Intestinal Coccidian Infections in Cancer Patients: A Case Series

Introduction Coccidian protozoa and microsporidian fungi are opportunistic pathogens increasingly implicated in infections in immunosuppressed individuals. These parasites typically infect the intestinal epithelium, resulting in secretory diarrhea and malabsorption. The disease burden and timeline are both greater and longer among immunosuppressed patients. Therapeutic options for immunocompromised individuals are limited. As a result, we wanted to better characterize the disease course and treatment efficacy of these parasitic gastrointestinal infections. Methods We performed a single-center, retrospective MedMined (BD Healthsight Analytics, Birmingham, AL, USA) chart review of patients between January 2012 and June 2022 diagnosed with coccidian or microsporidian infections. Relevant data were collected from Cerner's PowerChart (Oracle Cerner, Austin, TX, USA). Descriptive analysis was performed with IBM SPSS Statistics (IBM Corp., Armonk, NY, USA), and Microsoft Excel (Microsoft, Redmond, WA, USA) was used to generate graphs and tables. Results In these 10 years, there were 17 patients with Cryptosporidium infections, four with Cyclospora infections, and no positive cultures for Cystoisospora belli or microsporidian infections. In both infections, the majority of patients experienced diarrhea, fatigue, and nausea, with vomiting, abdominal pain, appetite loss, weight loss, and fever occurring to a lesser degree. Nitazoxanide was the most common treatment for Cryptosporidium, while trimethoprim-sulfamethoxazole or ciprofloxacin were the treatments of choice for Cyclospora. Of the Cryptosporidium infections, three received combination therapy with azithromycin, immunoreconstitution, or IV immunoglobulins. Among the four Cyclospora-infected patients, one received combination therapy of ciprofloxacin and trimethoprim-sulfamethoxazole. Treatment lasted around two weeks, and 88% of Cryptosporidium patients and 75% of Cyclospora patients had a resolution of symptoms. Conclusion The most detected coccidian infection was Cryptosporidium, followed by Cyclospora, with the lack of Cystoisospora or microsporidian infections likely due to diagnostic limitations and prevalence. Cryptosporidium and Cyclospora likely caused their associated symptoms in most cases, with other possible etiologies, including graft-versus-host disease, medications, and feeding tubes. The small number of patients receiving combination therapy prohibited a comparison with monotherapy. In our patient population, though, there was a clinical response to treatment despite immunosuppression. While promising, additional randomized control experiments are required to fully understand the efficacy of parasitic treatments.

Vitamin D enhances responses to interferon-β in MS

Objective

To determine the effect of vitamin D3 on interferon-β (IFN-β) response and immune regulation in MS mononuclear cells (MNCs).

Methods

MNCs from 126 subjects, including therapy-naive patients with different forms of MS, plus patients with MS receiving IFN-β or glatiramer treatment, plus healthy controls were incubated in vitro with IFN-β-1b ± vitamin D3 (calcitriol). Activation of the IFN-β–induced transcription factor, p-Y-STAT1, and antiviral myxovirus A (MxA) protein was measured with flow cytometry and Western blots; serum proteins were measured with a customized 31-protein multiplex assay.

Results

Vitamin D enhanced in vitro IFN responses, as measured by induction of p-Y-STAT1 and MxA in MNCs, T cells, and monocytes. Vitamin D augmentation of IFN responses was seen in untreated and in IFN-β-1b–treated MS. The combination of vitamin D plus IFN-β reduced Th1 and Th17 cytokines, and increased Th2 responses, reversing the effect of IFN-β alone. Exacerbations and progression in untreated patients reduced the vitamin D enhancement of IFN responses. Vitamin D had less effect on IFN response in clinically stable glatiramer-treated than in IFN-β–treated patients.

Conclusion

Vitamin D enhances IFN-β induction of multiple proteins and also reverses the Th1/Th2 bias in MS seen with IFN-β alone. The combination of vitamin D and IFN-β has potential benefit in ameliorating MS.

Gain of chromosome 3q is an early and consistent genetic aberration in carcinomas of the vulva

The aim was to determine whether specific gains of chromosome 3q and laminin-5gamma2-chain expression can improve early detection of invasive capacity in precancerous and squamous cell carcinoma of the vulva (VSCC). Six VSCC and three precancerous lesions were studied. Multicolor fluorescence in situ hybridization (FISH) probe sets were applied to nuclei suspensions prepared from archival material using the Hedley method. The probe panel consists of the centromers of chromosome 7, chromosome 3, and the TERC gene residing on the long arm of chromosome 3. Laminin-5gamma2-chain immunohistochemical analysis was performed on corresponding specimens and was expressed only in the VSCC. The genome-specific FISH analysis revealed 3q amplification in 43% of the nuclei analyzed for the VSCC and 22% of the nuclei for the precancerous lesions. Low-level 3q amplifications were found in precancerous lesions with an average fold increase of 1.15 for 3q. The invasive lesions showed higher average fold increases for 3q, averaging 1.32. Laminin-5gamma2-chain protein was expressed only in VSCC, whereas 3q gains were observed both in precancerous lesions and in VSCC, indicating that gain of chromosome 3q is an early and consistent event during carcinogenesis of VSCC.

Gain of chromosome 3q is an early and consistent genetic aberration in carcinomas of the vulva

The aim was to determine whether specific gains of chromosome 3q and laminin-5γ2-chain expression can improve early detection of invasive capacity in precancerous and squamous cell carcinoma of the vulva (VSCC). Six VSCC and three precancerous lesions were studied. Multicolor fluorescence in situ hybridization (FISH) probe sets were applied to nuclei suspensions prepared from archival material using the Hedley method. The probe panel consists of the centromers of chromosome 7, chromosome 3, and the TERC gene residing on the long arm of chromosome 3. Laminin-5γ2-chain immunohistochemical analysis was performed on corresponding specimens and was expressed only in the VSCC. The genome-specific FISH analysis revealed 3q amplification in 43% of the nuclei analyzed for the VSCC and 22% of the nuclei for the precancerous lesions. Low-level 3q amplifications were found in precancerous lesions with an average fold increase of 1.15 for 3q. The invasive lesions showed higher average fold increases for 3q, averaging 1.32. Laminin-5γ2-chain protein was expressed only in VSCC, whereas 3q gains were observed both in precancerous lesions and in VSCC, indicating that gain of chromosome 3q is an early and consistent event during carcinogenesis of VSCC.

Laminin-5 gamma 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract

During recent decades it has become apparent that there are two types of vulvar disease: the classic type found in elderly women with unicentric and unifocal lesions, and the type found in younger women, in which precancerous and invasive changes develop in the anogenital lower tract in a multicentric and multifocal fashion, often over a long period of observation. The laminin-5 gamma 2 chain is an extracellular protein that is a component of the basement membrane. Recently its expression has been recognized as a marker in cervical cancer that permits identification of invasive capacity. The aim of our study was to determine if laminin-5 gamma 2 chain antibody can act as a sensitivity marker of invasive capacity in precancerous and invasive carcinoma in women with uni- and multifocal changes in the anogenital tract. The result showed that all patients in the older group of women with invasive carcinoma of the vulva had moderate to high positive expression of the laminin-5 gamma 2 chain. In the group of younger patients with multifocal precancerous changes observed over long periods, most of the patients with vulva intraepithelial neoplasia (VIN) 3 showed laminin-5 gamma 2 chain positivity already in the precancerous changes, and all of them developed invasivity during the period of observation. Normal epithelium without atypia was mostly negative or of low immunoreactivity of laminin-5. In conclusion, positive laminin-5 gamma 2 chain expression seems to indicate the invasiveness potential of precancerous lesions and is also expressed in all investigated invasive carcinomas of the anogenital tract.

Laminin-5 γ 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract

Abstract.

Nordström B, Einhorn N, Silfverswärd C, Sjövall K, Tryggvason K, Auer G. Laminin-5 γ 2 chain as an invasivity marker for uni- and multifocal lesions in the lower anogenital tract.

During recent decades it has become apparent that there are two types of vulvar disease: the classic type found in elderly women with unicentric and unifocal lesions, and the type found in younger women, in which precancerous and invasive changes develop in the anogenital lower tract in a multicentric and multifocal fashion, often over a long period of observation.

The laminin-5 γ 2 chain is an extracellular protein that is a component of the basement membrane. Recently its expression has been recognized as a marker in cervical cancer that permits identification of invasive capacity.

The aim of our study was to determine if laminin-5 γ 2 chain antibody can act as a sensitivity marker of invasive capacity in precancerous and invasive carcinoma in women with uni- and multifocal changes in the anogenital tract. The result showed that all patients in the older group of women with invasive carcinoma of the vulva had moderate to high positive expression of the laminin-5 γ 2 chain. In the group of younger patients with multifocal precancerous changes observed over long periods, most of the patients with vulva intraepithelial neoplasia (VIN) 3 showed laminin-5 γ 2 chain positivity already in the precancerous changes, and all of them developed invasivity during the period of observation. Normal epithelium without atypia was mostly negative or of low immunoreactivity of laminin-5. In conclusion, positive laminin-5 γ 2 chain expression seems to indicate the invasiveness potential of precancerous lesions and is also expressed in all investigated invasive carcinomas of the anogenital tract.

Phase II study of mitomycin-C and cisplatin in disseminated, squamous cell carcinoma of the uterine cervix. A European Organization for Research and Treatment of Cancer (EORTC) Gynecological Cancer Group study

The aim of this study was to investigate the tumour response rate and toxicity of a combination chemotherapy consisting of mitomycin-C and cisplatin in patients with disseminated squamous-cell carcinoma of the uterine cervix. Chemotherapy consisted of mitomycin, 6 mg/m(2) intravenously (i.v.), and cisplatin, 50 mg/m(2) given i.v., both administered on day 1 of each cycle. The regimen was repeated at 4-weekly intervals. Mitomycin-C/cisplatin were used to treat 33 evaluable patients aged 29-67 years (median: 50 years). All patients except 1 had previously been treated with either surgery, radiation or both. At the initiation of chemotherapy, 8 patients had loco-regional and disseminated disease and 25 women had only distant metastases. The overall response rate was 42% (95% confidence interval (CI): 26-61%). Five complete and nine partial responses were observed with a median duration of response of 7.9 months (95% CI: 3.7-23.5 months). 9 patients had stable disease and 10 developed progressive disease during mitomycin-C/cisplatin-treatment. World Health Organization (WHO) grade III/IV side-effects were documented in 15 women, of whom 10 had gastro-intestinal toxicity, 3 had haematological toxicity, 1 had alopecia and 1 developed an allergic reaction to cisplatin. There were neither drug-related deaths nor severe or irreversible renal or hepatic dysfunction or peripheral neuropathy. The median progression-free survival was 5.0 months (95% CI: 3.6-6.2 months) for all patients and 10.5 months (95% CI: 6.2-15.2 months) for the responders. The median overall survival was 11.2 months (95% CI: 6.5-18.4 months).The mitomycin-C/cisplatin combination showed antitumour activity in the treatment of advanced or recurrent squamous-cell carcinoma of the uterine cervix. The regimen was well tolerated and could be administered on an outpatient basis.

D-TRP-6-LHRH (Triptorelin) is not effective in ovarian carcinoma: an EORTC Gynaecological Cancer Co-operative Group Study

Between March and September 1988, 74 patients with progressive ovarian cancer after prior platinum-based therapy were treated with the luteinizing hormone-releasing hormone (LHRH) agonist Triptorelin (Decapeptyl degrees). Treatment consisted of i.m. injection of 3.75 mg of microencapsulated Triptorelin on days 1, 8 and 28 followed by 4-weekly injections until tumor progression. No objective responses were observed. Eleven out of 68 evaluable patients (16%) had stable disease. The median progression-free survival was 5 months in patients with disease stabilization and 2 months for all evaluable patients. The median survival for patients with disease stabilization was 17 months, whereas for all patients it was 4 months. The treatment was well tolerated; the only reported adverse events were incidental hot flushes. This study showed that the LHRH agonist Triptorelin has only modest efficacy in patients pretreated with platinum-containing chemotherapy.

Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma

BACKGROUND

Previous studies on prognostic factors in stage I invasive epithelial ovarian carcinoma have been too small for robust conclusions to be reached. We undertook a retrospective study in a large international database to identify the most important prognostic variables.

METHODS

1545 patients with invasive epithelial ovarian cancer (International Federation of Gynaecology and Obstetrics [FIGO] stage I) were included. The records of these patients were examined and data extracted for univariate and multivariate analysis of disease-free survival in relation to various clinical and pathological variables.

FINDINGS

The multivariate analyses identified degree of differentiation as the most powerful prognostic indicator of disease-free survival (moderately vs well differentiated hazard ratio 3.13 [95% CI 1.68-5.85], poorly vs well differentiated 8.89 [4.96-15.9]), followed by rupture before surgery (2.65 [1.53-4.56]), rupture during surgery (1.64 [1.07-2.51]), FIGO 1973 stage Ib vs Ia 1.70 [1.01-2.85]) and age (per year 1.02 [1.00-1.03]). When the effects of these factors were accounted for, none of the following were of prognostic value: histological type, dense adhesions, extracapsular growth, ascites, FIGO stage 1988, and size of tumour.

INTERPRETATION

Degree of differentiation, the most powerful prognostic indicator in stage I ovarian cancer, should be used in decisions on therapy in clinical practice and in the FIGO classification of stage I ovarian cancer. Rupture should be avoided during primary surgery of malignant ovarian tumours confined to the ovaries.

Long-term follow-up of the Stockholm screening study on ovarian cancer

OBJECTIVES

Seventy percent of ovarian cancer is diagnosed at advanced stages. Having a method for early diagnosis is a very attractive concept. Several attempts have been made, using monoclonal antibody-based immunoassays, ultrasound, or combinations of both, to identify methods that might prove to be sufficiently sensitive and specific as a screening test. Despite promising results, a mortality study of a large population has yet to be completed due in part to the high cost involved.

METHODS

One of the first studies aimed at devising a screening strategy for ovarian cancer used the CA 125 immunoassay followed by ultrasound. The study was performed in Stockholm from 1986 through 1988. Ten years now having passed, an analysis has been performed to further evaluate the results of that study.

RESULTS

Screening led to the diagnosis of ovarian cancer in six patients, five of whom have since died of the disease. By searching the Cancer Registry, we were able to identify 20 ovarian cancer patients who developed the disease after the screening period. Of these, 12 died of the disease, 2 are alive with disease, and 6 have no evidence of disease following treatment. The median survival for patients diagnosed by screening was 100 months. Median survival for ovarian cancer patients identified subsequent to screening was 20 months. Although there was no difference in survival between these two groups, median survival was better for women diagnosed by screening (borderline significance, P = 0.059).

CONCLUSION

These results indicate that a study of a large number of women with a sufficiently long observation time will be required to establish whether or not screening can reduce ovarian cancer mortality. Such a study may also provide insight into the natural history of ovarian cancer.

Prognostic significance of cell cycle proteins and genomic instability in borderline, early and advanced stage ovarian carcinomas

Disturbed cell cycle-regulating checkpoints and impairment of genomic stability are key events during the genesis and progression of malignant tumors. We analyzed 80 epithelial ovarian tumors of benign (n = 10) and borderline type (n = 18) in addition to carcinomas of early (n = 26) and advanced (n = 26) stages for the expression of Ki67, cyclin A and cyclin E, p21WAF-1, p27KIP-1 and p53 and correlated the results with the clinical course. Genomic instability was assessed by DNA ploidy measurements and, in 35 cases, by comparative genomic hybridization. Overexpression of cyclin A and cyclin E was observed in the majority of invasive carcinomas, only rarely in borderline tumors and in none of the benign tumors. Similarly, high expression of p53 together with undetectable p21 or loss of chromosome arm 17p were frequent events only in adenocarcinomas. Both borderline tumors and adenocarcinomas revealed a high number of chromosomal gains and losses. However, regional chromosomal amplifications were found to occur 13 times more frequently in the adenocarcinomas than in the borderline tumors. The expression pattern of low p27 together with high Ki67 was found to be an independent predictor of poor outcome in invasive carcinomas. The results provide a link between disturbed cell cycle regulatory proteins, chromosomal aberrations and survival in ovarian carcinomas.

Is there place for radiotherapy in the treatment of advanced ovarian cancer?

BACKGROUND AND PURPOSE

Irradiation of advanced ovarian cancer has been performed during the years 1976-1984 with six-field technique. Results of this treatment in a long follow-up have never before been evaluated.

MATERIAL AND METHODS

Seventy-five patients with stage IIb-IV of invasive ovarian cancer have been treated with a combination of surgery, radiotherapy and chemotherapy. The results of the treatment were compared with 98 patients treated during the year 1991-1992 with surgery and chemotherapy only.

RESULTS

After controlling for the differences in background factors between the groups considered, there was still a significantly better survival rate for the patients treated with radiotherapy.

CONCLUSION

The results suggest that the role of radiotherapy in advanced ovarian cancer should be investigated in a prospective randomized trial.

Analysis of postoperative vaginal vault radiotherapy of stage I endometrial cancer with different radionuclides

A total of 213 patients in stage I grade 1 endometrial cancer were treated postoperatively with either radium or caesium vaginal applicators. The rate of complication and the incidence of second malignancies were studied in both groups. The frequency of grades 2 and 3 vaginal complications was higher among patients treated with caesium applicators but not statistically significant. The observed number of second malignancies was significantly higher than expected in the radium-treated group, in which the observed number of second malignancies with distant location was also significantly higher than expected, which could not be found in the caesium group.

Age is not a limiting factor for radical radiotherapy in pelvic malignancies

BACKGROUND AND PURPOSE

Pelvic radiotherapy (RT) toxicity in the elderly is poorly documented. We developed a study aiming to evaluate whether or not a limit of age could be identified beyond which toxicities in patients receiving pelvic RT were more frequent or more severe.

MATERIAL AND METHODS

1619 patients with pelvic cancers enrolled in nine EORTC trials, RT arms, were retrospectively studied. Patients were split into six age ranges from 50 years to 70 years and over. Survivals and late toxicity occurrence were calculated with the Kaplan-Meier method and comparison between age groups with the logrank test. A trend test was done to examine if chronological age had an impact on acute toxicity occurrence.

RESULTS

Survival was comparable in each age group for prostate (P = 0.18), uterus (0.41), anal canal cancer (P = 0.6) and slightly better for the younger group of rectum cancer (P = 0.04). A total of 1722 acute and 514 late grade > or = 1 were recorded. Acute nausea/ vomiting, skin complications and performance status deterioration were significantly more frequent in younger patients. There was no trend toward more aged patients to experience diarrhea (P = 0.149) and after adjustment on RT dose, acute urinary complications were observed equally in each age range (P = 0.32). Eighty percent of patients were free of late complication at 5 years in each age range (P = 0.79). For the grade > 2 late side-effects, a plateau was observed after 1 year at near 9% without any difference (P = 0.06) nor trend (P = 0.13) between age-groups.

CONCLUSION

Age per se is not a limiting factor for radical radiotherapy in pelvic malignancies.

Pitfalls of endoscopic carpal tunnel release

The article details various pitfalls of endoscopic carpal tunnel release. Highlighted are the two-portal Chow technique and the single-portal Agee technique.

Ovarian cancer

This synthesis of the literature on radiotherapy for cancer originating in the ovaries is based on 74 scientific articles, including 12 randomized studies, 18 prospective studies, and 36 retrospective studies. These studies involve 6,140 patients. Treatment for patients at early stages of ovarian cancer (stages I and II) is surgery. The value of adjuvant treatment, ie, chemotherapy or radiotherapy, is not demonstrated. Tumor volume is decisive to the success of radiotherapy. Microscopic or small macroscopic cancer residuals, remaining after surgery, may respond to radiotherapy, thereby promoting survival. The importance of radiotherapy for advanced ovarian cancer is controversial, and studies frequently show contradictory results. Two studies have shown the favorable role played by radiotherapy in consolidation treatment of patients if they become cancer-free at advanced stages. The role of radiotherapy in treating larger volumes of residual cancer has not been demonstrated, except for strictly palliative treatment.

Biological malignancy grading in early-stage ovarian carcinoma

The usefulness of adjuvant therapy in early ovarian cancer is a matter of controversy and there is a need for predictive methods to distinguish between low and high risk patients. Specimens from 95 early-stage ovarian cancer patients have been analysed for conventional clinical variables as well as for the biological markers--DNA content, MIB-1, p53, WAF-1--and correlated to survival. Prognostic significance achieved in univariate analysis could be improved by using a score based on several biological markers. Using a score based on DNA content, MIB-1, p53 and WAF-1, a significant predictor could be achieved with the aim of determining the postsurgical therapy. By using this tool, it is hoped that adjuvant therapy can be avoided for one-third of the patients with early-stage ovarian cancer.

Uterine cancer (corpus uteri)

This synthesis of the literature on radiotherapy for cancer originating in the endometrium of the uterus (corpus uteri) is based on 55 scientific articles, including 2 randomized studies, 1 prospective study, and 48 retrospective studies. These studies involve 13597 patients. Endometrial cancer is a radiosensitive cancer. Research findings compiled for the period 1948 to 1954 showed that 69% of the patients could be cured by radiotherapy alone. During the 1970s it was shown that combined radiotherapy and surgery yielded better results. There is agreement that patients at stage I should receive primary surgery. According to the literature, there is controversy about whether patients with poorly differentiated tumors should be given preoperative radiotherapy. Radiotherapy alone can be used successfully in patients who are inoperable because of age, general condition, or advanced spread of cancer. Vaginal postoperative radiotherapy is used in most patients and reduces the percentage of patients who develop vaginal metastases from 7%-20% to less than 1%. Patients with good prognostic factors have such a low risk for metastasis that withholding radiotherapy may be considered in this group. Postoperative external radiotherapy improves survival in patients with unfavorable prognostic factors, such as deep myometrium invasion or signs of node metastasis. Radiotherapy is delivered, in principle, to all patients with poorly differentiated disease. It can be expected that most cases of endometrial cancer will continue to be referred for some form of radiotherapy.

Cervical cancer (cervix uteri)

This synthesis of the literature on radiotherapy for cervical cancer (cervix uteri) is based on 59 scientific articles, including 8 randomized studies, 1 prospective study, and 36 retrospective studies. These studies involve 34,024 patients. Due to favorable anatomy and exceptionally good radiation tolerance of nearby pelvic organs, particularly the uterus, radiotherapy has become the dominant treatment method for cervical cancer. Surgery alone is used at the earliest stages where small tumor volumes are involved. Further pathological findings, where cancer is more extensive than expected preoperatively, or when lymph node metastases are discovered, motivate postoperative radiotherapy even at early stages. There is general agreement that advanced cervical cancer should be treated by radiotherapy alone. Clinical trials are under way that combine radiotherapy and chemotherapy, and even surgery. Two different methods of intracavitary brachytherapy are currently in use, low-dose rate therapy and high-dose rate therapy. High-dose rate therapy appears to be economically more favorable. The possibility of higher risks for later complications associated with high-dose rate therapy has not been fully studied.

Toward an optimal algorithm for ovarian cancer screening with longitudinal tumor markers

Stored samples from women in the Stockholm screening study were reassayed for CA125II (Centocor, Malvern, PA) and OVX1. The postmenopausal women older than age 50 without ovarian cancer were randomly split into a training set to develop a screening test based on longitudinal marker levels and a second set to validate the test. The CA125II data from each woman is summarized by the slope and intercept from a linear regression of log(CA125II) on time since first sample. The slope versus the intercept for the training set and the ovarian cancer cases formed a bivariate scatter plot. A curve was drawn on the scatter plot that separated most of the women with ovarian cancer from all other women; it delineated a screening test. The specificity of this test was examined on the validation set with a specificity of 99.8%. Bayes' theorem was used to calculate the risk of ovarian cancer (ROC) based on the intercept, slope, and assay variability. It is important to account for assay variability because it can produce large slopes over short periods of time. The maximum risk, which identified 83% (5 of 6) of the ovarian cancers detected within a year of last assay, was applied as a test to the training set and confirmed a high specificity of 99.7%. With this specificity and sensitivity, the ROC algorithm using the CA125II assay has an estimated positive predictive value of 16%, substantially greater than the positive predictive value based on a single assay. Further study is planned to confirm the sensitivity of this approach.

Different types of rupture of the tumor capsule and the impact on survival in early ovarian carcinoma

The significance of tumor spill in the early stages of ovarian carcinoma has been the subject of controversy. Since rupture of the capsule of the tumor may occur in several different ways, we analyzed all cases of early ovarian cancer treated at Radiumhemmet, Stockholm, Sweden, during the period 1974-1986, in which possible spill of tumor cells was catalogued in different groups. In 247 out of 394 patients (62%) the risk of spill had to be considered. There was no difference in survival between patients whose tumors had intact capsules and patients in whom rupture occurred during surgery-78% and 85%, respectively. On the other hand, a significant difference in survival was found between patients in whom rupture occurred before surgery and those with intraoperative rupture-59% and 85%, respectively. The conclusion can be drawn that manipulation during surgery which results in puncture or rupture does not have a negative influence on the outcome for the patients.

Paget's disease of the vulva: the Radiumhemmet series 1975-1990

Twenty-eight patients with a diagnosis of 'extramammary Paget's disease of the vulva' were referred to the Radiumhemmet, Karolinska Sjukhuset, Stockholm, during the period 1975-1990. A clinical and histopathologic retrospective review was undertaken. Six patients had associated malignancies (21.4%). The disease was considered primary invasive in three cases, whereas three patients later developed an invasive cancer. Surgery-local resection, hemivulvectomy or vulvectomy-was performed in 24 cases. Twelve patients, in which surgery was supposed to be radical with respect to free margins, had a significantly longer recurrence-free survival than 12 patients in which the surgical margins were dubious.

Treatment of ovarian cancer: the state of the art

The state of the art in the treatment of ovarian cancer is reviewed. Development in strategies for early and advanced ovarian cancer stages as well as prospects for the future are described.

Is there an altered steroid profile in patients with endometrial carcinoma?

BACKGROUND

Besides the well-known association between endometrial carcinoma (EC) and unopposed estrogen, androgens also may play a role in this respect; however, previous studies on endogenous estrogens and androgens in patients with EC and control subjects have yielded mostly divergent results, probably because of the use of poorly defined control groups.

METHODS

Circulating steroid and pituitary hormones and sex hormone-binding globulin were measured in patients with EC and matched control groups of either patients with nonmalignant postmenopausal bleeding (hospital control subjects) and healthy, symptom-free women (nonhospital control subjects).

RESULTS

Patients with EC had higher serum levels of adrenal C21 and C19 steroids, estrogens, and biologically active testosterone than nonhospital control subjects, whereas the hospital control subjects constituted an intermediate group in this respect.

CONCLUSIONS

The results clearly indicate an altered steroid homeostasis, probably reflecting an increased "adrenal drive" in patients with EC. The results also stress the necessity of using strictly defined, healthy, symptom-free control subjects instead of the frequently used hospital control subjects when studying more subtile endocrine aberrations.

Ovarian cancer. Early diagnosis and screening

Late diagnosis is the main reason for the poor outcome of ovarian cancer patients. An attempt to diagnose the disease methods for early diagnosis was recently investigated. The main effort of the study was in finding the role of ultrasonography and CA-125 and their sensitivity and specificity in the screening procedure. The preliminary reports suggest that a mortality study with a large women population has to be done before the usefulness of screening these methods can be established.

Prospective evaluation of serum CA 125 levels for early detection of ovarian cancer

Detection of ovarian cancer at an early stage should reduce the mortality associated with this disease. Through the Stockholm Population Registry, 5550 apparently healthy women were enrolled in a study designed in part to define the use of the CA 125 radioimmunoassay (RIA) as an initial test for early detection of ovarian cancer. Women whose CA 125 levels were elevated and an equal number of age-matched controls with normal levels were followed by means of pelvic examinations, transabdominal sonography, and serial CA 125 determinations. Of the 175 women with high CA 125 levels, six were found to have ovarian cancer: two each in stages IA, IIB, and IIIC. Of those with normal-range CA 125 levels, three had ovarian cancer as identified through the Swedish Cancer Registry; all three were under 50 years of age. Ovarian cancer was diagnosed on laparotomy in six of the women age 50 or over. Using thresholds of 30 and 35 U/mL, the rates of specificity for the CA 125 RIA were 97 and 98.5%, respectively, for women age 50 or older, and 91 and 94.5%, respectively, for those younger than 50 years of age. Thus, the specificity of the CA 125 RIA is adequate in postmenopausal women to undertake a larger study to determine whether screening using CA 125 influences survival of patients with ovarian cancer.

Clinical relevance of the CA 125 assay in monitoring of ovarian cancer patients

CA 125 levels were measured longitudinally during treatment and follow-up of 248 epithelial ovarian cancer patients referred to the Department of Gynecological Oncology at Radiumhemmet, Stockholm, from 1984 to 1986. The aim of the study was to evaluate the value of CA 125 monitoring in clinical practice according to tumor burden at the time of referral to Radiumhemmet, the correlation of CA 125 values to tumor mass at second-look laparotomy, the lead time between increasing CA 125 values and tumor relapse, and the predictivity of normal CA 125 values after completion of first-line therapy. Ninety-one percent (32/35) of patients with a tumor volume greater than 5 cm at referral had elevated CA 125 values; 62% (22/35) with no tumor mass had normal CA 125 values. Elevated CA 125 values greater than 35 U/ml before second-look laparotomy predicted remaining tumors in 77% (15/19) of patients. The mean lead time between increasing CA 125 values and tumor relapse was 3 months. Normal CA 125 values at the end of first-line therapy may predict long survival times.

Treatment of advanced condylomata acuminata with semi-purified and purified human leukocyte interferon

Twelve patients with advanced condylomata acuminata were treated by systemic human leukocyte interferon (IFN) therapy. Semi-purified and purified preparations were both able to affect condylomatous growth. Treatment of the patients at various periods of their disease resulted in one complete remission, 6 partial remissions, 4 minimal responses while one case showed progressive disease. Side-effects were unexpectedly common in these advanced patients and 4 of them had to stop IFN treatment.

Development of ploidy and cell proliferation in serial samples of ascites from patients with ovarian carcinoma

Repeated samples of ascites were obtained from 14 ovarian carcinoma patients over a period of 10 to 360 days. The samples were studied by means of flow-cytometry and monoclonal antibodies specific for bromodeoxyuridine. Ploidy and proliferation of tumor cell populations were measured to establish the significance of these properties in the development of the tumors. Ploidy was mostly a stable feature while the proportion of S-phase values increased significantly over the passage of time. This increase is discussed in relation to the expression of selective processes towards more aggressive tumor cell lines and to the development of chemoresistance.

The prognostic significance of growth pattern and its relation to tumor cell nuclear DNA content in endometrial carcinoma

Hysterectomy specimens from 21 endometrial carcinoma patients, who died from their disease, and 23 patients selected at random from 307 survivors, were analysed for tumor growth pattern and tumor cell nuclear DNA content. The results indicate that tumor growth pattern, reflected by the mode of infiltration, is significantly correlated to the clinical course of the disease. Patients with carcinomas exhibiting contiguous growth pattern had a better outcome than patients with discontiguously growing carcinomas. It was also found that tumor growth pattern correlated well with tumor nuclear DNA content. It is suggested that the pattern of infiltration of the tumors is a sensitive predictor of prognosis and that this prognostic information, which only can be obtained postoperatively, to a large extent is reflected by tumor cell nuclear DNA content in curetted diagnostic material, obtained prior to treatment.

Flow cytometric measurement of ploidy and proliferation in effusions of ovarian carcinoma and their possible prognostic significance

The cellular DNA pattern of ascites and pleural effusions from 81 patients with advanced ovarian carcinoma was prospectively studied by means of flow cytometric DNA analysis. The degree of ploidy and the proportion of S-phase values were correlated to histological differentiation, to status, and to the development of disease. According to DNA indices, the cell populations distributed in the diploid to peridiploid and in the tri-to tetraploid range. Aneuploidy was more frequently associated with poor degree of differentiation, with progressive disease, and with higher proportion of cells in S phase. Thus, although patients with stable disease had a significantly larger proportion of tumors with diploid DNA content, all except four patients were dead within a median survival period of 12 months. No correlation was observed between total survival period and ploidy; however a significantly shorter survival time was noted in patients whose ascites comprised cell populations with S-phase values exceeding 15%.

Hprt mutations and karyotype abnormalities in T-cell clones from healthy subjects and melphalan-treated ovarian carcinoma patients

In vivo mutations at the locus for hypoxanthine phosphoribosyl transferase (hprt) were studied in 6-thioguanine (TG)-resistant T-lymphocyte clones from healthy male and female subjects and ovarian carcinoma patients treated with melphalan. Southern blot analysis of 108 clones showed alterations in 14% (4/29) of the clones from healthy males, 4.3% (2/47) of the clones from healthy females and 3.1% (1/32) of the clones from melphalan-treated patients. 2 of the 7 abnormal clones had a total deletion of the hprt gene; the others had partial deletions. Karyotype analysis of 82 clones revealed 1 clonal abnormality in 29 mutant clones from healthy males (3.6%). Loss or structural aberration of 1 X-chromosome occurred in 6% of the clones from healthy females. The frequency of karyotypic abnormalities (excluding those affecting one of the X-chromosomes) was significantly higher in clones from patients (37%) as compared to healthy females (5.9%). No aberration was found to affect the hprt locus at Xq27 in any of the 82 clones studied.

CA 125 assay used in conjunction with CA 15-3 and TAG-72 assays for discrimination between malignant and non-malignant diseases of the ovary

It has previously been suggested by the authors that elevated serum CA 125 levels may be of value in discriminating malignant from non-malignant pathologies among women with pelvic masses. Enhancement of this discrimination capacity might be achieved by utilizing additional serum assays. To test this hypothesis CA 125, CA 15-3 and TAG-72 levels were determined in double-blind fashion on 219 sera from patients undergoing diagnostic laparotomy for pelvic masses at six gynecological departments in the Stockholm area. Patient diagnoses were verified by chart review. Of the 219 patients, 27 (12%) had non-mucinous ovarian carcinoma, of whom 26 (96%) had CA 125 levels of 35 U/ml or greater 23 (85%) had levels in excess of 65 U/ml. Of 27 patients with mucinous or borderline ovarian carcinoma and patients with other malignancies 18 (67%) had CA 125 levels greater than 35 U/ml. Of 165 women with non-malignant diagnoses 26 (16%) had CA 125 levels in excess of 35 U/ml and 8 (5%) greater than 65 U/ml. Using reference values of 35 U/ml, 30 U/ml and 10 U/ml for the CA 125, CA 15-3 and TAG-72 assay respectively, only 3 of 165 (2%) of non-malignant patients were categorized as positive, compared to 23 of 27 (85%) of those with non-mucinous ovarian carcinoma. Moreover, an analysis of postmenopausal women revealed that the combination of assays--in a model controlling for the effect of CA 125--increased the specificity for diagnosis of benign diseases in women with pelvic masses.

Comparative study of proportion of S-phase cells in ascites and pleural effusions in ovarian carcinoma using antibromodeoxyuridine monoclonal antibody and DNA flow-cytometry

Bromodeoxyuridine (Brd-Urd) was utilized in vitro to detect proliferating cells in 33 samples of ascitic and pleural effusions of ovarian malignancies and the results were compared with DNA flow-cytometry. Percoll separated tumor cells were incubated in vitro with Brd-Urd. After treatment with anti-Brd-Urd monoclonal antibodies the proportion of fluorescent cells was evaluated on slides by microscopy. A good correspondence (r = 0.93) was found between the proportion of cells labelled with Brd-Urd and the S-phase cells evaluated from the DNA histograms. S-phase values were found to be higher in tumors with aneuploid than in diploid DNA index. Poorly differentiated tumors had higher values as compared to moderately or well differentiated tumors.

Hormone receptor analysis in endometrial cytologic samples collected with the Gynoscann device

Eighteen patients underwent endometrial cytologic sampling using the Gynoscann instrument immediately before curettage. The material obtained was used for cytologic diagnosis and for measurements of estrogen receptors (ERs) and progesterone receptors (PRs). The material collected with the Gynoscann device provided conclusive cytologic diagnoses in 88% of the cases, as compared with the histologic classification of samples collected by curettage. The DNA content in the samples obtained by the Gynoscann device varied from 5 micrograms to 218 micrograms; this amount was sufficient for the analysis of both ER and PR. Thus, assays for steroid receptors may be performed on endometrial cytologic samples obtained by the Gynoscann; this method may be especially useful for cases in which it is difficult to take a surgical biopsy.

An initial analysis of preoperative serum CA 125 levels in patients with early stage ovarian carcinoma

Preoperative serum CA 125 levels were determined for 36 patients with Stage I and II ovarian carcinoma. Levels ranged from 9 to 1962 U/ml with a mean of 216 U/ml. In Stage I patients, CA 125 levels averaged 133 U/ml and in Stage II patients 382 U/ml. Nine of 24 Stage I (38%) and 9 of 12 Stage II patients (75%) had CA 125 levels in excess of 65 U/ml in a population somewhat overrepresented in mucinous tumors. Patients with non-mucinous neoplasms had CA 125 elevations more often--in 75% of the cases--than those with mucinous tumors. A larger study will be required to more precisely estimate the fraction of early stage patients with elevated preoperative serum CA 125 levels; however, this investigation demonstrates an assay sensitivity minimally adequate to initiate a pilot evaluation of serum CA 125 levels in a population at risk for ovarian carcinoma.

A phase II study on escalating interferon doses in advanced ovarian carcinoma

Twenty-four patients with advanced and therapy-resistant ovarian carcinoma were treated with escalating daily doses of human leukocyte interferon (IFN). Doses ranged from 3 X 10(6) to 27 X 10(6) IU/day. Fatigue, fever, thrombocytopenia, and leukopenia were the limiting factors in the escalation of doses. Of nine patients treated for at least 2 months, there were two patients with partial remissions and six with stable disease. Ascites production present in four patients became reduced in three. The level of 2',5'-oligoadenylate synthetase in peripheral blood lymphocytes increased following initiation of IFN therapy. We conclude that IFN-alpha can exert an antitumor effect in some patients with ovarian carcinoma that have previously failed on other therapy regimens.

Solid tumours and chromosome aberrations as late side effects of melphalan therapy in ovarian carcinoma

Fifty-five ovarian cancer patients treated with melphalan during 1968-1978 were followed during 309 person years and studied with cytogenetic analyses. During the clinical follow-up 7 patients developed a new primary solid tumour. The excess risk of developing new primary solid tumours in patients treated with melphalan was statistically significant (p less than 0.05) and the relative risk corresponded to 3.0. Patients developing a new solid tumour showed a similar pattern of chromosome aberrations in the peripheral lymphocytes to that previously shown for the whole cohort.

Symptomatology of ovarian cancer

The symptomatology of ovarian cancer was retrospectively reviewed in 362 patients. According to the stage at diagnosis, the disease was classified as early (stages IA-IIA) or advanced (stages IIB-IV). The most common initial symptoms were abdominal swelling and/or palpable tumour, pain and gastro-intestinal symptoms. The initial symptoms, however, were not necessarily those that prompted the patients to seek medical advice. Most were first seen by a gynecologist, which possibly explains the shortness of doctor's delay in the urbanized catchment region.

A case-control study of oral contraceptive use in women with adenocarcinoma of the uterine cervix

To evaluate oral contraceptive (OC) use as a possible cause of the changed ratio between adenocarcinoma and squamous cell carcinoma of the uterine cervix a case-control study was performed. The OC use among 23 women with adenocarcinoma of the uterine cervix was compared with that of a matched group of 46 women with squamous cell carcinoma. No differences in percentage of OC use, duration of such use or period of OC use in relation to diagnosis could be demonstrated between the two groups compared.

Influence of interferon on the growth of primary ovarian carcinoma cells in a semi-solid agar system: comparison with clinical effects of interferon therapy

The sensitivity of primary human ovarian cancer cells to interferon (IFN) was studied in vitro by the use of a tumor cloning system in semi-solid agar. Tumor colonies were found in 37% (34/93) of the experiments with tumor cells from ascites and in 35% (6/17) of the experiments with solid tumors. The relative colony-forming ability could not be correlated to prior treatment. In 15 out of 18 patients the ascitic tumor cells were sensitive to IFN-alpha. Sensitivity was found in one test out of three with solid tumors. The sensitivity was dependent on the dose of IFN but could vary for the natural IFNs alpha and gamma. In seven patients the relation between in vitro and in vivo sensitivity of the tumor cells to IFN could be studied. Any correlation between in vitro and in vivo sensitivity could not be revealed in this small group of patients.

The capacity of blood lymphoid cells to produce alpha- and gamma-interferon is decreased during alpha-interferon therapy

The influence of alpha-interferon (alpha-IFN) therapy on the capacity of blood lymphoid cells to produce alpha- and gamma-interferon (IFN) was studied in 21 patients with gynecological tumors, i.e., ovarian carcinoma (14 patients) or condylomata accuminata (7 patients). The mean capacity of the lymphoid cells to produce alpha-IFN in response to Sendai virus was increased, although not statistically significant, as compared to an age- and sex-matched control group, whereas the mean capacity of the patients' blood lymphoid cells to produce gamma-IFN in response to PHA or PWM was slightly decreased as compared to the control group. One day after the first injection of alpha-IFN there was a statistically significant decrease in the capacity of blood lymphoid cells to produce alpha-IFN and this decrease remained after 3 months of IFN therapy in most patients investigated. One week after initiation of alpha-IFN therapy there was a statistically significant decrease in the capacity of the cells to produce gamma-IFN in response to PHA or PWM and in most patients studied this decrease remained after 3 months of treatment. We conclude that the capacity of blood lymphoid cells to produce IFN is suppressed during exogenous alpha-IFN therapy.