Phase II Trial of Chemopreventive Effects of Levonorgestrel on Ovarian and Fallopian Tube Epithelium in Women at High Risk for Ovarian Cancer: An NRG Oncology Group/GOG Study

A large body of epidemiologic evidence has shown that use of progestin-containing preparations lowers ovarian cancer risk. The purpose of the current study was to gather further preclinical evidence supporting progestins as cancer chemopreventives by demonstrating progestin-activation of surrogate endpoint biomarkers pertinent to cancer prevention in the genital tract of women at increased risk of ovarian cancer. There were 64 women enrolled in a multi-institutional randomized trial who chose to undergo risk-reducing bilateral salpingo-oophorectomy (BSO) and to receive the progestin levonorgestrel or placebo for 4 to 6 weeks prior to undergoing BSO. The ovarian and fallopian tube epithelia (FTE) were compared immunohistochemically for effects of levonorgestrel on apoptosis (primary endpoint). Secondary endpoints included TGFβ isoform expression, proliferation, and karyometric features of nuclear abnormality. In both the ovary and fallopian tube, levonorgestrel did not confer significant changes in apoptosis or expression of the TGFβ1, 2, or 3 isoforms. In the ovarian epithelium, treatment with levonorgestrel significantly decreased the proliferation index. The mean ovarian Ki-67 value in the placebo arm was 2.027 per 100 cells versus 0.775 per 100 cells in the levonorgestrel arm (two-sided P value via Mann-Whitney U test = 0.0114). The karyometric signature of nuclei in both the ovarian and FTE deviated significantly from normal controls (women at average risk of ovarian cancer), but was significantly less abnormal in women treated with levonorgestrel. These karyometric data further support the idea that progestins may clear genetically abnormal cells and act as chemopreventive agents against ovarian and fallopian tube cancer.

Progestins inhibit calcitriol-induced CYP24A1 and synergistically inhibit ovarian cancer cell viability: An opportunity for chemoprevention

OBJECTIVES

Previously we have shown in endometrial cells that progesterone (P4) and calcitriol (CAL, 1,25(OH)2D3) synergistically promote apoptosis and that progestins induce expression of the vitamin D receptor. In the current study we examined the progestin/vitamin D combination in ovarian cells and searched for other progestin-related effects on vitamin D metabolism that may underlie the novel interaction between progestins and vitamin D, including whether progestins inhibit CYP24A1, the enzyme that renders CAL inactive.

METHODS

We investigated the impact of P4 on CAL-induced CYP24A1 expression in cancer cell lines expressing progesterone receptors (PRs), [OVCAR-5, OVCAR-3-PGR (PR-transfected OVCAR-3 ovarian line), and T47D-WT, T47D-A and T47D-B (breast lines expressing PRs or individual PR isoforms)] or lines that do not express PRs (OVCAR-3 and T47D-Y). We examined CYP24A1 expression using RT-PCR and western blotting, and apoptosis by TUNEL. We also investigated P4 inhibition of Cyp24a1 in ovaries from CAL-treated mice.

RESULTS

CAL treatment induced CYP24A1 expression. When co-treated with P4, cell lines expressing PRs showed marked inhibition of CYP24A1 expression (p<0.001), along with increased apoptosis (p<0.01); cells not expressing PRs did not. Mouse ovaries showed a significant reduction in CAL-induced Cyp24a1 mRNA (p<0.001) and protein (p<0.01) in response to P4.

CONCLUSIONS

We show for the first time that progestins and vitamin D synergistically reduce cell viability and induce apoptosis in ovarian cells and that progestins PR-dependently inhibit CAL-induced CYP24A1, thus extending CAL activity. The combination of progestins and vitamin D deserves further consideration as a strategy for inhibiting ovarian carcinogenesis.

Association of Metformin Use with Outcomes in Advanced Endometrial Cancer Treated with Chemotherapy

There is increasing evidence that metformin, a commonly used treatment for diabetes, might have the potential to be repurposed as an economical and safe cancer therapeutic. The aim of this study was to determine whether stage III-IV or recurrent endometrial cancer patients who are using metformin during treatment with chemotherapy have improved survival. To test this we analyzed a retrospective cohort of subjects at two independent institutions who received chemotherapy for stage III-IV or recurrent endometrial cancer from 1992 to 2011. Diagnosis of diabetes, metformin use, demographics, endometrial cancer clinico-pathologic parameters, and survival duration were abstracted. The primary outcome was overall survival. The final cohort included 349 patients, 31 (8.9%) had diabetes and used metformin, 28 (8.0%) had diabetes but did not use metformin, and 291 (83.4%) did not have diabetes. The results demonstrate that the median overall survival was 45.6 months for patients with diabetes who used metformin compared to 12.5 months for patients with diabetes who did not use metformin and 28.5 months for patients without diabetes (log-rank test comparing the three groups P = 0.006). In a model adjusted for confounders, the difference in survival between the three groups remained statistically significant (P = 0.023). The improvement in survival among metformin users was not explained by better baseline health status or more aggressive use of chemotherapy. Overall, the findings in this retrospective cohort of endometrial cancer patients with stage III-IV or recurrent disease treated with chemotherapy indicate that patients with diabetes who were concurrently treated with metformin survived longer than patients with diabetes who did not use metformin.

Patterns and utility of routine surveillance in high grade endometrial cancer

OBJECTIVE

To evaluate surveillance methods and their utility in detecting recurrence of disease in a high grade endometrial cancer population.

METHODS

We performed a multi-institutional retrospective chart review of women diagnosed with high grade endometrial cancer between the years 2000 and 2011. Surveillance data was abstracted and analyzed. Surveillance method leading to detection of recurrence was identified and compared by stage of disease and site of recurrence.

RESULTS

Two hundred and fifty-four patients met the criteria for inclusion. Vaginal cytology was performed in the majority of early stage patients, but was utilized less in advanced stage patients. CA-125 and CT imaging were used more frequently in advanced stage patients compared to early stage. Thirty-six percent of patients experienced a recurrence and the majority of initial recurrences (76%) had a distant component. Modalities that detected cancer recurrences were: symptoms (56%), physical exam (18%), surveillance CT (15%), CA-125 (10%), and vaginal cytology (1%). All local recurrences were detected by symptoms or physical exam findings. While the majority of loco-regional and distant recurrences (68%) were detected by symptoms or physical exam, 28% were detected by surveillance CT scan or CA 125. One loco-regional recurrence was identified by vaginal cytology but no recurrences with a distant component detected by this modality.

CONCLUSIONS

Symptoms and physical examination identify the majority of high grade endometrial cancer recurrences, while vaginal cytology is the least likely surveillance modality to identify a recurrence. The role of CT and CA-125 surveillance outside of a clinical trial needs to be further reviewed.

Doping of GaN by Ion Implantation: Does it Work?

Epitaxially grown GaN by metal organic chemical vapor deposition (MOCVD) on SiC were implanted with 100 keV Si+ (for n-type) and 80 keV Mg+ (for p-type) with various fluences from 1×1012 to 7×1015 ions/cm2 at liquid nitrogen temperature (LT), room temperature (RT), and 700 °C (HT). High temperature (1200 °C and 1500 °C) annealing was carried out after capping the GaN with epitaxial AIN by MOCVD to study damage recovery. Samples were capped by a layer of AIN in order to protect the GaN surface during annealing. Effects of implant temperature, damage and dopant activation are critically studied to evaluate a role of ion implantation in doping of GaN. The damage was studied by Rutherford Backscattering/Channeling, spectroscopic ellipsometry and photoluminescence. Results show dependence of radiation damage level on temperature of the substrate during implantation: implantations at elevated temperatures up to 550 °C decrease the lattice disorder; “hot implants” above 550 °C can not be useful in doping of GaN due to nitrogen loss from the surface. SE measurements have indicated very high sensitivity to the implantation damage. PL measurements at LT of 80 keV Mg+ (5×1014 cm-2) implanted and annealed GaN showed two peaks : one ∼100 meV and another ∼140 meV away from the band edge.

Unique Dermatologic Aspects of the Postmenopausal Vulva

Aging and estrogen deficiency compromise the skin barrier's defense mechanisms, resulting in greater microbial colonization of the skin. Susceptibility to mechanical injury and chemical irritation also increases. Menopause blunts the cell-mediated immune response to microbes and allergens. Healing after an insult is delayed. Skin disorders such as lichen sclerosus or allergic dermatitis may not be clinically obvious. A biopsy interpreted by a dermatopathologist is often helpful. Some conditions require long-term use of topical steroid ointments, and antimicrobial therapy. A compounding pharmacist may be necessary to find a base for the topical cream that does not irritate.

Technetium-99m HMPAO labeled leukocytes as the primary diagnostic tool in a case of brain abscess

The authors present a case in which Tc-99m HMPAO labeled autologous leukocytes were used to demonstrate a brain abscess in a patient undergoing evaluation for fever of unknown origin. The abscess was demonstrated on both 1-hour and 24-hour images. The positive 1-hour image led to CT and MRI studies, which are included for correlation. In addition to its previously identified role as a secondary diagnostic test in the differentiation of tumor and abscess, the authors propose that Tc-99m HMPAO is useful as a primary diagnostic tool in the identification of brain abscess. Furthermore, the authors suggest that Tc-99m HMPAO is preferable to In-111 labeled leukocytes because of its better resolution and earlier imaging characteristics.