressure, abdominal or back pain, and lack of energy are prominent symptoms in women with ovarian cancer and distinguish them from controls. Information on symptoms may make women and physicians more aware of changes associated with ovarian cancer.

Tumor suppressor gene, cell surface adhesion molecule, and multidrug resistance in Müllerian serous carcinomas: clinical divergence without immunophenotypic differences

OBJECTIVES

We hypothesize that differences in the expression of selected tumor suppressor genes, cell surface adhesion molecules, and multidrug resistance glycoproteins could account for some of the reported differences between uterine serous carcinoma (USC) and extrauterine serous carcinomas (ESC), including ovarian and primary peritoneal carcinoma (OSC and PSC, respectively).

METHODS

We studied the expression of the following antigens in 20 USCs, 20 OSCs, and 10 PSCs: p53 and mdm-2 (tumor suppressor genes), CD44 and CD44v6 (cell surface adhesion molecules), and the p-glycoprotein (a multidrug resistance protein recognized by two antibodies, C494 and JSB1). We further studied chemotherapeutic drug resistance by examining reports prepared using the Oncotech Extreme Drug Resistance Assay from 24 of the 50 study patients. Clinical data were obtained from medical record review.

RESULTS

USC, OSC, and PSC patients were similar with respect to mean age at diagnosis, mean gravidity, mean parity, personal history of breast cancer, percentage treated with chemotherapy, and survival at 3 and 5 years postdiagnosis. Significant clinical differences included a high prevalence of nulliparity in OSC (P = 0.05), a low prevalence of Caucasian race in USC (P = 0.008), a paucity of stage I patients in OSC and PSC (P = 0.03), a high prevalence of familial breast cancer in OSC (P = 0.06), and superior 2-year survival in OSC (P = 0.02). Seventy-five percent of USCs, 52% of OSCs, and 60% of PSCs expressed p53. Five percent of USCs, 19% of OSCs, and 0% of PSCs expressed mdm-2. Forty percent of USCs, 33% of OSCs, and 10% of PSCs expressed CD44. None of the USCs, OSCs, or PSCs expressed CD44v6. Sixty-one percent of USCs and OSCs and 82% of PSCs expressed C494 while 17% of USCs, 19% of OSCs, and 20% of PSCs expressed JSB1. None of these apparent differences was statistically significant. USC, OSC, and PSCs patients did not demonstrate significant differences with respect to extreme drug resistance. However, the following trends were noted (P = 0.06): more prevalent low drug resistance for cyclophosphamide in OSC compared with USC and more prevalent extreme drug resistance for etoposide in OSC compared with USC.

CONCLUSIONS

Therefore, despite significant clincial differences, the USCs and ESCs in our series do not differ significantly with respect to the expression of the tumor suppressor genes, cell surface adhesion molecules, and drug resistance proteins studied. It is premature, however, to recommend that USCs and ESCs should be treated identically.

Desmoplastic small round cell tumor with primary ovarian involvement: case report and review

BACKGROUND

Desmoplastic small round cell tumor (DSRCT) is a rare, aggressive, malignant neoplasm that has recently been characterized. It has not been associated with a primary visceral organ. In women, cases are even more rare and often have some ovarian involvement.

CASE

An 11-year-old girl presented with abdominal pain, nausea, and vomiting. A CT scan revealed a large heterogeneous pelvic mass with cystic components and an 8-cm midabdominal mass. During exploratory laparotomy, the patient was found to have a pelvic mass measuring 12. 9 cm replacing normal ovarian tissue. The midabdominal mass was also removed. Pathology, cytology, and immunohistochemistry confirmed a desmoplastic small round cell tumor. Even with aggressive surgical and medical intervention, the patient died 11 months after initial diagnosis.

CONCLUSION

We present a rare small cell tumor that is associated with ovarian involvement. The prognosis in these patients is extremely poor and very few survivals have been reported.

IgA antibodies to the 27-kDa heat-shock protein in the genital tracts of women with gynecologic cancers

Heat-shock proteins promote cell survival under adverse environmental conditions. Synthesis of the 27-kDa (HSP27), 70-kDa (HSP70), and 90-kDa (HSP90) heat-shock proteins is increased in malignantly transformed cells and has been associated with tumor proliferation, metastasis, and resistance to chemotherapeutic agents. The increased expression of heat-shock proteins and their association with tumor-specific antigens may result in local immunity to the heat-shock proteins. We examined the occurrence of IgA antibodies to HSP27, HSP70, and HSP90 in the lower genital tracts of women with possible gynecologic cancers. Cervical samples were obtained from 119 consecutive women being evaluated for a gynecologic malignancy or returning for a follow-up examination following cancer treatment. Aliquots were tested for IgA anti-heat-shock protein antibodies by ELISA. Aliquots were also tested for IgG antibodies to HSP27 as well as for human papillomavirus. Anti-HSP27 IgA was detected in 85.7% of 21 women with endometrial cancer tested prior to diagnosis and in 41.1% of 17 women tested after treatment. In women with ovarian cancer, 77.8% of 9 women tested prior to diagnosis and 75.0% of 24 women evaluated after treatment were anti-HSP27 IgA-positive. Of 6 women with cervical cancer tested prior to diagnosis, 5 were positive for this antibody. None of 25 women with benign diagnoses or 46 healthy women were cervical IgA anti-HSP27-positive (P < 0.0001). In contrast, anti-HSP27 IgG was not associated with a gynecologic malignancy. HSP27 cervical antibodies were not associated with the presence of human papillomavirus. Cervical IgA antibodies to HSP90 were associated with ovarian cancer; antibodies to HSP70 were not cancer-associated. We conclude that cervical IgA antibodies to HSP27 may be indicators of a gynecologic malignancy.

Serum antibodies to the 27-kd heat shock protein in women with gynecologic cancers

OBJECTIVES

Among women the association between heat shock protein immunity and cancer has been examined primarily for breast cancer. Autoantibodies to the 27-kd heat shock protein were detected in some patients with breast cancer but not in control subjects, and the presence of these antibodies was correlated with improved survival. We examined the relationship between autoimmunity to heat shock proteins and the diagnosis of malignancies of the female genital tract.

STUDY DESIGN

Serum samples from women seen for possible gynecologic malignancies or returning for evaluation after surgery, radiation, chemotherapy, or a combination for gynecologic cancers were tested for immunoglobulin G antibodies to the 27-kd, 60-kd, 70-kd, and 90-kd heat shock proteins by enzyme-linked immunosorbent assay with the purified recombinant proteins bound to wells of a microtiter plate. Serum samples from women with no history of malignancies served as control preparations.

RESULTS

Antibodies to the 27-kd heat shock protein were detected in only 1 of 29 healthy control subjects (3.4%) and 1 of 23 women whose lesions were benign (4.3%). In marked contrast, 39 of 96 women with gynecologic cancers (40.6%) had positive antibody detection (P =.0004 vs benign). The percentages of positive results seen for ovarian (17/34, 50%), endometrial (13/34, 38.2%), cervical and uterine (3/10, 30%), vaginal and vulvar (3/5, 60%), and other (3/13, 23.1%) cancers were not significantly different from each other. Similar prevalences of antibodies to the 27-kd heat shock protein were seen among patients with cancer who had untreated active disease and after treatment. Unlike the results with antibodies to the 27-kd heat shock protein there was no relationship between antibodies to the other heat shock proteins and any gynecologic cancer.

CONCLUSION

Circulating autoantibodies to the 27-kd heat shock protein were found to be associated with malignancies of the female genital tract.

Familial papillary serous carcinoma of the cervix, peritoneum, and ovary: a report of the first case

OBJECTIVE

We report an occult primary papillary serous carcinoma of the endocervix that was encountered in a woman whose mother and identical twin sister died of papillary serous carcinomas (PSCs) of the peritoneum and ovary, respectively.

METHODS

The medical records and the histologic material belonging to the patient, her sister, and her mother were reviewed.

RESULTS

The cervical PSC was histologically similar to the peritoneal and ovarian carcinomas. The patient has recurred with peritoneal carcinomatosis 24 months following surgery and postoperative radiotherapy and chemotherapy.

CONCLUSIONS

Primary papillary serous carcinoma of the cervix is a very rare adenocarcinoma variant; there have been approximately 30 such cases reported, and, to our knowledge, this is the first documented case of familial peritoneal/ovarian/uterine papillary serous carcinoma. The prophylaxis achieved through bilateral oophorectomy in individuals with a family history of ovarian cancer does not address the risk of PSCs arising in the uterus, cervix, or peritoneum.

Infrared spectroscopy of normal and abnormal cervical smears: evaluation by principal component analysis

Fourier-transform infrared (FT-IR) spectra of malignant and dysplastic cervical scrapings were abnormal, as first described in our study of a limited number of samples, where the spectra were evaluated by visual inspection and peak intensity ratios. We have expanded our study to evaluate more cervical conditions, and to analyze the spectra by a chemometric approach (principal component analysis [PCA]). Cervical samples from 436 females were evaluated by FT-IR and Papanicolaou testing; 40/436 spectra were nonanalyzable. The remaining were as follows: normal, 174; malignant, 19; dysplasia, 8; atypia, 113; atrophy, 19; inflammatory, 47; bloody smear, 12; hypocellular, 4. PCA analysis followed by chi2 test revealed that statistically significant frequencies of being predicted malignant by FT-IR were associated with samples diagnosed as malignant (P < 0.0001), and also those diagnosed as "atrophy" (P < 0.001), "atypical with bloody smear" (P < 0.05), "atypical with atrophic pattern" (P < 0.05), and "dysplasia" (P < 0.05). Based on these findings, for the diagnosis of cervical cancer by FT-IR, as defined here, the sensitivity is 79%, the specificity is 77%, the positive predictive value is 15%, and the negative predictive value is 98.6%. Our findings (a) demonstrate the application of a chemometric approach to the study of cervical FT-IR spectra; (b) assess its potential diagnostic role; (c) suggest that atrophic and neoplastic samples share structural features; and (d) suggest that blood may interfere with such spectroscopic evaluation. These findings warrant further evaluation of FT- IR spectroscopy in cervical and other malignancies.

The practice of surgical staging and its impact on adjuvant treatment recommendations in patients with stage I endometrial carcinoma

A survey of American gynecologic oncologists was undertaken to assess their compliance with current surgical staging criteria in patients with early endometrial carcinoma. One hundred forty-four members of the Society of Gynecologic Oncologists responded to the survey. Respondents treated an average of 22 new cases annually. Tumor grade and intraoperative determination of depth of myometrial invasion were demonstrated to influence the frequency of lymphatic dissection. In grade 1, 2, and 3 lesions, 76, 60, and 34% of responders, respectively, indicated that depth of invasion influenced their decision to perform lymphadenectomy. In addition, depth of invasion was important in determining type and extent of lymphatic resection. Further, the impact of pathologic lymph node status on postoperative adjuvant radiation therapy recommendations was evaluated for various stratifications of endometrial adenocarcinoma confined to the corpus. The greatest differences in treatment recommendations were noted in the 50-66% invasion category. For grade 1 and 2 cancers, adjuvant therapy recommendations were reduced by 23 and 16% respectively when comparing pelvic and combined therapy versus none and vaginal therapy. The effect of surgical staging data on clinical decisions is clearly evident. The knowledge of pathologically negative lymph node status reduces the recommendation for postoperative adjuvant radiotherapy in patients with adenocarcinoma otherwise confined to the uterine corpus.

HIV-related primary non-Hodgkin's lymphoma of the vulva

We reported on a 25-year-old HIV-positive woman diagnosed with Ann Arbor Stage IEB primary extranodal immunoblastic lymphoma arising in the vulva. This is the first documented instance of an HIV-associated malignant lymphoma originating in the lower female genital tract, and only the 16th reported case of primary malignant lymphoma of the vulva. The nonspecific clinical presentation coupled with the unanticipated finding of lymphoma made diagnostic confirmation an arduous task, requiring weeks of persistence. The patient's disease was refractory to three courses of chemotherapy, but did respond to a brief palliative course of external beam irradiation prior to her demise 7 months after presentation. Our findings are presented, and 15 cases from the literature, the largest series to date, are discussed.

Mucinous adenocarcinoma of the endometrium with intestinal differentiation: a case report

Mucinous differentiation of endocervical type has been well documented in endometrial carcinoma. However, we describe an unusual case of adenocarcinoma of the endometrium showing diffuse histological, immunohistochemical, and ultrastructural evidence of intestinal differentiation. Although intestinal differentiation has been described in mesodermally derived tissues including endocervix, ovary, and urinary tract, it has not been reported in normal endometrium. One previous case has been reported showing this pattern in endometrial carcinoma. Possible histogenetic mechanisms of this pattern are discussed.

Perforation of the inferior vena cava by a recently inserted Greenfield filter

The Greenfield filter is an effective device which provides protection against emboli to the lungs from the deep veins of the lower half of the body. Specific complications, such as perforation, may occur following the placement of caval filters. We report a case of inferior vena cava perforation by a Greenfield filter diagnosed at the time of surgery. With the increasing use of caval filter placement, specific complications such as this will be encountered.

Infrared spectroscopy of exfoliated human cervical cells: evidence of extensive structural changes during carcinogenesis

Infrared spectra were obtained from exfoliated cervical cells from 156 females, of whom 136 were normal, 12 had cervical cancer, and 8 had dysplasia. The spectra of the normal women, essentially identical, differed from those obtained from patients with either cancer or dysplasia. In malignant samples we noted (i) significant changes in the intensity of the glycogen bands at 1025 cm-1 and 1047 cm-1, the bands at 1082 cm-1 and 1244 cm-1, the C--O stretching band at 1155 cm-1, and the band at 1303 cm-1, (ii) significant shifts of the peaks normally appearing at 1082 cm-1, 1155 cm-1, and 1244 cm-1, and (iii) an additional band at 970 cm-1. Further study of several of these bands, including the pressure dependence of their frequencies, revealed that in the malignant cervical tissue there were extensive changes in the degree of hydrogen bonding of phosphodiester groups of nucleic acids and C--OH groups of proteins, as well as changes in the degree of disorder of methylene chains of lipids. The IR spectra of samples with dysplasia demonstrated the same changes with cancer samples, except that the changes were of lesser magnitude and the phosphodiester peak normally appearing at 1082 cm-1 did not shift. These spectroscopic changes appear to progress in tandem with the morphological changes that lead normal cervical epithelium to cancer through the premalignant stage of dysplasia. The diagnostic potential of IR spectroscopy is discussed.

An epidemiologic study of Pap screening histories in women with invasive carcinomas of the uterine cervix

The present study was designed to determine the Pap screening histories of 261 women, ages 20 through 69 years, who were diagnosed with an invasive carcinoma of the uterine cervix. Women who were residents of New York State, exclusive of New York City, and who received a diagnosis between July 1983 and September 1985, were selected for this study. Fifty-four percent of the patients had not received at least one Pap test within three years prior to diagnosis. Women who had not received a prior Pap smear tended to be older, less sexually active, less well educated, and to have more extensive disease at the time of diagnosis than women who had received cytologic examinations. The present study results, coupled to findings of previous reports, demonstrate the need for an intensified effort to insure that all women have access to quality Pap screening services. Particular emphasis needs to be placed on reaching older women who are less likely than younger ones to receive periodic Pap screening. Physicians need to routinely offer older patients who present with nongynecologic conditions the opportunity of receiving cytologic testing.

Septic pulmonary embolism complicating a central venous catheter

Bacteremia is a recognized complication in patients with indwelling central venous catheters. More recently pulmonary embolism in such patients has also been described. Despite abundant clinical experience with these devices, to our knowledge, septic pulmonary embolism has not been reported in adult patients. This case illustrates such a complication.

Estrogen and progestin binding in cytosols of ovarian adenocarcinomas

Because a few ovarian adenocarcinomas respond favorably to endocrine therapy, we tested the hypothesis that some ovarian adenocarcinomas have functional similarity with sex-hormone-sensitive endometrial and breast tumors. Cytosols from 23 ovarian adenocarcinomas and 27 control tissues were examined for receptorlike estrogen and/or progestin binding. Eight of 16 primary ovarian adenocarcinomas had estrogen and/or progestin receptorlike components; among the metastases tested, one third retained estrogen binding. No correlations were found between binding characteristics and histopathologic grade. The presence of estrogen binding in a lung lesion helped confirm recurrent ovarian disease. Estrogen binding occurred in specimens from women with no histories of exposure to exogenous estrogen. Because tamoxifen and nafoxidine could inhibit estradiol binding, it is likely that antiestrogens will prove beneficial against some ovarian cancers.

Endometrial cancer after menopausal use of estrogens

The incidence of endometrial cancer has increased rapidly during recent years, paralleling the increased postmenopausal use of estrogens. The relation of endometrial cancer to disease conditions in which estrogens are elevated and three case-control epidemiologic studies suggest the likelihood of a cause-and-effect relation between estrogen use and endometrial cancer. These studies and New York State Cancer Registry data further suggest that the incidence will continue to rise in coming years. A thorough reevaluation of the medical indications for estrogen replacement therapy is urgently needed. Women with long-term exposure to estrogens should have periodic cancer screening examinations.

The surgical management of invasive cancer of the cervix in pregnancy

During a 13 year period ending in July, 1974, 42 obstetric patients with a diagnosis of invasive carcinoma of the cervix were seen. Nine patients were treated with primary radiation therapy; 33 patients were treated with primary surgery. Total hysterectomy with partial vaginectomy was performed in seven patients with Stage I-A, and extensive abdominal hysterectomy with bilateral pelvic lymphadenectomy was performed in 26 patients (14 with Stage I-A, nine with Stage I-B, and three with Stage II-A). Thirty-eight patients are alive and well from three months to 13 years following treatment. Extensive abdominal hysterectomy and pelvic lymphadenectomy can be done in selected obstetric patients with invasive carcinoma of the cervix with an acceptable morbidity and cure rate. Normal ovaries left in place will continue to function normally. Seven patients with a conization diagnosis of Stage I-A had a planned delay in definitive treatment until delivery at term.