Abstract PD09-09: The Akt inhibitor MK-2206 is an effective radio-sensitizer of p53 deficient triple negative breast cancer (TNBC) cells

Purpose: Triple negative breast cancer (TNBC) is an aggressive tumor with a higher locoregional recurrence compared to estrogen receptor (ER) positive breast cancer. Mutations in the PI3K/Akt/mTOR pathway leading to up-regulation of Akt occur with high frequency in TNBC. Hyperactive Akt is associated with increase radiation resistance, mediated through inhibition of apoptosis and up-regulation of DNA damage-induced G2 arrest. p53 plays a key role in mediating G1 cell cycle arrest following genotoxic stress such as radiation; p53-deficient cells however must rely on alternate mechanisms for cell cycle arrest in S- and G2-phases. Inhibition of Akt therefore would be expected to act in a synthetic lethal fashion to radiosensitize p53 deficient TNBC cells by decreasing their ability to arrest in G2. Given that p53 mutations occur in 44% of TNBC this may be an effective strategy for radiosensitizing TNBC.

Methods: Experiments were conducted using MDA-MB-468, MDA-MB-231 and SUM 149 cells, all well established models for p53-deficient TNBC. Cells were treated with MK-2206, a potent allosteric Akt inhibitor, alone or in combination with increasing doses of radiation from 0–8 Gy. In vitro studies preformed included; cell survival assays, MTT assay, immunoblot analysis of key proteins, FACS analysis for cell cycle, apoptosis, and gH2AX staining.

Results: We found that the combination of IR and Akt inhibition by MK-2206 is synergistic. MK-2206 inhibited both endogenous and radiation-induced Akt activation and phosphorylation of its down-stream targets. Decreased clonogenic survival was seen after 2 or 24 hours pretreatment with MK-2206 as well as decreased viability by MTT assay. Cell cycle analysis demonstrates MK-2206 decreases the proportion of cells in G2/M arrest following irradiation, as well as induced a greater proportion of apoptosis. Evaluation of the DNA damage response pathway demonstrated decreased levels of total DNA-PK, as well as a delayed DNA damage response.

Conclusions: These studies demonstrate that targeted inhibition of Akt effectively radiosensitizes p53 deficient TNBC cells lines, possibly through a synthetic lethal effect on the DNA damage response.

Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr PD09-09.

Anti-tumor activity of histone deacetylase inhibitors and the effect on ATP-binding cassette in ovarian carcinoma cells

INTRODUCTION

Ovarian cancer is of worldwide importance, and has a significantly high mortality rate due to therapy failure. Drug resistance might be one of most importance factors. Histone deacetylase inhibitors (HDACi) have been reported to be a new class of promising anti-tumor agents, thus this study aimed to investigate the effect of HDAC on the chemo-resistance genes of human ovarian carcinoma cell lines.

METHODS

The expressions of ATP binding cassette (ABC) transporter genes, multidrug-resistant protein (MDR1) and multidrug resistance-associated proteins (MRP1 and 2) of ovarian cancer cell lines OC-109 and SK-OV-3 after HDACi treatment were determined.

RESULTS

HDACi, including sodium butyrate (NaB), suberoylanilide hydroxamic acid (SAHA) and trichostatin A (TSA) reduced ovarian cancer cell viability from 4.4% to 68.8%, in both dose- and time-dependent manners. The effect of HDACi on MDR1, MRP1, and MRP2 showed induced expression of MDR1 mRNA, but reduced mRNA expression of MRP1 and MRP2.

CONCLUSIONS

The effect of HDACi on the reduced viability of ovarian cancer cell lines, concomitant with the induced expression of MDR1 and reduced expression of MRP1 and 2, might provide additional benefits in the management of ovarian cancers in the future.

Blockade of interleukin 6 accelerates acinar cell apoptosis and attenuates experimental acute pancreatitis in vivo

BACKGROUND

It remains unclear whether interleukin (IL) 6 plays a role in initiating either the inflammatory or antiapoptotic responses in severe acute pancreatitis. This study examined the effect of neutralizing antibody against IL-6 on the induction of pancreatic acinar cell apoptosis and attenuation of the severity of severe acute pancreatitis.

METHODS

Experiments were conducted on laboratory mice with severe acute pancreatitis induced by lipopolysaccharide injection following six injections of caerulein at intervals of 6 h. Neutralizing monoclonal anti-IL-6 antibody was administered either 5 min or 2 h after the first caerulein injection. Apoptosis in pancreatic sections was determined by the terminal deoxynucleotidyltransferase-mediated dUTP-biotin nick-end labelling method.

RESULTS

Administration of caerulein and LPS induced an increase in serum amylase and IL-6 levels, severe acute pancreatitis, pancreatitis-associated lung injury, and phosphorylation of signal transducer and activator of transcription (STAT) 3 in the pancreas. A neutralizing antibody against IL-6 effectively suppressed these responses. Application of IL-6 neutralizing antibody caused the induction of apoptosis in the pancreatic acinar cells of mice with acute pancreatitis.

CONCLUSION

Blocking IL-6 suppresses STAT-3 activation in the pancreas and consequently attenuates the severity of severe acute pancreatitis by promotion of pancreatic acinar cell apoptosis.

Radical hysterectomy: past, present, and future

After an analysis of 3,441 radical hysterectomies performed in our department, we found, after modification of the operative technique in 1983, the more lateral the excision the less the recurrence rate. The recurrence rate for Stage 1b-2a and Stage 2b patients comparing the years before 1983 to the years after decreased to 12.4% from 15.7% (158/1,006 vs 268/2,163; p = 0.009) in Stage 1b-2a and 24.6% from 55.8% (38/68 vs 47/191; p = 0.0007) in Stage 2b, respectively. With the modern trend of aspiring for an easier lifestyle, most physicians practice earlier. Therefore only very few physicians study radical hysterectomy. As the skill of surgery needs a longer period of education and training, it may only interest physicians who work with medical professionals as part of a team at a medical center. In the future, we should provide gynecological residents not only with a training program using the classic textbooks, but also with different points of view on changes and developments in radical hysterectomy. We hope to promote an attitude of offering patients access to different choices and opportunities of therapy. Radical hysterectomy is in fact a treatment option for patients with bulky cervical lesions and Stage 2b in particular.

Detection of HPV infection by analyzing the changes in structure of peripheral blood lymphocytes specifically induced by HPV E7 antigen

PURPOSE

Detection of human papilloma virus (HPV) infection in clinical practice was examined based on the observation that peripheral blood lymphocytes exposed in vitro to antigenic or mitogenic stimulation change their intracellular structures as measured by polarization of fluorescent light emitted by labeled cells.

MATERIALS AND METHODS

A total of 47 women were enrolled in this study. They were classified into four groups based on the results of HPV-DNA detection in cervical tissues by the Hybrid Capture II kit (Digene, Gaithersburg, MD, USA) and pathological examination. Ten women with no HPV-DNA detection were used as a normal control group. Fifteen women without pathological diagnosis in the cervical tissues had HPV-DNA detection. Ten women with CIN lesions had 80% HPV-DNA detection. Twelve women with invasive squamous cell carcinoma had 100% HPV detection. Peripheral blood lymphocytes derived from all women were collected and then exposed to HPV-E7 antigen and PHA mitogen.

RESULTS

The positive response rate of HPV-E7 antigen was ten percent (1/10) in the normal control group, 73.3% (11/15) in the HPV infectious women, 50% (5/10) in the CIN women, and 91.7% (11/12) in the cervical cancer patients. The overall sensitivity rate of blood tests was 77.1% and the specificity rate was 57.8% when the Hybrid Capture II HPV Test kit was used as the standard detection method for cervical tissue.

CONCLUSIONS

The results showed that peripheral blood lymphocytes derived from patients with cervical lesions might be another choice to be used as a screening method to detect HPV infection compared with conventional methods.

Improved early detection of cervical intraepithelial lesions by combination of conventional Pap smear and speculoscopy

PURPOSE

To evaluate the efficacy of the addition of speculoscopy to a Pap smear in cervical cancer screening.

METHODS

All women were screened using the Pap smear plus speculoscopy (PapSure) and colposcopy in the multicenter trial. The final diagnosis of each patient was based on a histological evaluation of the colposcopic target biopsy. Results were analyzed using a proportional compare test, sensitivity, specificity and predictive value with significant value determined at less than 0.05.

RESULTS

Of 1,717 eligible cases, 26 cases had LGSIL and 16 cases had HGSIL. Of the Pap smears, five cases had LSIL and 14 cases had HGSIL. Of the combination of the PapSure, 23 cases had LGSIL and 16 cases had HGSIL. The sensitivity of the Pap smear to that of PapSure was calculated at 45.2% and 92.9%, respectively (p < 0.001). The estimated cost to detect a cervical lesion using PapSure is less than that of the Pap smear.

CONCLUSION

The addition of speculoscopy along with a Pap smear screening results in early detection of cervical lesions in comparison to the Pap smear alone. This screening combination is also more cost-effective and requires fewer visits to the clinic in comparison to a Pap smear screening alone.

Extramammary Paget's disease found by abnormal vulvar brush sampling

INTRODUCTION

Doctors are usually reluctant to perform a vulvar biopsy on a patient with non-specific chronic vulvitis--especially because of the rarity of vulvar malignancy in young women--until the lesion is suspected of being malignant. Therefore, most cases of extramammary Paget's disease (EMPD) were originally misdiagnosed as chronic and recurrent vulvar lesions. Late diagnosis of invasive lesions occurring in elderly females have resulted in cases of death.

CASE

A 37-year-old patient showed an extended lesion on the vulva and perineum. In addition, abnormal cells were found from a vulvar scrape smear, and a following punch biopsy was used to diagnose and determine the extension of the disease.

CONCLUSION

Diagnosis and demarcation of EMPD remain difficult due to the multifocal lesions and subtle nature of the disease. Brush sampling taken from suspicious areas can be a guide for multiple biopsies to demarcate the lesion before major surgery. A brush biopsy is presented as a first-step method to detect vulvar malignancy.

Identifying local tumor variables for operable node-negative, margin-free patients with bulky cervical carcinoma of FIGO stage IB, IIA and IIB without adjuvant therapies

PURPOSE

To identify local risk factors for FIGO IB, IIA and IIB bulky cervical squamous cell carcinoma (tumor size > or = 4 cm) patients with node-negative, margin-free tumors treated by radical hysterectomy, pelvic lymph node and para-aortic lymph node dissections without adjuvant therapies.

MATERIALS AND METHODS

Thirty-four patients were recruited between 1976 and 1989 because they all declined any postoperative adjuvant therapy. The pathology reports showed that all the specimen margins were free from cancer cells with no para-aortic or pelvic lymph node metastases. The survival interval was calculated starting from the time of surgical intervention to the time of death or the end of this study in the year 2000.

RESULT

Tumor variables including cell differentiation, depth of stromal invasion, parametrial invasion, vaginal invasion, uterine body invasion, age, and FIGO stage were analyzed. Only vaginal invasion showed statistical significance for decreasing patient disease-free survival in both univariate and multivariate analyses with p values of 0.003 and 0.002, respectively.

CONCLUSION

For node-negative and margin-free patients with bulky cervical squamous cell carcinoma with operable stage IB and IIB, surgical intervention alone could suffice when no vaginal invasion is noted plus an 85% survival rate could be achieved. A prospective pilot study should be initiated although this study showed an excellent survival rate which is perhaps due to the limited number of cases.

Cross [2 + 2] cycloaddition of bicyclic alkenes with alkynes mediated by cobalt complexes: a facile synthesis of cyclobutene derivatives

Bicyclic alkenes 1a-e and 5 undergo [2 + 2] cycloaddition with a variety of alkynes PhC(triple bond)CPh, (TMS)C(triple bond)CH, HC(triple bond)C(CH(3))(2)OH, (TMS)C(triple bond)CCO(2)Et, PhC(triple bond)CCH(3), C(2)H(5)C(triple bond)CC(2)H(5), CH(3)C(triple bond)CC(3)H(7), and CH(3)C(triple bond)CC(2)H(5) in the presence of Co(PPh(3))(2)I(2), PPh(3), and Zn powder in toluene to afford the corresponding exo-cyclobutene derivatives 3a-m, 6, and 8a-g in fair to excellent yields. The yield of this cycloaddition is highly sensitive to the cobalt catalyst, solvent, ligand, and temperature used. A mechanism involving a metallacyclopentene intermediate is proposed to account for this cobalt-catalyzed cyclization.

Establishment and characterization of a cell line, MT-213-VGH, isolated from a mixed müllerian tumor of the uterus

OBJECTIVE

To establish a cell line from a woman with malignant mixed müllerian tumor of the uterus and to examine the biologic properties of this cell line (MT-213-VGH).

STUDY DESIGN

Cells were cloned by the limiting dilution method. Histologic staining of mixed müllerian (mesodermal) tumor (MMMT) cells was performed with May-Grünwald-Giemsa and hematoxylin and eosin stain. After more than 20 passages, cells were used to estimate the population-doubling time and colony-forming efficiency of MMMT cells. The cell line exhibited considerable variation in the degree of sensitivity to diverse chemotherapy drugs in vitro.

RESULTS

MMMT cells containing antigens for vimentin and myoglobin were detected, but those for CA-125, carcinoembryonic antigen, cytoskeleton, desmin, epithelial membrane antigen and fibronectin were not found. In addition, MT-213-VGH cells contained a mucinous substance; its chromosome model number is 45. This cell line showed differential sensitivities to chemotherapeutic agents, such as bleomycin, cisplatin, 5-fluorouracil and vinblastine.

CONCLUSION

The establishment and availability of the number cell line MT-213-VGH for a malignant mixed müllerian tumor of the uterus should assist in research on new methods of managing this type of gynecologic cancer.

Power Doppler angiographic appearance and blood flow velocity waveforms in invasive cervical carcinoma

OBJECTIVES

The aim of this study was to investigate the effectiveness of transvaginal power Doppler angiography in predicting cervical malignancy by detecting intratumoral blood flow and to understand the relationship between squamous cell carcinoma (SCC) serum levels and intratumoral blood flow analysis of invasive cervical carcinoma before treatment.

METHODS

Thirty-eight patients with cervical carcinoma (35 with stages Ia to IVb invasive carcinoma, 3 with cervical carcinoma in situ) were enrolled for the evaluation of tumor flow using transvaginal ultrasound accompanied with power Doppler angiography before surgery. The pulsatility, resistance index, and vascular index of tumor flow were measured. Thirty patients with proven healthy cervices were used as the control group. Pretreatment SCC serum levels were obtained in 34 women with cervical carcinoma.

RESULTS

The pulsatility index and resistance index were significantly lower in the study group than in the control group (P < 0.0001). The vascular index was also significantly lower in the study group than in the control group (P < 0.0001). There were no significant differences among patients with SCC type and non-SCC type cervical carcinoma (P > 0.05) among the six parameters. There was no significant correlation between the pretreatment SCC serum levels with any of the six parameters obtained from the intratumoral blood flow analysis in the SCC group.

CONCLUSIONS

Transvaginal ultrasound with power Doppler angiography is a valuable diagnostic tool for differentiating benign tumors of the cervix from malignant ones. Intratumoral blood flow of the cervix supplied us with practical diagnostic information before surgery and may aid in early prediction and management of cervical carcinoma. The use of transvaginal ultrasound with power Doppler angiography in the grading of vascularity ratio within cervical masses provided more sonographic characteristics among the different subclassifications of cervical cancer and is more useful than color Doppler imaging in the visualization of sonographic morphology.

Ruptured metastatic ovarian carcinoma presenting as acute abdomen

Acute abdomen is a challenge to first-line physicians because of frequently missed diagnoses and potential follow-on legal problems. Improving the management of these patients is of paramount importance, not only for saving lives, but also for reducing untoward problems associated with improper management. We present a case of a patient with acute abdomen due to intraperitoneal hemorrhage secondary to rupture of an ovarian tumor. Following emergency surgery, the patient was diagnosed with metastatic ovarian carcinoma. Because of improper preparation of the gastrointestinal tract, the patient underwent repeat exploratory laparotomy for colon carcinoma. Although this situation did not affect the outcome of the patient in this case, we are concerned that the patient did not benefit from a single operation, with primary complete excision of the tumor plus a colostomy. The outcome of patients with pelvic malignancy, especially those with ovarian carcinoma, might be better if initial surgery achieved optimal tumor debulking. This is possible with good preoperative planning and preparation. We emphasize the importance of preoperative preparation in spite of urgently needed care. Furthermore, every first-line physician should communicate the possibility of malignancy to patients and their families.

Treatment of primary pure angiosarcoma of ovary with multiple lung metastases: a case report

Angiosarcomas rarely involve the female genital tract. There have only been sporadic case reports of angiosarcomas of the cervix, uterus, vagina, parametrium, broad ligament and pelvis, and only 11 well-documented case reports of primary ovarian angiosarcoma in the English language literature to date. We present a case of primary pure ovarian angiosarcoma with lung metastasis that had partial response after chemotherapy with adriamycin and ifosfamide. But pulmonary hemorrhage and respiratory failure resulted in her death 7 months after initial diagnosis.

Accidentally delayed diagnosis of ruptured ovarian carcinoma in a young woman: a care report

Ovarian carcinoma commonly occurs in postmenopausal women and often presents with an insidious course. Acute abdomen is rarely an initial symptom. When these patients present with abdominal discomfort, the disease has already spread throughout the peritoneal cavity. We present a case of mucinous cystadenocarcinoma in a young woman who presented with acute abdomen and intra-abdominal bleeding. This 24-year-old woman was previously diagnosed with a ruptured left ovarian cystic tumor at a primary clinic. She underwent emergency exploratory laparotomy, followed by unilateral salpingo-oophorectomy at the clinic. No thorough examination of the peritoneal cavity was done during surgery. The diagnosis of mucinous cystadenocarcinoma was accidentally over-looked until one month later when she returned for routine follow-up. Upon referral to our clinic, the patient underwent a repeat laparotomy. The surgicopathologic diagnosis was intraperitoneal carcinomatosis stage IIIC that could not be excised completely, even though rigorous staging surgery including washing cytology, total abdominal hysterectomy, salpingo-oophorectomy, retroperitoneal lymphadenectomy, appendectomy, infracolic omentectomy and excision of any suspicious and removable lesions were performed. This case alerts us to consider the possibility of ovarian malignancy when a young woman presents with an acute abdomen secondary to ruptured ovarian cystic tumor and intraperitoneal hemorrhage. Careful preoperative preparation and thorough intrasurgical examination of the peritoneal cavity along with a prompt pathologic diagnosis of suspicious lesions will prevent missed diagnoses.

Primary malignant lymphoma of the cervix in pregnancy. A case report

BACKGROUND

Malignant lymphoma arising from the uterine cervix is a very rare entity. Only two such patients have been reported as pregnant at the time of diagnosis.

CASE

A 35-year-old woman (negative Pap smear at antenatal clinics) was referred because of the accidental finding of a huge cervical mass during labor. The patient underwent cesarean section because of arrest of cervical dilatation and persistent floating of the fetal head. The final diagnosis of this cervical mass was malignant lymphoma, low grade B cell, after radical abdominal hysterectomy.

CONCLUSION

Although labor obstructed by a tumor of the pelvic organs is a relatively rare event and the majority of cases are benign leiomyomas of the uterus or cervix, the risk of pelvic malignancies should be considered. Bimanual examination and pelvic ultrasound and/or color Doppler ultrasound should be applied without hesitancy in any uncertain situation during pregnancy or labor.

Ovarian tumors complicating pregnancy. Emergency and elective surgery

OBJECTIVE

To retrospectively evaluate the different effects and characteristics of ovarian surgery performed under emergency conditions and electively during pregnancy and to search for risk factors contributing to emergency ovarian surgery.

STUDY DESIGN

Between 1980 and 1996, 174 patients undergoing adnexal surgery during pregnancy or the puerperium were reviewed at Veterans General Hospital-Taipei. Of these 174 patients, 32 underwent emergency surgery (group A), while 142 patients underwent elective surgery (group B). In order to search for differences between the emergency and elective operations, patients in both groups were analyzed, with particular emphasis on the characteristics and outcome of pregnancy.

RESULTS

In contrast to elective operations, there were five distinct aspects of emergency surgery. First, half of them occurred in the first trimester. Second, they contributed to 75% (9/12) of the total fetal wastage and 85.7% (6/7) of spontaneous fetal loss (P = .00016). Third, tumor sizes (11.1 +/- 4.2 cm) were significantly larger than those found (8.3 +/- 3.76 cm) in the elective surgery group (P < .05). Fourth, tumors less than 5 cm never caused symptoms requiring surgery. Fifth, an increasing incidence of completely extirpative surgery and general anesthesia was noted (P < .005). Incidence of tumors greater than 10 cm during pregnancy increased with malignancy (P = .0295) and before emergency surgery (P = .00001).

CONCLUSION

We could remove ovarian tumors greater than 10 cm in diameter or with a teratoma component at earlier stages of pregnancy (after the seventh week of gestation) to avoid unpredictable complications. This reduces the risks of malignancy and emergency surgery. There was no evidence of increasing risk of fetal loss when surgery was performed after the seventh week of gestation.

Malignant mixed mesodermal tumor presenting as metastatic lymph node adenosquamous cell carcinoma: a case report

A solitary inguinal lymph node metastasis from a poorly differentiated adenosquamous cell carcinoma of unknown origin in a 52-year-old female is described. The patient was reported to have had a 2-cm palpable mass in the left inguinal area for three years. She had made regular annual clinic visits for Pap smears since the age of 45 years. Her last visit was eight months prior to a complaint of progressive abdominal distention and dull pain of three months' duration. Physical examination showed a huge pelvic mass, and ultrasound and magnetic resonance imaging of the abdomen showed a 12-cm complex solid mass on the left ovary. The patient underwent a complete excisional biopsy of the left inguinal lymph node. Frozen section pathology revealed a poorly differentiated adenosquamous cell carcinoma. Exploratory laparotomy immediately followed pathologic confirmation of malignancy of the left inguinal lymph node. Complete surgical staging including abdominal cytology, total abdominal hysterectomy, bilateral salpingo-oophorectomy, infracolic omentectomy, retroperitoneal lymph node sampling and excisional biopsy was performed for all suspicious lesions. Stage IIIC malignant mixed mesodermal tumor (MMMT) was diagnosed due to positive left inguinal lymph node metastasis. However, the retroperitoneal lymph node and intra-abdominal cavity did not show spread of the tumors, except those confined to the left ovary with adhesion to the cul-de-sac, and sole lymph node metastasis in a left inguinal lymph node. Although we could not prove that the left inguinal lymph node metastasis had been present for the three years that it was palpable without histologic confirmation, we believe that any enlarged inguinal lymph node might be the first hint of underlying malignancy in the pelvic area, lower extremities or perineal area. In cases of a poorly differentiated carcinoma of inguinal lymph nodes of unknown origin, the abdomen should be carefully evaluated.

Preoperative diagnosis of primary fallopian tube carcinoma by magnetic resonance imaging: a case report

Because of the rarity and insidious onset of primary adenocarcinoma of the fallopian tube, early diagnosis is very difficult. Primary fallopian tube carcinoma is also rarely diagnosed preoperatively. This report reviews the value of magnetic resonance imaging (MRI) in aiding the detection of early-stage primary fallopian tube carcinoma in a 48-year-old female. The diagnosis was based on clinical suspicion, elevated CA-125 and MRI. MRI demonstrated the tumor as an area of solid masses with marked enhancement after gadolinium-diethylenetetraaminepentaacetic acid (Gd-DTPA) administration. Primary fallopian tube carcinoma was confirmed by pathologic examination. We hope that, with improvements in imaging, early diagnosis of such a malignant disease could become routinely possible in the future.

Ovarian surgery during pregnancy and puerperium: twelve-year experience at the Veterans General Hospital-Taipei

BACKGROUND

This study was performed in order to assess the surgical effects and characteristics of ovarian tumors during pregnancy and analyze their prognosis.

METHODS

Between 1982 and 1993, 121 patients who had undergone ovarian surgery during pregnancy or puerperium were reviewed at the Veterans General Hospital-Taipei. These patients were analyzed with particular emphasis on the length of gestation at the time of surgery, complications related to the stage of pregnancy, surgical and pathologic findings and the outcome of pregnancy.

RESULTS

Ovarian tumors were commonly detected during the second trimester (54.5%) and most of them (79.3%) were asymptomatic. The pathologic review found 38 patients (31.4%) with benign teratoma, 16 patients (13.1%) with corpus luteum and four patients (3.3%) with malignancy. There was a significant difference between emergent ovarian surgery and elective ovarian surgery in the spontaneous fetal wastage rate (14.1% vs 1%, p = 0.009). Compared with elective surgery, cases necessitating oophorectomy, with or without salpingectomy, increased significantly during emergency surgery (57% vs 36%, p = 0.03). All ovarian surgeries performed before a gestational age of seven weeks resulted in spontaneous fetal wastage.

CONCLUSIONS

Although the majority of the ovarian tumors detected during pregnancy were benign, emergency laparotomy was sometimes required, which led to an increase in the risk of a fetal wastage. Preconception counseling should be emphasized because early removal of non-functional ovarian tumor before conception, especially teratoma, would decrease the incidence of ovarian surgery during pregnancy. Furthermore, elective and well-prepared surgical intervention appears to be a crucial factor for favorable pregnancy outcome.

Squamous cell carcinoma of the cervix after laparoscopic surgery. A case report

BACKGROUND

Although more than 50 cases of recurrence at the sites of cannula insertion after laparoscopy for malignant tumors have been reported in the literature, the majority were adenocarcinoma. We report a case of intraperitoneal carcinomatosis and abdominal wall metastases of the trocar site after laparoscopically assisted radical vaginal hysterectomy for the treatment of squamous cell carcinoma of the cervix.

CASE

A 47-year-old woman underwent curative, laparoscopically assisted radical vaginal hysterectomy and pelvic lymphadenectomy for treating squamous cell carcinoma of the cervix, stage IB. The postoperative course was uneventful until two months later when abdominal recurrences at the trocar site and diffuse peritoneal carcinomatosis were noted. Pathology proved recurrent intraperitoneal squamous cell carcinoma with invasion of the abdominal port site.

CONCLUSION

This case further alerts gynecologic oncologists of the potential risks of laparoscopic surgery for potentially curable gynecologic malignancies.

Port site metastasis after laparoscopic-assisted vaginal hysterectomy for endometrial cancer: possible mechanisms and prevention

Only 19 cases of metastases at the cannula insertion site after laparoscopy for gynecological malignancy have been reported in the literature. One case has been diagnosed with cervical squamous cell carcinoma, whereas the others have been diagnosed with ovarian cancer and borderline ovarian tumor. We present a novel case of laparoscopy-site abdominal wall metastasis from endometrial cancer after laparoscopic-assisted vaginal hysterectomy (LAVH). The 56-year-old female patient exhibited metastases of an abdominal wall trocar site and a perineal site after undergoing LAVH and laparoscopic-assisted (LA) bilateral pelvic lymph node sampling as well as LA para-aortic lymph node sampling for treating endometrial carcinoma, surgical staging IIIC, G3. The interval between the surgical extirpation of endometrial carcinoma and diagnosis of the tumor recurrence was 6 months, suggesting that overmanipulation of the diseased organ during laparoscopic surgery may have resulted in tumor spillage, intraperitoneal dissemination, and wound contamination. Although this procedure has been proven beneficial to patients with benign disease or early-stage gynecologic malignancies, laparoscopic-assisted vaginal hysterectomy may not be efficacious to eradicate advanced gynecological malignancy.

Epithelial ovarian tumors of borderline malignancy

BACKGROUND

Epithelial ovarian tumors of borderline malignancy are different from benign tumors and malignant neoplasms. They exist with relatively benign clinical course, younger age and better prognosis as compared with invasive malignant carcinomas. Most of them are discovered at early stage, for example, stage Ia. This retrospective review evaluates the clinical features, treatments and prognosis of 48 patients with borderline malignancy of ovarian tumors.

METHODS

Forty-eight patients with ovarian tumors of borderline malignancy, aged from 14 to 69 years (mean: 39.2 years; median: 36 years), were retrospectively studied. The histopathologic diagnosis was based on the morphologic criteria published by Tazelaar et al. in 1985. All cases, including 16 cases diagnosed before 1985, were pathologically reviewed. All information of clinical stage, surgical intervention and prognosis was achieved by reviewing hospital record or contacting patients by telephone. Two patients were lost to follow up. One patient died of sepsis resulting from another operation for another gynecological cancer. Totally forty-five patients were included for evaluation.

RESULTS

Thirty-nine of the 48 patients (81.3%) were at stage Ia, 6 cases (12.5%) were at stage Ib, 2 cases (4.1%) were at stage Ic, and the remaining one patient (2.1%) was at state IIIc. Thirty-four patients (71%) were with mucinous cystadenoma of borderline malignancy, 11 cases (23%) were of serous type, and 3 patients (6%) were of mixed serous and mucinous type. Twenty-two patients underwent total abdominal hysterectomy and bilateral salpingo-oophorectomy (TAH and BSO), but one of them remained partial ovary due to young age (27 y/o). Twelve patients were treated with unilateral oophorectomy or unilateral salpingo-oophorectomy (USO). Twelve patients underwent USO and wedge resection of contralateral ovary. One case underwent debulking surgery. One patient underwent enucleation of ovarian tumor and biopsy of contralateral ovary. Eighteen patients were treated with chemotherapy after operation. One patient developed recurrence 4 months after the primary operation. Excluding two cases lost to follow up and one case with surgical mortality for another gynecological cancer, forty-five patients were alive and were followed from 9 months to 165 months. (median: 48 months; mean: 46 months)

CONCLUSIONS

Most of the patients were at the early stage of disease when first diagnosed, 81.3% were at stage Ia and only one case was at stage IIIc. Sixty-three percent of our patients underwent surgical treatment alone while the rest of them (37%) had post-operative chemotherapy with either alkeran or PAC. The use of adjuvant chemotherapy seemed unwarranted as there was no difference in survival between those with and without it. (P > 0.05) The low recurrent rate of 2% in our patients again confirmed the 9 P relative benign clinical course of this disease.

Modified pelvic anterior exenteration

During a 20-year time period, 117 patients with various histologic types of cancer underwent pelvic exentereation. Six of the 107 patients who needed anterior exenteration with urinary diversion received partial excision of the urinary bladder and modification surgery, of which three had uretero-cystostomy, two had mobilization of bladder and uretero-cystostomy and one had uretero-uterostomy. These six patients, except for two, died of disease in 1 year. Two patients are alive and happy, with quality of life because they can urinate normally. We suggest that anterior exenteration should be modified whenever possible to preserve the bladder and not to do an urinary diversion.

An evaluation of chemotherapy in patients with cancer of the cervix and lymph node metastases

During the past twelve years, out of the 288 cervical cancer patients who had lymph node involvement, the recurrence rate in the lymph node, was 26.6% if one or two nodes were involved and 50.8% if three or more nodes were involved (P < 0.0001). The recurrence rate of patients who received eight intravenous treatments (at monthly intervals) of multi-agent chemotherapy was lower than those who did not receive treatment. Of patients with one or two positive lymph nodes, 114 received treatment while 50 did not; their respective recurrence rates were 19.3% and 42.0%, a statistically significant difference (P < 0.025). Of patients with three or more positive lymph nodes, 97 received treatment and 27 did not, their respective recurrence rates, were 46% and 66% (P = 0.30) and the difference is not statistically significant. It would seem that multi-agent chemotherapy may reduce the recurrence rate in patients with cancer of the cervix and positive lymph nodes.

Studies of a tumor-associated antigen, COX-1, recognized by a monoclonal antibody

Monoclonal antibodies against an ovarian tumor cell line, OC-3-VGH, were generated using modified hybridoma technology. Among the seven that were selected for their high specificity and affinity to ovarian cancer cells and low cross-reactivity to most normal human tissues, RP 215 was shown to react specifically with a tumor-associated antigen, COX-1, from certain ovarian/cervical cancer cell lines. By Western blot assay, COX-1 was shown to have a subunit molecular mass of about 60 kDa and exist as an aggregate in the native state. COX-1 could also be detected in the shed medium of certain cultured tumor cells. A solid-phase sandwich enzyme-immunoassay procedure was designed for quantitative determinations of COX-1 in the shed medium or in patients' sera using RP 215 for both well-coating and the signal detection. Highly purified COX-1 was obtained from the shed medium of cultured OC-3-VGH tumor cells mainly by hydroxyapatite and immunoaffinity chromatography with RP 215 as the affinity ligand. At neutral pH, purified COX-1 also exists as an aggregate and is relatively stable at temperatures below 50 degrees C. Its immunoactivity was found to decrease with time in the presence of trypsin. However, the immunoactivity of COX-1 was not affected upon incubation with carbohydrate-digestive enzymes or concanavalin A and only partially inactivated in the presence of NaIO4 or iodoacetamide. Treatments of COX-1 with dithiothreitol and guanidine thiocyanate resulted in a complete loss of activity. Furthermore, rabbit antisera raised against purified COX-1 exhibited similar immunospecificity to that of RP 215. The results of this study suggest that COX-1 is a glycoprotein consisting of a 60 kDa subunit, which is recognized by RP 215 through its peptide determinant. Preliminary retrospective clinical studies were performed to assess the utility of a COX-1 enzyme immunoassay kit for detection and monitoring of patients with ovarian and cervical cancers.

Chemosensitivity testing of an ovarian cancer cell line: comparison of MTT assay and [3H]-thymidine incorporation

Chemosensitivity test has its role in cancer therapy. Using an accurate, efficient, and simple way to choose the proper chemosensitive drugs in our clinical study will help advance our work. The MTT assay is a rapid, precise, and new method to perform drug sensitivity assay. We used an ovarian cancer cell line (OC-3L-VGH) to compare the accuracy of the MTT and the [3H]-TdR incorporation assay in measuring chemosensitivity of 7 anticancer drugs. Good correlation was observed between the MTT and the [3H]-TdR assay for drug sensitivity testing (r = 0.893, P less than 0.001). Based on this study we found it may be preferable to use the MTT assay for chemosensitivity screening.

Clinical diagnosis in microinvasive carcinoma of the uterine cervix

This retrospective study collected the surgical tissues and the clinical records of 197 surgically treated patients with microinvasive carcinoma of the cervix, which was defined as a limited microinvasion not more than 3 mm in depth regardless of lymph-vascular involvement. Depth of invasion was 1 mm or less in 13.2% and 1.1 to 3 mm in 86.8%. The mean age was 47.2 years. About half of the patients were asymptomatic but suspected cytologically. Random cervical biopsy alone was inadequate for diagnosis. Cone biopsy demonstrated an accuracy of 94% in diagnosis, but failed to eliminate microinvasive carcinoma in 23.0% of the hysterectomy specimens. In 14 cases, the invasion was more extensive in the uterus than in the cone. A positive correlation has been found between the diagnostic rate of conization and the depth of stromal invasion. Cervical conization, while relatively accurate in assessing the existence of stromal invasion that characterizes microinvasion, failed to diagnose those with deeper stromal invasion, especially beyond 1 mm. The recommended approach in diagnosing microinvasion is careful colposcope-directed cone biopsy and proper examination of the conization specimen in order to exclude the possibility of more advanced disease.

Granulosa cell tumor of the ovary

In the past 20 years, approximately half of the 25 women with granulosa cell tumor of the ovary studied, were dead. The results showed that recurrence or metastasis had a statistically significant correlation with survival. The other factors, such as the patients' age, the content of the tumor, ascites, endometrial change, mitosis and rupture, have no relationship with the survival rate in our study.

Vaginal intraepithelial neoplasia: diagnosis and management

A review of 42 patients with vaginal intraepithelial neoplasia (VAIN) seen in Gynecologic Department of Veterans General Hospital-Taipei between 1971 and 1987 was made. The patients were from 36 to 79 years of age with a mean 58 of years. Fifteen patients (36%) had synchronous cervical neoplasia, 26 cases (62%) had antecedent cervical neoplasia and one had undergone operation for uterine myoma. Twenty-four of 27 patients with VAIN alone presented an abnormal Papanicolou smear. The upper one third of the vagina was the most common site of the lesion. Multifocal lesions were demonstrated in 58% cases while unifocal disease accounted for 42% cases who had VAIN subsequent to cervical neoplasia. Colposcopically directed biopsies were used for diagnosis in 13 patients. White epithelium and punctation were the most common findings of VAIN. While the results of different treatments were reviewed, surgical excision was found to be the most frequently employed method and radiotherapy was the second. Both were effective and 5 patients died of vaginal disease. On account of the relatively benign nature of VAIN than that of invasive vaginal cancer and the need for preservation of a functional vagina, more conservative approaches, for example, topical 5-Fluorouracil application and carbon dioxide laser vaporization, are discussed.

Adenosquamous cell carcinoma of the cervix--a clinical analysis of 23 cases

From January 1976 through December 1985, 895 patients with cervical carcinoma were treated with radical hysterectomy and pelvic lymphadenectomy. The surgical specimens of 23 cases were proved to be adenosquamous cell carcinoma, the incidence being 2.6%. Among them, 15 were at stage IB, 7 were at stage IIA and one was at stage IIB. The overall 5-year survival rate was 55.0% and there was no difference between patients at stage IB and IIA. During the same period the 5-year survival rate of squamous cell carcinoma was 87.5% for patients at stage IB and 75.0% for patients at stage IIA. Pelvic lymph node metastasis and parametrial involvement are considered to be poor prognostic factors. When metastasis or invasion happens, the metastatic or invasive lesions can be found in the form of pure squamous carcinoma or adenocarcinoma. Postoperative adjuvant radiotherapy (external irradiation plus brachytherapy) seems to be effective in preventing recurrence. Chemotherapy (PVB regimen) needs more clinical evaluation. In this study, when metastasis or recurrence developed, the response to radiotherapy and/or chemotherapy were poor and 75% of patients died within one year.

Leiomyosarcoma of uterus: a review of 14 cases

A detailed clinicopathologic study of 14 patients with leiomyosarcoms of the uterus was made. Twelve of 14 patients were followed up for 2 or more years. The median age was 49, the youngest patient was 20, and the oldest was 68. The predominant symptoms were abnormal vaginal bleeding and abdominal pain. The preoperative dilation and curettage established the correct diagnosis was 2 of 6 patients (33%). The predominant method of treatment was total abdominal hysterectomy (TAH). Five patients had adjuvant chemotherapy, 4 had adjuvant radiotherapy, 2 patients had chemotherapy and radiotherapy for adjuvant treatment, and one had adjuvant hormonal therapy. The overall cumulative probability of survival rate at 5 years was 29.6%. The mitotic count, margin type, tumor size, and the presence of necrosis did not affect the prognosis. Favorable prognostic features are low pleomorphism, lower staging, and aggressive management.

Simultaneous endometrioid carcinoma of the uterine corpus and ovary

The carcinoma with simultaneous involvement of the endometrium and the ovary is an uncommon but well recognized event. The determination of clinical stage depends on which of the two sites is considered to be the primary. Combined involvement may occasionally represent independent primary neoplasm. A review of all cases with a tissue diagnosis of endometrioid ovarian carcinoma and concomitant endometrial carcinoma was undertaken to identify those cases which possibly had independent primaries. Three such cases with disease confined to the pelvis were identified on the basis of pathologic features. The incidence of endometrial carcinoma in patients with endometrioid ovarian carcinoma was 15.8% (3/19). They were treated surgically with adjuvant therapy. Two patients died of disseminated carcinoma 1 and 4 years later respectively. The only one patient alive had been free of disease for 25 months after initial therapy. These endometrioid neoplasms simultaneously occurring in ovary and endometrium are considered to be primary tumors. The morphologic reasons for this view are discussed.

Colposcopic assessment in microinvasive carcinoma of the cervix

Forty of the 87 patients with microinvasive carcinoma (MIC) of the uterine cervix who underwent surgery were diagnosed colposcopically and the results were compared with the cytological and histological diagnoses. The cytology showed preinvasive carcinoma in 20 (50.0%) patients and invasive carcinoma in 19 (47.5%) patients. A correct colposcopic diagnosis was made in nine (22.5%) patients as having microinvasive carcinoma, 21 (52.5%) patients preinvasive carcinoma and eight (20%) patients invasive carcinoma, to sum up accuracy rate as 32.1%. The abnormalities most commonly observed in colposcopy were mosaic, punctuation and white epithelium. In microinvasive carcinoma, the triad co-existed in 43% of the patients. Atypical vessels, characteristic of invasion, were found in only one third of the patients. Microinvasion, therefore, may not be evident on colposcopy alone. It is therefore necessary to apply cone biopsy, prior to definite therapy, to make an accurate assessment of the maximum depth and extent of the invasion prior to definitive therapy.