Final analysis of a phase I/IIa trial of the folate-binding protein-derived E39 peptide vaccine to prevent recurrence in ovarian and endometrial cancer patients

BACKGROUND

E39, an HLA-A2-restricted, immunogenic peptide derived from the folate-binding protein (FBP), is overexpressed in multiple malignancies. We conducted a phase I/IIa trial of the E39 + GM-CSF vaccine with booster inoculations of either E39 or E39' (an attenuated version of E39) to prevent recurrences in disease-free endometrial and ovarian cancer patients(pts). Here, we present the final 24-month landmark analysis.

PATIENTS AND METHODS

HLA-A2 + patients receiving E39 + GM-CSF were included in the vaccine group (VG), and HLA-A2- pts (or HLA-A2 + patients refusing vaccine) were followed as the control group (CG). VG group received 6 monthly inoculations as the primary vaccine series (PVS) and were randomized to receive either E39 or E39' booster inoculations. Demographic, safety, immunologic, and disease-free survival (DFS) data were collected and evaluated.

RESULTS

Fifty-one patients were enrolled; 29 in the VG and 22 in the CG. Fourteen patients received <1000 μg and 15 received 1000 μg of E39. There were no clinicopathologic differences between VG and CG or between dose groups. E39 was well tolerated. At the 24 months landmark, DFS was 55.5% (VG) vs 40.0% (CG), P = 0.339. Patients receiving 1000 μg and boosted patients also showed improved DFS (P < 0.03). DFS was improved in the 1000 μg group after treatment of primary disease (90.0% vs CG:42.9%, P = 0.007), but not in recurrent patients. In low-FBP expressing patients, DFS was 100.0% (1000 μg), 50.0% (<1000 μg), and 25.0% (CG), P = 0.029.

CONCLUSIONS

This phase I/IIa trial reveals that E39 + GM-CSF is safe and may be effective in preventing recurrence in high-risk ovarian and endometrial cancer when optimally dosed (1000 μg) to FBP low patients being treated for primary disease.

Interim analysis of a phase I/IIa trial assessing E39+GM-CSF, a folate binding protein vaccine, to prevent recurrence in ovarian and endometrial cancer patients

BACKGROUND

Folate binding protein(FBP) is an immunogenic protein over-expressed in endometrial(EC) and ovarian cancer(OC). We are conducting a phase I/IIa trial of E39 (GALE 301)+GM-CSF, an HLA-A2-restricted, FBP-derived peptide vaccine to prevent recurrences in disease-free EC and OC patients. This interim analysis summarizes toxicity, immunologic responses, and clinical outcomes to date.

METHODS

HLA-A2+ patients were vaccinated(VG), and HLA-A2- or -A2+ patients were followed as controls(CG). Six monthly intradermal inoculations of E39+250mcg GM-CSF were administered to VG. Demographic, safety, immunologic, and recurrence rate(RR) data were collected and evaluated.

RESULTS

This trial enrolled 51 patients; 29 in the VG and 22 in the CG. Fifteen patients received 1000mcg E39, and 14 received <1000mcg. There were no clinicopathologic differences between groups(all p ≥ 0.1). E39 was well-tolerated regardless of dose. DTH increased pre- to post-vaccination (5.7±1.5 mm vs 10.3±3.0 mm, p = 0.06) in the VG, and increased more in the 1000mcg group (3.8±2.0 mm vs 9.5±3.5 mm, p = 0.03). With 12 months median follow-up, the RR was 41% (VG) vs 55% (CG), p = 0.41. Among the 1000mcg patients, the RR was 13.3% vs 55% CG, p = 0.01. Estimated 2-year DFS was 85.7% in the 1000mcg group vs 33.6% in the CG (p = 0.021).

CONCLUSIONS

This phase I/IIa trial reveals that E39+GM-CSF is well-tolerated and elicits a strong, dose-dependent in vivo immune response. Early efficacy results are promising in the 1000 mcg dose cohort. This study proves the safety and establishes the dose of E39 for a larger prospective, randomized, controlled trial in HLA-A2+ EC and OC patients to prevent recurrence.

Abstract CT073: Comparing an attenuated booster (E39’) vs E39 booster to potentiate the clinical benefit of the folate binding protein (FBP)-derived vaccine (E39 + GM-CSF) in a phase I/IIa trial to prevent recurrence in endometrial (EC) and ovarian cancer (OC) patients

Background: We have completed treatment in a phase I/IIa trial utilizing E39 (GALE-301, FBP 191-199, EIWTHSYKV), an HLA-A2 restricted, FBP-derived peptide + GM-CSF vaccine to prevent recurrence in EC and OC patients (pts). This vaccine has been shown to be safe and immunogenic, with promising early clinical results. Booster inoculations have improved disease-free survival (DFS) in our previous peptide vaccine trials, but repeated boosting can theoretically lead to overstimulation and loss of vaccine-induced T cells. To avoid this, we have developed an attenuated version of E39, E39’ (GALE-302, EIWTFSTKV), which has been shown to expand FBP-specific cytolytic T cells in vitro and in vivo. Therefore to assess this strategy, E39-vaccinated pts from the phase I/IIa trial were randomized to receive a booster series of either E39’ or E39 + GM-CSF and compared for safety, immunologic response, and DFS.

Methods: HLA-A2+ pts were vaccinated (VG), and HLA-A2- pts were followed as controls (CG). Six monthly intradermal inoculations of E39 + 250mcg GM-CSF were administered to the VG to complete the primary vaccine series (PVS). Patients were then randomized to receive 2 booster inoculations of 500mcg of E39’ or E39 + 250mcg GM-CSF at 6 (B1) and 12 (B2) months post-PVS. Local reactions (LR) were recorded 48-72 hours after each booster. Demographic, safety, immunologic, and DFS data were collected and evaluated with the appropriate statistical tests.

Results: A total of 51 pts were enrolled; 29 in VG and 22 in CG. 17 pts continued on to the booster series and were randomized. For B1, 9 received E39’ and 8 received E39; B2 included 7 pts in each group. There were no significant clinicopathologic differences between groups. No difference in toxicities were seen with no grade 3 or 4 toxicities in either group. The average LR for the E39’ vs E39 groups were 79.7+14.0 mm vs 82.1+8.3 mm, respectively for B1 (p = 0.45) and 74.1+11.5 mm vs 78+11.2 mm, respectively for B2 (p = 0.41). Clinically, the recurrence rate was 22.2% in the E39’ boost group vs 25% for E39. The estimated 2-year DFS for B1 pts for E39’, E39 and the CG were 66.7%, 58.3%, and 36.0%, respectively; and for B2 pts were 66.7%, 66.7%, and 36.0%. Comparing just the boosted groups, for B1 the hazard ratio (HR) for E39’ vs E39 = 0.71 (95% CI: 0.1 - 5.13), and for B2 the HR for E39’ vs E39 = 0.82 (95% CI: 0.05 - 13.24).

Conclusion: The use of an attenuated peptide (E39’) booster was safe and as immunogenic as the wildtype peptide (E39) in this randomized trial of optimal boosting strategies. More importantly, there appears to be a potential clinical advantage to the attenuated booster in this small trial. These results must be corroborated by further evaluation of this attenuated peptide vaccine and boosting strategy in a larger clinical trial.

Citation Format: Doreen O. Jackson, Timothy J. Vreeland, Diane F. Hale, Garth S. Herbert, Julia M. Greene, Erika J. Schneble, John S. Berry, Alfred F. Trappey, Guy T. Clifton, John C. Elkas, Chad Hamilton, Kathleen M. Darcy, George L. Maxwell, George E. Peoples. Comparing an attenuated booster (E39’) vs E39 booster to potentiate the clinical benefit of the folate binding protein (FBP)-derived vaccine (E39 + GM-CSF) in a phase I/IIa trial to prevent recurrence in endometrial (EC) and ovarian cancer (OC) patients. [abstract]. In: Proceedings of the 107th Annual Meeting of the American Association for Cancer Research; 2016 Apr 16-20; New Orleans, LA. Philadelphia (PA): AACR; Cancer Res 2016;76(14 Suppl):Abstract nr CT073.

The Use of Acellular Dermal Allograft for Vulvovaginal Reconstruction

Background:

Many different techniques that require the surgeon to harvest autologous tissue to create a neovagina have been described in the literature.

Technique:

We describe a technique for creating a neovagina with the use of an acellular dermal allograft as a replacement for split-thickness skin graft. Three patients are presented who had a successful creation of a neovagina with this technique. The indications for vaginoplasty include vaginal agglutination from lichen planus, squamous cell carcinoma of the vagina, and vaginal agenesis.

Conclusion:

The creation of a neovagina using an acellular dermal allograft can be successfully accomplished in patients undergoing constructive and exenterative procedures. The use of an acellular dermal allograft decreases operative time and decreases the incidence of postoperative morbidity because harvesting autologous tissue for the neovagina is not required.

Diffuse laminar endocervical glandular hyperplasia: a case report

BACKGROUND

Diffuse laminar endocervical glandular hyperplasia is extremely rare with only 14 cases reported in the literature. Diffuse laminar endocervical glandular hyperplasia is a benign lesion that is easily confused with malignancy.

CASE REPORT

We present a 22-year-old woman referred to our gynecologic oncology service with a 2.0 x 4.0-cm exophytic cervical mass. Colposcopic-directed cervical biopsies were diagnosed as adenocarcinoma, suggestive of minimal deviation adenocarcinoma. Computed tomographic scans of the abdomen and the pelvis failed to reveal any metastatic foci. A radical abdominal hysterectomy with pelvic and para-aortic lymph node sampling was performed without complications. Final pathology revealed diffuse laminar endocervical glandular hyperplasia.

CONCLUSIONS

Diffuse laminar endocervical glandular hyperplasia is an uncommon histological type of pseudoneoplastic glandular lesions that may be found in the cervix, and this entity should be considered in the differential diagnosis of a potentially malignant endocervical glandular lesion.

Metastatic leiomyosarcoma diagnosed after uterine artery embolization

Uterine artery embolization (UAE) allows treatment of recalcitrant fibroids, but does not provide a surgical specimen. In the rare instance that a uterine mass represents a uterine leiomyosarcoma (LMS), UAE may delay diagnosis. We report a case of a 45-year-old woman who underwent resection of a substernal mass five years after UAE. Pathology demonstrated LMS. She received radiation therapy to the surgical site. Upon recovery, she underwent a hysterectomy and bilateral salpingo-oophorectomy. Pathology demonstrated uterine LMS. She was managed conservatively and is without evidence of disease over two years after excision of her substernal mass. Multiple case reports have described a delay in diagnosis of uterine LMS after UAE. The current case is unique in that it the diagnosis was made based on the presence of a distant metastasis, which occurred years after UAE.

Normal endometrial cells in liquid-based cervical cytology specimens in women aged 40 or older

OBJECTIVE

The 2001 Bethesda System consensus statement directs the reporting of endometrial cells on cervical cytologic preparations in women aged 40 years or older. Our objective was to assess the significance of endometrial cells on cervical liquid-based cytology (LBC) specimens in this population.

METHODS

The population included women aged 40 years or older in whom endometrial cells were identified in otherwise normal LBC specimens from December 2001 through June 2005, and who subsequently underwent endometrial sampling within a 12-month period. Patient age, menopausal status, hormonal use, the presence or absence of co-incident symptoms and endometrial sampling results were recorded.

RESULTS

Endometrial cells were identified on LBC specimens in 2494 women during the study period, for an incidence of 0.4%. Of these, 370 women underwent endometrial sampling within 12 months of the incident LBC preparation and met inclusion criteria. In asymptomatic premenopausal women, sampled solely due to the presence of endometrial cells, 2.1% were identified with significant endometrial pathology, compared to 2.6% of symptomatic premenopausal women. In menopausal women, only those with symptoms (mainly bleeding) had significant pathology on subsequent sampling (25%); none of the asymptomatic menopausal women were found to have hyperplasia or carcinoma. No significant differences were identified in premenopausal women according to the time of sampling during the menstrual cycle or use of oral contraceptives.

CONCLUSION

Endometrial cells on LBC preparations, even in the absence of symptoms in premenopausal women aged 40 years or older, are associated with significant uterine pathology.

Is atypical squamous cells that cannot exclude high-grade squamous intraepithelial lesion clinically significant?

OBJECTIVE

To determine the cumulative risk of cervical intraepithelial neoplasia (CIN) 2 or 3 in patients with atypical squamous cells, cannot exclude HSIL (ASC-H).

METHODS

A retrospective analysis was performed to identify patients referred to the dysplasia clinic with ASC-H. Initial evaluation included colposcopy, endocervical curettage, and an ectocervical biopsy, when indicated, in all the patients. A follow-up evaluation was performed at 6 and 12 months. Cumulative histological diagnosis of CIN 2 or 3 at 12 months served as the clinical end point.

RESULTS

Two hundred twenty-nine patients with ASC-H and with a mean age of 32.8 years were evaluated. At the time of initial colposcopy, only 10.0% (23/229; 95% CI = 6.5%-15%) of the patients had histological evidence of CIN 2 or 3. The cumulative risk of CIN 2 or 3 was 12.2% (95% CI = 8%-17%).

CONCLUSIONS

Evaluation of patients with ASC-H with colposcopy does lead to the detection of CIN 2 or 3 but perhaps at a rate lower than previously reported.

Hematologic changes after splenectomy for cytoreduction: implications for predicting infection and effects on chemotherapy

Postsplenectomy leukocytosis and thrombocytosis are common findings in trauma patients. The intent of this study is to describe postsplenectomy hematologic changes in gynecological oncology surgery and subsequent chemotherapy. We performed a retrospective record review of gynecological oncology patients at our institutions. Postsurgical hematologic changes, infectious morbidity, and pre- and post-chemotherapy hematologic changes were noted. Data were analyzed using repeated measures analysis of variance. We identified 27 patients who underwent cytoreductive surgery with splenectomy. Thirteen patients with splenectomy had postoperative chemotherapy data available, and we matched these patients with 13 control patients who underwent cytoreduction surgery without splenectomy and postoperative chemotherapy. Nine of the 27 splenectomy patients had documented infectious morbidity. There was a significant difference in postoperative platelet counts between the infected and the noninfected splenectomy patients (P= 0.037), and a significant difference between splenectomy and control patients for white blood cell (WBC) counts (P = 0.007). Patients with splenectomy had higher precycle WBC, absolute neutrophil count (ANC), platelet counts, and higher postcycle nadir levels in all cycles compared to control patients. There was a significant overall difference between splenectomy patients and controls with regard to WBC (P = 0.001), ANC (P = 0.005), and platelet counts (P = 0.016) during chemotherapy cycles. Median postchemotherapy nadir WBC was 4.4 (range: 3.4-4.8) for the splenectomy group versus 2.8 (range: 2.5-3.0) for the control group. Median postchemotherapy nadir ANC was 1800 (range: 1320-2450) for the splenectomy group and 1001 (range: 864-1064) for the control group. Median postchemotherapy nadir platelet count was 222 (range: 181-277) for the splenectomy patients and 169 (range 164-215) for the control patients. In conclusion, the patients who undergo splenectomy as part of cytoreductive surgeries have a statistically significant leukocytosis and insignificant thrombocytosis relative to the control patients. Leukocytosis alone is not an accurate indicator of infection. Splenectomy is not associated with an increased risk of chemotherapy-related neutropenia and thrombocytopenia.

A phase I trial of oxaliplatin and topotecan in recurrent ovarian carcinoma

OBJECTIVE

Oxaliplatin and topotecan have demonstrated activity as single agents against recurrent platinum-sensitive and -resistant ovarian cancer, as well as synergy in vitro. This was a dose-finding study of combination therapy with weekly topotecan and alternating-week oxaliplatin in patients with recurrent epithelial ovarian cancer.

METHODS

Eligible patients had a diagnosis of recurrent ovarian or primary peritoneal carcinoma, a performance status of 0-2, and normal bone marrow, renal, and hepatic function. On days 1 and 15 of a 28-day cycle, patients received a fixed dose of oxaliplatin (85 mg/m2) via intravenous infusion. On days 1, 8, and 15, patients received an escalating dose of intravenous topotecan (2.0-4.0 mg/m2). Five dose levels were planned with a minimum cohort of 3 patients at each level.

RESULTS

Thirteen patients were enrolled and received a total of 50 cycles of chemotherapy. The maximum tolerated dose was 85 mg/m2 of oxaliplatin and 3.0 mg/m2 of topotecan, and grade 3 neutropenia was the dose-limiting toxicity. Four of nine (44%) evaluable patients had stable disease or a partial response to the drug combination as assessed by cancer antigen-125 levels.

CONCLUSIONS

A 28-day schedule of oxaliplatin and topotecan is safe and well tolerated. Because of the in vitro synergy observed between topoisomerase I inhibitors and platinum derivatives and the tolerability reported in the current study, this regimen warrants further investigation.

Sustained response to bevacizumab in refractory well-differentiated ovarian neoplasms

BACKGROUND

Bevacizumab has demonstrated activity against a variety of solid tumors, including ovarian carcinoma. However, there have not been reproducible prognostic features associated with its activity.

CASES

One patient each with recurrent, refractory well-differentiated serous-endometrioid ovarian carcinoma, micropapillary serous carcinoma of the ovary, and primary peritoneal micropapillary serous carcinoma were treated with single agent bevacizumab (15 mg/kg [DOSAGE ERROR CORRECTED] intravenously every 3 weeks). All three have had dramatic sustained responses of 15, 15, and 22 months' duration.

CONCLUSION

Bevacizumab may have significant activity against well-differentiated ovarian carcinoma and micropapillary serous carcinomas of the ovary or peritoneum. Since these tumors are generally indolent and not responsive to adjuvant therapy, further investigation is warranted.

Cost-effectiveness analysis of liquid-based cytology and human papillomavirus testing in cervical cancer screening

OBJECTIVE

To compare the outcomes of several cervix cancer screening strategies in a military population using a model that considers both direct and indirect costs of health care.

METHODS

A Markov model of the natural history of cervical cancer was used to simulate an age-stratified cohort of 100,000 active duty women in the U.S. Army. Total costs and incremental cost-effectiveness ratios were estimated for different modalities of screening: liquid-based cytology with testing for human papillomavirus (HPV) irrespective of cytologic results compared with liquid-based cytology with HPV detection for cytologic results of atypical cells of undetermined significance (reflex HPV). The costs and outcomes of these screening methods were evaluated separately as well as in combination (liquid-based cytology and reflex HPV before age 30 years and DNA and Pap test every 3 years thereafter). Each of these screening methods was evaluated at 1-, 2-, and 3-year intervals.

RESULTS

A screening strategy of liquid-based cytology and reflex HPV every 2 or 3 years is the least costly strategy among active duty women irrespective of age, especially when accounting for time costs associated with screening, diagnosis, and treatment of cervix cancer. A strategy of liquid-based cytology and HPV testing irrespective of cytology results is the most effective strategy; however, it is also the most costly of the strategies tested, even when performed in patients older than 30 years of age.

CONCLUSION

In the U.S. Army, cervix cancer screening performed with liquid-based cytology and reflex HPV testing of atypical squamous cells of undetermined significance performed every 2 years is cost-effective, especially when indirect costs are considered.

Spontaneous pregnancy following cytoreduction with peritonectomy and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Spontaneous pregnancy is rare after radical cytoreduction and intraperitoneal chemotherapy.

CASE

We present a case of a 28-year-old female with extensive, bulky malignant peritoneal epitheliod mesothelioma who underwent optimal cytoreduction with peritonectomy followed by intraoperative hyperthermic cisplatin and postoperative intraperitoneal paclitaxel and fluorouracil. Fourteen months after the conclusion of her therapy, she spontaneously conceived, resulting in an uneventful term pregnancy and spontaneous vaginal delivery.

CONCLUSION

Fertility may be preserved in select patients after radical cytoreduction and hyperthermic intraperitoneal chemotherapy.

The prevalence of HR-HPV DNA in ASC-US Pap smears: A military population study

OBJECTIVE

To determine the prevalence of HR-HPV DNA in ASC-US Pap smears following implementation of the Bethesda 2001 classification system.

METHODS

A computer database of Pap smears obtained within Department of the Army medical facilities was queried for the study period August 2002 to June 2004. All ASC-US Pap smears that underwent reflex testing for HR-HPV DNA were included. Additional clinical and demographic data were obtained from facilities within the US northeast region to evaluate the differences in ASC-US and SIL rates between the current and former Bethesda classification systems.

RESULTS

550,000 Pap smears were collected during the study period. The HR-HPV prevalence was 40.8% (95% confidence interval [CI] = 40.3 to 41.3) among 40,870 patients with ASC-US Pap smears. Within the northeast region, the HR-HPV prevalence in ASC-US Pap smears decreased from 61.2% (95% CI = 57.4 to 64.8%) in patients 18-22 years old to 24.9% (95% CI = 23.1 to 26.8%) in patients age 29 and older. When comparing the two classification systems, significant increases in both ASC-H and SIL and decreases in ASC-US were appreciated after the institution of Bethesda system 2001.

CONCLUSION

In our large, diverse cohort, the implementation of the Bethesda II system has resulted in a decrease in ASC-US Pap smear results. Additionally, the prevalence of HR-HPV in the ASC-US population was 40.8%, significantly lower than the rate noted in the ALTS trial under the Bethesda I classification system.

The impact of converting to liquid-based cervical cytology in a military population

OBJECTIVE

The liquid-based cytology Pap test was adopted as the exclusive collection method for cervical cytology in military treatment facilities within the National Capital Area in 2001. We sought to determine the impact of converting from conventional to liquid-based cervical cytology.

METHODS

A retrospective population-based study was performed to analyze the cervical cytology results from the National Capital Area for fiscal years 1999, 2000, 2002, and 2003. Using a computer database, the results of 78,738 conventional and 76,675 liquid-based cervico-vaginal cytology examinations were reviewed. All cytology samples during the study period were collected with the same collection device and were processed in a single laboratory.

RESULTS

An increase of 116% (P < 0.005) in the mean rate of LSIL detection and a 38% (P < 0.005) increase in HSIL detection were noted with conversion to liquid-based cytology. A 65% (P < 0.005) decrease in the mean rate of atypical glandular cell detection was also observed. However, a mean increase of 46% (P < 0.005) per year was noted in the unsatisfactory rate with conversion to liquid-based cytology. The incidence of cervical carcinoma did not change during the study period.

CONCLUSIONS

Consistent with previous reports, conversion from conventional to liquid-based Pap testing in this population resulted in a significant increase in the detection rates of both LSIL and HSIL. Contrary to earlier studies, we noted an almost 50% increase in the number of unsatisfactory samples after conversion. Further studies are warranted to determine the potential etiology of these findings to include the role of collection devices.

Novel techniques to improve split-thickness skin graft viability during vulvo-vaginal reconstruction

BACKGROUND

Split-thickness skin grafts are often utilized for vulvo-vaginal reconstruction. Unfortunately, infection and sloughing may occur in up to 22% of patients with standard techniques especially at irradiated recipient sites.

CASES

We report seven cases of vulvo-vaginal reconstruction using split-thickness skin grafts. In this series, we used fibrin tissue adhesives with and without vacuum-assisted closure devices to augment graft adherence and viability. We briefly describe the clinical history, surgical techniques, and outcomes of the cohort.

CONCLUSION

Fibrin tissue adhesives and wound vacuum-assisted closure devices may improve the viability of split-thickness skin grafts during vulvo-vaginal reconstruction.

Gynecologic Malignancies in Women Aged Less Than 25 Years

OBJECTIVE

To describe the epidemiologic characteristics of gynecologic malignancies in patients 25 years of age or younger.

METHODS

The Automated Central Tumor Registry (ACTUR), the cancer registry for the Department of Defense, was used to identify children, adolescents, and young adults diagnosed with gynecologic malignancies. Specifically, primary ovarian, uterine, cervical, vaginal, and vulvar malignancies diagnosed between 1990 and 2002 were included in the analysis. Data from the Department of Defense tumor registry were then compared with results obtained from the national Surveillance, Epidemiology, and End Report (SEER) program database.

RESULTS

Two hundred fifty-one cases were identified in the Department of Defense tumor registry. The most common primary site was ovary, with 116 cases (46%), followed by cervix, with 108 cases (43%). The most common histological types were germ cell (35%) for ovary, squamous cell (52%) for cervix, choriocarcinoma (18%) for uterus, and squamous cell (30%) for vulva/vagina. The 21- to 25-year-old age group had the greatest number of cases for the entire cohort (23%). Most patients had only local disease at time of diagnosis, and the 5-year survival percentage was 86% (95% confidence interval 80-91) for all patients with ovarian and cervical carcinoma. Data from the SEER program demonstrated a similar distribution and incidence pattern.

CONCLUSION

The ovary and cervix are the most common primary sites of gynecologic malignancies in patients 25 years of age or younger. Health maintenance programs for patients in this age group should continue to include pelvic exams and Pap test screening.

Conservative Management of Extra-Adrenal Pheochromocytoma During Pregnancy

BACKGROUND

Extra-adrenal pheochromocytomas are catecholamine-secreting tumors that arise from chromaffin cells of the paraganglion sympathetic system. All of the previously reported cases have described surgical resection during the antepartum period.

CASE

At 14 weeks of gestation, a multiparous patient was diagnosed with an extra-adrenal dopaminergic pheochromocytoma. A decision was made to delay surgical intervention until the postpartum period. Phenoxybenzamine, 10 mg per day, was subsequently started. At 35 + 2 weeks of gestation, the patient delivered a 2,600 g infant via an uncomplicated cesarean. Three weeks later, the extra-adrenal pheochromocytoma was removed, and she also underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and rectosigmoid resection with end-to-end colostomy.

CONCLUSION

Conservative management of dopaminergic-secreting extra-adrenal pheochromocytomas can result in favorable maternal and fetal outcomes.

Lower urinary tract reconstruction with ileum in the treatment of gynecologic malignancies

INTRODUCTION

Advanced or recurrent gynecologic malignancies can invade or obstruct the lower urinary tract. If extirpation is necessary for cytoreduction or repair of radiation sequelae, treatment has typically involved creation of either an ileal conduit or a cutaneous continent urinary diversion. As an alternative, a more limited resection with urinary tract reconstruction using ileum for interposition or augmentation may allow for the preservation of urethral voiding.

CASES

We describe the use of ileal segments for lower urinary tract reconstruction in the treatment of ten patients with advanced or recurrent gynecologic malignancies. The clinical history, surgical technique, and patient outcomes are reviewed.

DISCUSSION

These cases demonstrate that limited bladder or ureteral resection with reconstruction using ileal segments may offer select patients preservation of urethral voiding.

The Use of Acellular Dermal Graft for Vulvovaginal Reconstruction in a Patient With Lichen Planus

BACKGROUND

Vulvovaginal lichen planus is an inflammatory dermatosis that can progress to an erosive form with scarring of the vulva, resorption of the labia minora, vaginal synechiae, and vaginal obliteration secondary to desquamative vaginitis. Traditionally, conservative medical therapy has consisted of topical corticosteroids and immunosuppressants.

CASE

A 61-year-old woman with a history of refractory erosive vulvovaginal lichen planus presented with complete obliteration of the vaginal vault. The patient failed both medical and conservative surgical management and desired definitive management. After performing a skinning vulvectomy and simple vaginectomy, acellular dermal graft was used for grafting the vulva and creating a neovagina.

CONCLUSION

Acellular dermal graft is a suitable graft material for vulvar and vaginal reconstruction in select patients, and it avoids the postoperative pain associated with graft harvest sites.

The utility of hand-assisted laparoscopy in ovarian cancer

INTRODUCTION

The traditional approach to patients with ovarian cancer is cytoreductive surgery and surgical staging through a vertical midline laparotomy. While laparoscopy has become an integral part of gynecologic surgery, debulking procedures have not been feasible to date with standard minimally invasive techniques.

METHODS AND MATERIALS

Twenty-five patients with ovarian carcinoma underwent surgical staging and cytoreduction using hand-assisted laparoscopy. We review the surgical technique and clinical outcomes.

RESULTS

Twenty-five patients were managed during this study time frame with hand-assisted laparoscopy. Six patients had apparent advanced stage ovarian cancer at the time of referral, and 17 patients had apparent early-stage ovarian cancer. Of the 19 patients with presumed early-stage disease, 5 patients were upstaged based on retroperitoneal lymph node involvement, 3 with disease to other pelvic structures, and 2 patients had microscopic disease in the omentum. Twenty-two patients had their surgeries completed via hand-assisted laparoscopy, and three cases required conversion to laparotomy for completion of debulking surgery. Complication rates were low with three complications requiring reoperation or hospitalization. The mean hospital stay was 1.8 days for the 22 patients who had a successful hand-assisted laparoscopic evaluation. Operating times were variable and ranged from 81 to 365 min.

CONCLUSION

Hand-assisted laparoscopy may be employed in the initial management of early and advanced stage ovarian carcinoma. This approach allows for thorough evaluation of peritoneal and retroperitoneal structures and surgical cytoreduction while retaining the advantages of minimally invasive surgery.

Prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions diagnosed during pregnancy

BACKGROUND

In the current study, the authors sought to examine the prognosis and recurrence risk for patients with cervical squamous intraepithelial lesions (SILs) diagnosed during pregnancy.

METHODS

A retrospective review of all women who gave birth at Walter Reed Army Medical Center (Washington, DC) or the National Naval Medical Center (Bethesda, MD) between 1986 and 1997 was performed. One hundred fifty-seven patients with SILs who underwent antepartum and postpartum evaluation were identified from a total of 6248 records of birth at these two institutions. Patient demographics and cervical cytology and histology were reviewed.

RESULTS

One-hundred twenty-nine patients were diagnosed with low-grade squamous intraepithelial lesions (LSILs) antepartum. Of these patients, 49 (38%) had a previous history of abnormal cervical cytology (30 LSILs and 19 high-grade squamous intraepithelial lesions [HSILs]). Twenty-eight patients were diagnosed with HSIL antepartum. Of these patients, 24 (86%) had a history of abnormal cervical cytology. Sixty-two percent of patients with antepartum LSILs had disease regression postpartum, 32% had persistent LSILs postpartum, and 6% experienced progression of an LSIL to an HSIL. All cases of HSIL that were diagnosed antepartum persisted on postpartum cytologic examination. Three patients were found to have microinvasive squamous cell carcinoma after postpartum conization. Five years of follow-up data were available for 98 patients (60%), 78 of whom had antepartum LSILs and 20 of whom had antepartum HSILs. Sixty percent of patients with antepartum LSILs detected on Pap smear developed recurrent LSILs within 5 years, and all 20 patients with antepartum HSILs developed recurrent HSILs within 5 years.

CONCLUSIONS

Most cases of LSIL regressed or remained stable during pregnancy. All cases of HSIL diagnosed antepartum persisted in the postpartum period, and 11% of patients with antepartum HSILs were found to have invasive carcinoma postpartum. High rates of recurrence for both LSIL and HSIL were noted 2-5 years after the diagnosis of SIL in the antepartum.

The utility of gastrojejunostomy in secondary cytoreduction and palliation of proximal intestinal obstruction in recurrent ovarian cancer

BACKGROUND

Gastrointestinal obstruction is a common complication of recurrent ovarian cancer. Proximal intestinal obstruction, at the level of the duodenum or proximal jejunum, can result from bulky intraperitoneal or retroperitoneal disease. Classic management has been palliation of symptoms with a gastrostomy or jejunostomy tube.

CASE

We describe a series of four patients with recurrent ovarian carcinoma and proximal intestinal obstructions treated with a bypass stapled side-to-side gastrojejunostomy at the time of secondary cytoreduction or surgical palliation. The clinical history, preoperative evaluation, surgical technique, and outcomes of each patient are reviewed.

CONCLUSIONS

Gastrojejunostomy may offer patients with ovarian cancer and a proximal intestinal obstruction symptomatic relief and an opportunity for resumption of enteral feedings.

The use of continuous infusion topotecan in persistent and recurrent ovarian cancer

We retrospectively review our experience with continuous infusion topotecan for the treatment of persistent or recurrent ovarian cancer in this paper. Nine patients were identified who were treated at the University of California Los Angeles Medical Center between January 1997 and December 1999 using a 14-21 day continuous infusion schedule (0.3-0.7 mg/m2/d). Dose adjustments were performed for grade 3-4 toxicities and treatment was discontinued for persistent severe toxicity or progressive disease. Response to treatment was analyzed and stratified by platinum refractory, resistant, and sensitive disease. A total of 41 treatment cycles were given to nine patients with a median of five per patient (range 1-11). Median follow-up was 8 months. There were two partial responses (22%) and four patients had stable disease (44%), which included two patients with platinum-refractory tumors. No grade 3 or 4 hematologic toxicities were observed. However, two patients suffered grade 3 gastrointestinal toxicity during the first cycle leading to discontinuation of topotecan administration. There was no cumulative toxicity. Topotecan administered by continuous infusion demonstrated response rates comparable to other dosing schedules with minimal hematologic toxicity. Treatment of patients with persistent or recurrent ovarian cancer with continuous infusion topotecan warrants further investigation.

A human ovarian carcinoma murine xenograft model useful for preclinical trials

OBJECTIVE

To establish a murine xenograft model of human ovarian carcinoma.

METHODS

A slurry of fresh human tumor from patients with intraperitoneal malignancies was heterotransplanted intraperitoneally into nude (nu/nu) and severely combined immunodeficient mice (CB-17, SCID). Xenograft growth was assessed by serial examination and necropsy. The xenografts were passaged to new animals when tumors were palpably greater than 1 cm(3). Histopathologic analysis of the xenografts was performed at each passage as well as immunohistochemical staining for p53 mutations. Persistent expression of human genes by the xenografts at higher passages was assessed by RT-PCR amplification of the human beta-globin gene. This xenograft model was used in the preclinical evaluation of an adenoviral vector containing a beta-galactosidase reporter gene and a wild-type p53 gene.

RESULTS

Tumor growth was not established in any of the nude mice heterotransplanted with tissue from six different ovarian cancer patients. Eleven of 13 specimens established xenograft growth when injected in SCID mice. Nine xenografts have been subsequently passaged between 6 and 24 animal generations to date. All xenografts retained histopathologic similarities to their original human tumors and the p53 expression patterns remained stable through higher passages. Within 24 h after intraperitoneal administration of an adenoviral vector, transduction of the reporter gene was evident in the xenografts. In addition, administration of an adenoviral vector containing a wild-type p53 gene significantly decreased the tumor burden compared to controls (P < 0.04).

CONCLUSIONS

This murine xenograft model of human ovarian carcinoma appears to be reliable and reproducible and has utility for the study of novel therapeutics.

Modified technique for urinary diversion with incontinent conduits

BACKGROUND

Incontinent urinary diversions are frequently performed in gynecologic oncology. The incontinent urinary diversions generally utilize a short segment of distal ileum or colon as a conduit. Conduit complications such as anastomosis leaks and strictures may be related to the technique utilized for inserting and securing the ureters and the degree of postimplant manipulation.

TECHNIQUE

We describe a technique using a metal Yankaur suction device placed through the conduit's matured stoma to facilitate the mucosa-to-mucosa anastomosis of the ureters. This procedure allows for tension-free ureteral anastomoses, the isolation of the ideal conduit length, optimal stomal maturation, and reduced manipulation of the conduit after the ureteral anastomoses.

CONCLUSION

This modification provides an elegant, yet simple and expedient, method of ureteral anastomosis to the incontinent urinary conduit.

Effect of 1st-trimester loss on restoration of the hypothalamic-pituitary-ovarian axis

This randomized prospective study was conducted to determine the length of time required for re-establishment of the reproductive axis following a 1st-trimester spontaneous abortion. The spontaneous gonadotropin secretion was significantly depressed during the first menstrual cycle after pregnancy loss, while the estradiol levels had normalized. Provocative testing revealed blunted gonadotropin release in the first menstrual cycle with return to normal during the first menstrual cycle after a spontaneous abortion. Endometrial biopsy specimens were also abnormal during the first menstrual cycle with normal histological characteristics by the second menstrual cycle. Therefore, restoration of the hypothalamic-pituitary- ovarian axis after a 1st-trimester loss is achieved within two menstrual cycles, as determined by return of normal pituitary function.