Exemestane in advanced and recurrent endometrial carcinoma. A phase II study

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Background: Most entrometrial adenocarcinomas of the endometrioid type express estrogen receptors and are potentially hormone sensitive. The aim of this phase II study was to evaluate the responsiveness of these tumors to treatment with Exemestane, an aromatase inhibitor. Methods: So far, 31 patients have been recruited to this ongoing study. Patients had to have a measurable tumor. Evaluation of response by CT was performed every 3 months. Evaluation of estrogen receptors (ER) was performed by immunohistochemistry and was positive in 17 patients, negative in 5 and not performed in 6 of the 28 patients evaluable for response. Treatment was given with Exemestane 25 mg orally daily. Results: Radiotherapy had been given as part of the initial therapy to 16 patients. Before inclusion into the study, 22 patients had received chemotherapy and 7 of these had also received hormonal treatment with gestagens for relapse. Response to Exemestane treatment was evaluable in 28 patients. In 17 patients with ER positive tumors, 1 showed a complete response, 1 partial response and 6 have had stable disease for 3+ months (3 patients), 6+ months (2) and 9+ months (1). The treatment was well tolerated with no major toxicity. Updated response rates will be presented. Conclusions: Treatment with Exemestane orally showed effect in patients with ER positive tumors in this heavily pre-treated group of patients with endometrioid adenocarcinoma of the endometrium.

No significant financial relationships to disclose.

Joint effects of different human papillomaviruses and Chlamydia trachomatis infections on risk of squamous cell carcinoma of the cervix uteri

This case-control study based in Nordic serum banks evaluated the joint effects of infections with genital human papillomavirus (HPV) types, and Chlamydia trachomatis in the aetiology of cervical squamous cell carcinoma. Through a linkage with the cancer registries, 144 cases were identified and 420 controls matched to them. Exposure to past infections was defined by the presence of specific IgG antibodies. The odds ratio (OR) for the second-order interaction of HPV16, HPV6/11 and C. trachomatis was small (1.0) compared to the expected multiplicative OR, 57, and the additive OR, 11. The interactions were not materially different among HPV16 DNA-positive squamous cell carcinomas. When HPV16 was replaced with HPV18/33 in the analysis of second-order interactions with HPV6/11 and C. trachomatis, there was no evidence of interaction, the joint effect being close to the expected additive OR. Possible explanations for the observed antagonism include misclassification, selection bias or a true biological phenomenon with HPV6/11 and C. trachomatis exposures antagonizing the carcinogenic effects of HPV16.

A prospective study of the relationship between prediagnostic human papillomavirus seropositivity and HPV DNA in subsequent cervical carcinomas

Several prospective studies with invasive carcinoma as endpoint have supported Human Papillomavirus as a cause of cervical carcinoma. However, the largest study used seroepidemiology and did not analyse presence of Human Papillomavirus DNA in the subsequent tumour. Linkage of serum bank registries and cancer registries had identified 196 women with a registered cervical carcinoma after donation of a serum sample. For the present study, biopsies for 127 cases could be located, verified to contain invasive carcinoma and be amplified by PCR. Three control women who had remained alive and without cervical carcinoma during an equal length of follow-up had been matched to each of the case women and tested for HPV antibodies. Presence of Human Papillomavirus DNA in the tumours was analysed by general primer and type specific PCR. HPV16-seropositive women had a relative risk of 4.4 (95% CI: 2.2-8.8) to develop cervical carcinoma carrying HPV16 DNA. By contrast, there was no excess risk for Human Papillomavirus 16-seropositive women to develop cervical carcinoma devoid of HPV16 DNA. Prediagnostic HPV16 seropositivity was strongly correlated with later HPV16 DNA positivity of the tumour (P<0.001) and prediagnostic HPV18 seropositivity correlated with HPV18 DNA in the tumour (P<0.03). The link between prediagnostic seropositivity and type of viral DNA in the cancer implies that the carcinogenic effect of infection with these viruses is dependent on persistent presence of type-specific viral DNA.

[Surgery and sentinel node examination in early vulvar cancer]

BACKGROUND

Less than radical vulvectomy for primary vulvar cancer has been controversial. Less mutilating surgery without sacrificing benefits in prognosis is warranted.

MATERIAL AND METHODS

Based on relevant literature and our own experience, we give a review of surgery and sentinel node examination in early vulvar cancer.

RESULTS

Regional lymph node metastasis rarely occurs when tumour thickness is less than 1 mm. Smaller lesions (< 2 cm in diameter) should therefore be treated by wide excision only and without lymph node dissection. Other T1 lesions with deeper invasion should be radically excised with at least 2 cm margins and extend deep to the inferior fascia of the urogenital diaphragm. Complete inguinal-femoral lymphadenectomy should be performed in patients without groin metastases to avoid a small, but definite risk of recurrence, although the incidence of lymph node metastases for all clinical stage I patients is less than 10%. Lymphatic mapping with 99mTechnetium and patent blue technique is a potentially valuable intraoperative tool for assuring removal of the sentinel node most likely to have metastasis, defining the extent of the superficial inguinal lymphadenectomy and identifying uncommon anatomic variations.

INTERPRETATION

Until reliable data on the benefits of selective lymphadenectomy using intraoperative lymphoscintigraphy are available, the procedure should only be performed in an approved research setting.

[Borderline tumors of the ovary]

Only within the last decade we have begun to fully appreciate the natural history and biologic behaviour of borderline tumours in the ovaries. In contradiction to invasive epithelial tumours, most borderline tumours are confined to the ovary(ies) (stage I). Because the prognosis of stage I serous borderline tumours is excellent, with five-year survival rates of almost 100%, some experts are advocating that this subset should be classified as benign. Although the standard treatment for older patients is abdominal hysterectomy and bilateral salpingo-oophorectomy, many young patients who have not completed childbearing can be safely treated with unilateral salpingo-oophorectomy coupled with comprehensive surgical staging, thereby preserving their fertility potential. Another major controversy associated with borderline tumours is the clinical management of patients with advanced-stage disease or peritoneal implants. Many experts strongly believe that surgery is the only effective treatment for borderline tumours. Others routinely employ postoperative chemotherapy for at least some subset of patients with peritoneal implants. Several investigators have focused on DNA ploidy as a predictor of recurrence and survival, but their findings are conflicting.

Randomized study on adjuvant chemotherapy in stage I high-risk ovarian cancer with evaluation of DNA-ploidy as prognostic instrument

PURPOSE

Adjuvant chemotherapy versus observation and chemotherapy at progression was evaluated in 162 patients in a prospective randomized multicenter study. We also evaluated DNA-measurements as an additional prognostic factor.

PATIENTS AND METHODS

Patients received adjuvant carboplatin AUC 7 every 28 days for six courses (n = 81) or no adjuvant treatment (n = 81). Eligibility included surgically staged and treated patients with FIGO stage I disease, grade 1 aneuploid or grade 2 or 3 non-clear cell carcinomas or clear cell carcinomas. Disease-free (DFS) and disease-specific (DSS) survival were end-points.

RESULTS

Median follow-up time was 46 months and progression was observed in 20 patients in the treatment group and 19 in the control group. Estimated five-year DFS and DSS were 70% and 86% in the treatment group and 71% and 85% in the control group. The hazard ratio was 0.98 (95% confidence interval (95% CI): 0.52-1.83) regarding DFS and 0.94 (95% CI: 0.37-2.36) regarding DSS. No significant differences in DFS or DSS could be seen when the log-rank test was stratified for prognostic variables. Therefore, data from both groups were pooled for the analysis of prognostic factors. DNA-ploidy (P = 0.003), extracapsular growth (P = 0.005), tumor rupture (P = 0.04), and WHO histologic grade (P = 0.04) were significant independent prognostic factors for DFS with P < 0.0001 for the model in the multivariate Cox analysis. FIGO substage (P = 0.01), DNA ploidy (P < 0.05), and histologic grade (P = 0.05) were prognostic for DSS with a P-value for the model < 0.0001.

CONCLUSIONS

Due to the small number of patients the study was inconclusive as regards the question of adjuvant chemotherapy. The survival curves were superimposable, but with wide confidence intervals. DNA-ploidy adds objective independent prognostic information regarding both DFS and DSS in early ovarian cancer.

[DNA ploidy in epithelial ovarian cancer--an independent prognostic factor]

Ovarian cancer is the most lethal of the gynecological malignancies. One of the aims of the ongoing research in this field is the search for prognostic and/or predictive factors which can contribute to a more individualized patient treatment. All studies performed at The Norwegian Radium Hospital with regard to the prognostic significance of DNA ploidy in borderline, early and advanced ovarian cancer, were reviewed. The conclusions emanating from these studies were compared to the international literature. DNA ploidy analysis is of definite independent prognostic significance in borderline and early (FIGO stage I) ovarian cancer, and is of help in the selection of patients expected to benefit from adjuvant chemotherapy, or in whom a more conservative surgical procedure can be acceptable. DNA ploidy status is also of prognostic significance in advanced ovarian cancer; however, for the time being this information has no direct consequences for patient treatment. We conclude that DNA ploidy analysis should be incorporated in the routine histopathological evaluation of borderline and early (stage I) ovarian cancer.

A multicentric European study testing the reproducibility of the WHO classification of endometrial hyperplasia with a proposal of a simplified working classification for biopsy and curettage specimens

This study was designed to assess intraobserver and interobserver agreement in the diagnosis of 56 endometrial specimens by five European expert gynecologic pathologists using the WHO classification and to establish which histologic features are significantly associated with each classification category. The seven categories were simple hyperplasia, complex hyperplasia, atypical hyperplasia, well-differentiated adenocarcinoma, proliferative endometria, secretory endometria, and other. Slides were reviewed twice for diagnosis, with accompanying evaluation of a checklist of histologic features. These seven categories were eventually reduced to four and three for the purposes of data analysis. The four modified diagnostic categories consisted of hyperplasia (previously simple hyperplasia and complex hyperplasia), atypical hyperplasia, well-differentiated adenocarcinoma, and cyclical endometrium (previously proliferative, secretory, and other). The three diagnostic categories consisted of hyperplasia, endometrioid neoplasia (previously atypical hyperplasia and well-differentiated adenocarcinoma), and cyclical endometrium. Intraobserver and interobserver agreement was assessed using the percentage agreement and kappa statistics. The associations among the various histologic features and diagnoses was analyzed using multiple logistic regression to identify those features that were useful for distinguishing diagnostic categories. When using seven categories, kappa values ranged from 0.53 to 0.74 (percentage agreement, 61-79%) and from 0.33 to 0.59 (percentage agreement, 43-63%) for intraobserver and interobserver agreement, respectively. When using four categories, kappa values ranged from 0.68 to 0.73 (percentage agreement, 77-80%) and from 0.39 to 0.64 (percentage agreement, 54-73%) for intraobserver and interobserver agreement, respectively. When using three categories, kappa values ranged from 0.70 to 0.83 (percentage agreement, 80-89%) and from 0.55 to 0.73 (percentage agreement, 70-82%) for intraobserver and interobserver agreement, respectively. Data were analyzed in each diagnostic category. When using four or three diagnostic categories, the mean intraobserver and interobserver agreements varied less between categories and achieved higher values, with smaller 95% confidence intervals. The mean percentage agreement was lowest for complex hyperplasia and for atypical hyperplasia. For distinguishing cyclical endometrium versus hyperplasia, the useful histologic feature was glandular crowding. For hyperplasia versus atypical hyperplasia and for hyperplasia versus endometrioid neoplasia, the useful features were nuclear enlargement, nuclear pleomorphism, vesicular chromatin, and nucleoli, but of these, only nuclear pleomorphism achieved substantial mean intraobserver and interobserver agreements. For discriminating atypical hyperplasia from well-differentiated adenocarcinoma, the only useful feature was stromal alterations, which achieved only fair mean intraobserver and interobserver agreements. In summary, in endometrial biopsy or curettage specimens, the lack of agreement in the diagnoses of complex hyperplasia and atypical hyperplasia and the lack of reproducibility in the recognition of the histologic feature of stromal alterations to differentiate atypical hyperplasia from well-differentiated adenocarcinoma suggest that the histologic classification should be simplified by including a combined category for simple and complex hyperplasia, called hyperplasia, and a combined category for atypical hyperplasia and well-differentiated adenocarcinoma, called endometrioid neoplasia. Diagnoses of hyperplasia and endometrioid neoplasia are highly reproducible between observers from different institutions. Glandular crowding is the best histologic feature to differentiate cyclical endometrium from hyperplasia, whereas nuclear pleomorphism is the reproducible cytologic feature to differentiate hyperplasia from endometrioid neoplasia.

Human papillomavirus infection in Norwegian women with cervical cancer

The objective of the present study was to determine the prevalence of human papillomavirus (HPV) infections in Norwegian women with cervical cancer. We used the polymerase chain reaction (PCR) and Southern blot techniques to assess the prevalence of HPV in cervical biopsies of 133 women admitted to the Norwegian Radium Hospital for treatment of cervical cancer. At the time of sampling (from February 1988 to April 1989) about 85% of Norwegian women with cervical cancer were treated at the Norwegian Radium Hospital. HPV was found in biopsies of 91 (68%) of women with cancer; 70 (53%) biopsies contained HPV type 16, 19 (14%) HPV type 18, 4 (3%) HPV type 33, 2 (1.5%) HPV type 11, and 3 (2%) HPV DNA of unknown type (HPVX). Five percent of biopsies were doubly infected, chiefly with HPV 16 + 18. We found a significant association between HPV 18 and low age, poorly differentiated tumors and adenocarcinomas. Our results show that there is an association between HPV types 16 and 18 and cervical cancer also in a Norwegian setting. PCR was more sensitive than Southern blotting for detection of HPV. Thirty-six (27.5%) of cancer biopsies were positive by PCR but negative by Southern blotting, as against 49 (73.5%) positive by both methods; we also encountered 4 samples positive by Southern blotting and negative by PCR. In 23/53 cancer biopsies positive by Southern blotting we found evidence for integrated or rearranged HPV genomes.

Are borderline tumors of the ovary overtreated both surgically and systemically? A review of four prospective randomized trials including 253 patients with borderline tumors

The optimal treatment of early-stage ovarian borderline tumors is controversial. Only a few randomized trials evaluating adjuvant treatment for this disease have been published. Between 1970 and 1988 four consecutive randomized trials, including patients with ovarian borderline tumors, were conducted at the Norwegian Radium Hospital. After surgery, 253 stage I-II borderline tumors without residual disease were randomly allocated to these protocols. The adjuvant treatment in the four trials consisted of [1] external irradiation (Ext) combined with intraperitoneal instillation of radioactive gold (198Au) or Ext alone, [2] intraperitoneal radioactive therapy followed by thio-TEPA or no further treatment, [3] thio-TEPA or no adjuvant therapy, and [4] cisplatin or 32P treatment. The patients were equally distributed according to prognostic variables within the eight randomization groups. The overall corrected and crude survival were 99 and 94%, respectively. In 83% of the patients a hysterectomy, bilateral salpingo-oophorectomy, and omentectomy was performed. None of the patients with less extensive surgery relapsed. Adjuvant therapy did not seem to improve the overall corrected survival. On the contrary, toxicity was added with small bowel complications after radiation therapy, neurotoxicity after cisplatin treatment, and bone marrow toxicity after thio-TEPA therapy. It is concluded that stage I borderline tumors should not receive any adjuvant treatment.

How often is dysplasia diagnosed by biopsy or smear examination? Application of a maximum likelihood based method to the assessment of detection rates in the nasal mucosa of nickel workers

In view of the known increased risk of nasal carcinoma and the high prevalence of dysplastic lesions of the nasal mucosa among nickel workers, regular screening for the existence of possibly precancerous dysplastic lesions is offered to workers in a Norwegian nickel refinery. Unfortunately, available sampling techniques do not allow the identification of all subjects in whom dysplastic changes are present. Independent histological and cytological (brush cytology) diagnoses, obtained for each of a group of 90 workers, have been used to estimate, by a maximum likelihood method, the probabilities that existing dysplastic lesions will be detected by each of these two screening methods. In the group studied, cytology performed rather less well than histology in unambiguously detecting dysplasia. However, when cytological specimens showing irregular (possibly dysplastic) epithelial cells were grouped with those showing clear dysplastic changes, detection probabilities were estimated at 0.52 by histology and 0.57 by cytology. Detection probabilities were estimated to be higher among subjects with a previously known history of dysplasia, particularly by histology (P < 0.01), probably due to larger dysplastic areas. In view of both its greater facility and speed of sampling, and its greater acceptability, brush cytology may be preferable to biopsy sampling for the screening of large numbers of workers at risk.

Multispectral analysis of uterine corpus tumors in magnetic resonance imaging

The goal of this prospective study was to evaluate multispectral analysis techniques for automatic recognition of uterine cancer in magnetic resonance (MR) imaging. The first part of this study was an open training phase in which the statistical parameters of the various normal and pathological tissue types were estimated. This was followed by a test phase that was done as a blind experiment. Results from an extensive pathological examination of the surgically removed organs served as the reference for the diagnosis and various geometric measurements of the lesions. A radiological examination of the MR images was also performed. All malignant test tumors were correctly or close to correctly classified. However, parts of normal endometrium and other mucosal linings were also classified as adenocarcinomas. In addition, parts of some of the malignant tumors were classified as normal endometrium. The geometrical extension of the tumor and its relationship to the surroundings were slightly better predicted than those obtained by the radiologist. The results indicate that it is possible to differentiate and determine the local extension of some types of uterine malignancies based on the information present in MR images.

Clinical stage I carcinoma of the cervix: value of MR imaging in determining degree of invasiveness

The depth of tumor invasion measured at histologic examination is the most important prognostic factor in early-stage carcinoma of the uterine cervix. The ability of MR to estimate the depth of tumor invasion was studied in 47 patients who subsequently underwent radical hysterectomy. In two patients, MR failed to detect tumors with infiltration depths of 2 and 4 mm. The maximum sagittal tumor length along the axis of the cervix (D) and the maximum tumor area on sagittal (S) and axial (A) images were measured with MR. The depth of tumor infiltration determined histologically (I) correlated with the degree of infiltration noted on MR images. The univariate correlation coefficients for log I vs log D, log S, and log A were .87, .84, and .77, respectively. By stepwise inclusion of the variables in a multivariate analysis, the contributions to the coefficient of determination from including log S and log A after log D were less than 1%. The regression analysis showed that the best estimate for the depth of invasion was close to half of the sagittal tumor length measured on MR, I = D/2. Our experience shows that MR is valuable in determining the degree of invasiveness in clinical stage I tumors.

[A phase II study of 5-fluorouracil/cisplatin in recurrent cervical cancer]

50 patients with recurrent cervical carcinoma were included in a phase II study of cisplatinum and 5-fluorouracil. They were divided into patients with recurrent lesions outside the previously irradiated area (group 1) and those with at least one recurrent lesion inside this area (group 2). The treatment schedule consisted of 5-fluorouracil 1,000 mg/m2 intravenously during days 1 to 5, and cisplatinum 100 mg/m2 intravenously in day 1. 45 patients could be evaluated for response and toxicity with a median survival of 14+ months, (range 4-38+). In group 1 (29 patients) seven achieved complete response with a median duration of 14+ months, (range 3(+)-26+), median survival of 19+ months, (range 5(+)-28+), and 13 achieved partial response with a median duration of 8+ months, (range 3(+)-25+), median survival of 16 months, (range 6(+)-31+). In group 2 (16 patients) one patient achieved complete response and two partial response. One patient in this group with stationary disease is still alive after 38+ months. All the patients suffered from nausea and vomiting. The dose-limiting factor was bone marrow suppression. The response rate in group 1 of 69%, with a median survival of 19+ months, is higher than previously achieved with other cytostatic regimens. We found the regimen to be very toxic, however, for patients with central recurrences in previously irradiated areas, though some of these patients did achieve marked relief from pain.

Endometrial squamous cell carcinoma: report of three cases and review of the literature

A histopathologic review of 1993 cases of confirmed endometrial carcinoma produced two cases of primary squamous cell carcinoma. A third possible case is included to illustrate the diagnostic problems in this type of tumor. All patients presented with advanced disease and died within a year. The literature is reviewed and the criteria for acceptance of a diagnosis of endometrial squamous cell carcinoma are discussed.

Nasal mucosa in workers exposed to formaldehyde: a pilot study

This study evaluates the histological changes, especially the presence of possible precancerous lesions, in the nasal mucosa of workers exposed to formaldehyde. Nasal biopsies of 37 workers occupationally exposed to formaldehyde for more than five years and 37 age matched referents showed a higher degree of metaplastic alterations in the former group. In addition, three cases of epithelial dysplasia were observed among the exposed. These results indicate that formaldehyde may be potentially carcinogenic to man. Combination of this finding with the inconclusive epidemiological studies suggests that formaldehyde is a weak carcinogen and that occupational exposure to formaldehyde alone is insufficient to induce nasal cancer.

A phase II study of 5-fluorouracil/cisplatinum in recurrent cervical cancer

Thirty-seven patients with recurrent cervical carcinoma entered a phase II study of cisplatinum and 5-fluorouracil (5-FU). They were divided into patients with recurrent lesions outside previously irradiated area (group 1) and those with at least one recurrent lesion inside this volume (group 2). The treatment schedule consisted of 5-FU 1,000 mg/m2 i.v. days 1 to 5 and cisplatinum 100 mg/m2 i.v. day 1. Thirty-two patients were evaluable for response and toxicity. In group 1, 4 out of 19 patients had complete response with a median duration of 18 months, 9 out of 19 had partial response with a median duration of 10 months. Only 2 out of 13 patients in group 2 achieved partial response. All patients suffered from nausea and vomiting. The dose limiting factor was bone marrow suppression. The response rate in group 1 (68%) is impressive and higher than previously reported after other chemotherapy regimens. We found, however, the regimen too toxic for patients with central recurrences in previously irradiated areas, though some of these patients achieved substantial pain relief.

Colony-forming ability of human ovarian carcinomas in the Courtenay soft agar assay

One hundred and twenty-one ovarian carcinomas were cultivated in soft agar according to the Courtenay & Mills (C-M) soft agar method. 71% of the tumours formed colonies, and 54% formed more than 30 colonies. Tumour cells from malignant fluids grew more frequently than did solid tumours, whereas the plating efficiencies (PEs) were higher in the case of solid tumours. In general, the PEs were higher and more tumours formed colonies in the C-M method compared to the Hamburger-Salmon (H-S) method. The colony-forming ability did not show statistically significant correlation to histopathological type and grade, previous treatment and S-phase fraction, but was related to DNA ploidy. In poorly differentiated tumours a high colony-forming ability was associated with a poor prognosis, whereas the opposite was found in well and moderately differentiated tumours. Differential dose-response relationships were obtained after in vitro treatment with anticancer agents.

Alveolar soft-part sarcoma in the uterine cervix

We describe a case of an alveolar soft-part sarcoma of the cervix in a 35-year-old woman. The light- and electron-microscopic and immunohistochemical findings are described. Periodic acid-Schiff-positive, diastase resistant, intracytoplasmic crystals, pathognomonic for alveolar soft-part sarcoma, were present. The cells expressed immunoreactivity for neuron-specific enolase and protein S100. The results of our own immunohistochemical examinations and those presented in the literature are discussed.

A randomized trial of adjuvant progestagen in early endometrial cancer

A randomized, controlled trial was designed to determine whether adjuvant progestagen therapy improves survival in patients with Stage I or Stage II endometrial cancer. After surgery, 1148 patients were randomly assigned to adjuvant treatment with progesterone or were given no additional therapy. The duration of follow-up ranged from 42 to 132 months (median follow-up, 72 months). Crude survival and relapse rates were similar for both groups. Death due to intercurrent disease was higher in the progesterone group (P = 0.04). The median survival of the group of patients with cancer-related death was higher in the progestagen group than in the control group (30 and 22 months, respectively; P = 0.03). In 461 high-risk patients, a tendency towards fewer cancer-related deaths and a better disease-free survival in the treatment group was observed, but crude survival was unchanged. We conclude that there is little to gain from adjuvant progestagen therapy in patients with low-risk endometrial cancer, and that further studies are needed in high-risk patients.

[Intestinal spirochaetosis]

It is well known that spirochetes may be found in the digestive tract of various species, including humans. We describe a homosexual man with long-standing diarrhoea, probably caused by intestinal spirochaetosis. The diagnosis was based upon light microscopic demonstration of a thin haematoxyphilic bandlike layer covering the intestinal surface epithelium, which is an established diagnostic characteristic of intestinal spirochaetosis. The spirochaetosis was further confirmed by electron microscopy. The pathogenetic significance of spirochetes in human intestinal disease is not fully understood. However, intestinal spirochaetosis should be suspected in patients with long-standing diarrhoea. Symptomatic spirochaetosis in the gut responds well to treatment with metronidazole. The spirochetes of the human digestive tract constitute a newly defined genus of the family Treponemataceae.

Small cell carcinoma of the ovary. A report of six cases

Six cases of small cell carcinoma of the ovary are presented. The tumors occurred in women with an average age of 27.5 years. According to the International Federation of Gynecology and Obstetrics (FIGO), two patients had Stage I, three Stage II, and one Stage III disease. The tumors behaved highly malignantly, as four of the patients died from disseminated disease within 20 months. Three of the tumors were found to be associated with elevated serum calcium levels. By light microscopy three of the tumors were originally misinterpreted: one as an undifferentiated tumor, probably of stromal origin; one as a germ cell tumor, probably endodermal sinus tumor; and the third as a granulosa cell tumor. In four tumors examined by electron microscopy, the epithelial nature was confirmed, and three of them contained neuroendocrine granules. Immunocytochemical examination in five cases revealed positive staining for neuron-specific enolase (NSE) and negative staining for beta 2-microglobulin, whereas one case was negative for NSE and positive for beta 2-microglobulin. A positive immunoreaction for parathyroid hormone was observed in three cases (all NSE positive). In two of these a raised serum calcium level was documented. This finding possibly gives a clue to the hypercalcemia so frequently found in these patients.

Observer variation in histologic classification of malignant and borderline ovarian tumors

Eight hundred sixty-nine primary malignant or borderline ovarian tumors reported to the Norwegian Cancer Registry were reviewed. The histologic slides were randomly distributed to six observers and classified according to the World Health Organization classification of ovarian tumors. By rotation of slides, each tumor was successively reviewed by three observers. Each observer was given approximately 40 duplicates of slides he or she had typed before, mixed in with the slides for the third review. A contracted version of the classification with 27 entries was used in the analysis. Mean intraobserver reproducibility was 62% (kappa, 0.53), varying from 50% to 75% (kappa, 0.34 to 0.70) for the individual observers. The mean rate of agreement between two observers was 56% (kappa, 0.46), varying from 46% to 65% for the individual pairs of observers. The rate of full agreement among three observers was 41%. The most common disagreements were between different specific types of carcinoma, between undifferentiated and differentiated carcinoma, between borderline and malignant tumors, between unclassified and classified carcinoma, and between mixed and pure types of carcinoma. Very low reproducibility was obtained for mixed and unclassified carcinoma.

Primary adenocarcinoma localized to the fallopian tubes: report on 33 cases

Thirty-three cases of primary adenocarcinoma localized to the fallopian tubes were analyzed according to prognostic factors such as depth of infiltration, tumor differentiation, and lymph vessel invasion. Fifteen patients (45, 5%) died of recurrence within 5 years. Only for positive vessel invasion was the survival significance worse. Combination chemotherapy seems promising compared to radiotherapy in these early stages.

Development of brush cytology for detection of metaplastic and dysplastic nasal mucosa lesions. A preliminary report

Nickel workers and wood workers have an increased incidence of carcinoma and of lesions of the nasal mucosa regarded as precancerous, i.e. dysplasia. This preliminary study demonstrates how metaplastic and dysplastic changes of the nasal epithelium may be diagnosed independently from cytological smears and from histological sections of samples from the same middle nasal turbinate. The sampling technique described yielded excellent material for cytological diagnosis and was also suitable for detailed cell surface characterization by scanning electron microscopy (SEM). Exfoliative cytology was found to be a reliable means of detecting preneoplastic changes in the nasal mucosa of individuals in selected risk groups. The sampling procedure causes less discomfort to the subjects and requires fewer resources than biopsy procedures.

Sarcoid reaction of hilar and paratracheal lymph nodes in patients treated for testicular cancer

Bilateral hilar lymph node enlargement developed in four patients 1 to 8 years after successful radiotherapy for testicular cancer Stage I was performed. Two had additional paratracheal involvement. Biopsy showed sarcoid reaction in all four cases. An increased frequency of sarcoid reaction is assumed in patients treated for testicular cancer. The pathogenesis remains unknown. The clinical and radiologic findings should not be misinterpreted as showing recurrent malignant disease. In an otherwise disease-free patient in whom mediastinal lymph node enlargement develops, a biopsy should always be performed.

Prevalence of antibodies to herpes simplex virus and frequency of HLA antigens in patients with preinvasive and invasive cervical cancer

Previous herpes simplex virus type 2 (HSV-2) infections are known to predispose women for the development of cervical cancer, but causal relationship between the virus and the cancer has never been proven. Forty-six patients with cervical carcinoma (13 with preinvasive lesions and 33 with various stages of invasive disease) were selected for the present study. Among the patients 96% were seropositive for the presence of antibodies to herpes simplex virus compared to 87% of the 30 controls. Antibodies specific for HSV-2 were found in the sera from 24% of the patients and 17% of the controls by the use of an immunoblotting test. Patients and controls were typed for HLA-A,B,C and D/DR antigens, but no significant associations were found.

Multi-modality treatment of advanced malignant germ cell tumours in males. I. Experience with cis-platinum-based combination chemotherapy

Three-weekly cis-platinum-based combination chemotherapy with or without subsequent surgery and/or radiotherapy resulted in a 58% 3-year-survival in 79 patients with advanced malignant germ cell tumours. Poor risk factors were relapse after previous chemotherapy, retroperitoneal bulky disease, liver metastases and extremely high serum levels of AFP, beta-HCG, and LDH. Patients with pure seminoma had a high curation rate. The overall toxicity was acceptable. Cis-platinum-based chemotherapy is at present the most effective cytotoxic treatment for patients with advanced malignant germ cell tumours. The relatively low survival rate in poor-risk patients necessitates more aggressive primary chemotherapy in this subgroup of patients.

Clinical (stage III) as compared to subclinical intrapelvic extrauterine tumor spread in endometrial carcinoma: a clinical and histopathological study of 175 patients

One hundred and seventy-five patients with endometrial cancer, seen in the Norwegian Radium Hospital from 1960 to 1977, had tumor extension outside the uterus but not outside the true pelvis. One hundred and eight of these patients had clinical stage III disease and in 67 patients, originally classified as stage I or stage II, the intrapelvic extrauterine tumor spread was first detected at surgery or at histopathological examination of the operation specimen. The 40% 5-year-actuarial survival of the latter group differed significantly from the 16% found in clinical stage III (P less than 0.001). This must be largely contributed to the fact that radical surgery could only be performed in 13% of the clinical stage III group as compared to 70% in the group of patients with subclinical extrauterine disease. Surgical eradication of all macroscopic tumor was of major prognostic importance for patients with clinical stage III, resulting in an actuarial 5-year survival of 41%, nearly identical to 42% for the group of patients with subclinical extrauterine tumor extension. Adjuvant progestagen therapy seemed to be of some benefit, but the need, however, for a more effective systemic treatment, possibly using cytotoxic drugs, is evident.

Multi-modality treatment in males with advanced malignant germ cell tumours. II. Experience with surgery and radiotherapy following cis-platinum-based chemotherapy

After chemotherapy with cis-platinum, vinblastine and bleomycin, 33 surgical procedures were performed in 29 patients with advanced malignant germ-cell tumours. The tumour masses could be completely resected macroscopically in 26 patients. Histology of the operation specimens showed fibrosis/necrosis (9 specimens), mature teratome (13 specimens) and vital malignant tumour (11 specimens). Patients with fibrosis/necrosis or completely resected mature teratoma had an excellent prognosis, whereas only 5 of the 11 patients with vital malignant tumour survived in spite of second-line treatment with chemotherapy/radiotherapy. Preoperatively elevated serum levels of AFP, beta-HCG and/or LDH indicated the presence of residual vital malignant germ cell tumour. Eight of 14 patients were rendered tumour-free by radiotherapy given as second- or third-line treatment. In general, tumour masses, remaining after cis-platinum-based induction chemotherapy should be resected as completely as possible even in the case of mature teratoma or fibrosis/necrosis. Radiotherapy should be considered as second- and third-line treatment in selected patients.

Recurrent adenocarcinoma of the endometrium: a clinical and histopathological study of 379 patients

Three hundred and seventy-nine patients with recurrent endometrial cancer were seen in the Norwegian Radium Hospital from 1960 to 1976. Local recurrence was found in 190 patients (50%), distant metastases in 108 patients (28%), and in 81 patients (21%) local recurrence and distant metastases were found simultaneously. Thirty-two percent of all patients had no symptoms at the time of diagnosis of the recurrence. The median time interval between primary treatment and detection of recurrence was 14 months for patients with local recurrence and 19 months for those with distant metastases. Thirty-four percent of all recurrences was detected within 1 year and 76% within three years of primary treatment. In 10% recurrence was diagnosed more than 5 years after primary treatment. Twenty-two of the 190 patients (12%) with local recurrence, 5 of the 108 patients (5%) with distant metastases, and 2 of the 81 patients (2%) with local recurrence together with distant metastases survived and were without evidence of disease at the end of the observation period (3-19 years). Radiotherapy alone or in combination with surgery was given in 24 of the 29 "cured" patients; 16 of them received progestagens in addition. Three of the survivors were treated with progestagens alone. The median survival time for patients with lung metastases only, who were treated with progestagens, was considerably longer when compared to those without treatment (9 vs 2 months). The need for nonhormonal cytotoxic chemotherapy in the treatment of recurrent endometrial carcinoma is stressed.

Stage IV endometrial carcinoma: a clinical and histopathological study of 83 patients

From 1960 to 1977, eighty-three patients with stage IV endometrial carcinoma were treated in the Norwegian Radium Hospital. The lung was the main site of extrapelvic tumor extension (36%), followed by "multiple sites" (23%), lymph nodes (inguinal, supraclavicular, axillar; 13%), and bladder (13%). The actuarial 5-year-survival rate was 10%. Complete clinical remission was achieved in 5 patients with lung metastases, in 2 with inguinal lymph node metastases, and in 1 patient with ascites with positive cytology. Control of pelvic disease could be achieved in 20 of 72 patients (28%) by radiotherapy alone or combined with surgery and/or progestagens. Progestational agents proved to be of benefit especially for patients with lung metastases. A complete remission of all visible lesions was observed in 8 out of 26 patients (31%). Patients with well- and moderately differentiated primary adenocarcinoma had a response rate of 83% as opposed to 14% for patients with poorly differentiated adenocarcinomas and adenosquamos carcinomas. Extrapelvic tumor localizations, suitable for radiotherapy, were supraclavicular and axillary lymph nodes and bone metastases.

Granulocytic sarcoma (chloroma) of the uterine cervix: report of two cases

Two cases of granulocytic sarcoma in the cervix are described, adding to the six previously reported cases. Both our cases were primarily misdiagnosed as other types of small-cell malignant tumors. Misdiagnosis often occurs in granulocytic sarcomas, especially for those in extraskeletal sites or when the tumor precedes development of frank leukemia. A conclusive diagnosis of granulocytic sarcoma depends upon the demonstration of granulocytic differentiation of the tumor cells. For this purpose, special staining methods like the Leder stain and the antilysozyme immunoperoxidase stain are particularly useful.

Individualized treatment of stage I carcinoma of the vulva

A series of 117 patients with stage I squamous cell carcinoma of the vulva was followed for 3 to 21 years. Twenty recurrences (17.1%) were found, 12 in the vulva or vagina, 7 in the groin, and 1 in a patient who developed distant metastases. Invasion of tumor cells in lymph or blood vessels was found in operative specimens from 19 patients (16.2%), 8 of whom (42.1%) developed local recurrences of metastases. Of 76 patients who underwent lymphadenectomy, 7 had ipsilateral and 1 had bilateral metastases to the inguinal lymph nodes. Five-year crude survival rate for the whole series was 79%, but only 52% for the group of patients with vessel invasion. Treatment should in most cases be hemivulvectomy with ipsilateral inguinal lymphadenectomy.

Postoperative external irradiation and prognostic parameters in stage I endometrial carcinoma: clinical and histopathologic study of 540 patients

From 1968 to 1974, 540 patients with stage I adenocarcinoma of the corpus uteri entered a prospective clinical trial to evaluate the effect of postoperative external pelvic irradiation. After primary surgery all patients received intravaginal radium irradiation; 6000 rads was delivered to the surface of the vaginal mucosa. At the time vaginal radium was given, randomization was performed: Group A received no further treatment (controls); group B received additional high-voltage irradiation to the pelvic field with a dose of 4000 rads to the pelvic lymph nodes. During the follow-up period of 3 to 10 years a significant reduction in vaginal and pelvic recurrences was found in group B as compared with group A (1.9 versus 6.9%, P < .01). On the other hand, more patients in group B developed distant metastases than those in group A (9.9 versus 5.4%). Thus, the 5-year survival rate was not improved by external irradiation. A more detailed analysis of the series led to the conclusion that only patients with poorly differentiated tumors (grade 3), which infiltrate more than half the myometrial thickness, might benefit from additional external radiotherapy. In almost 20% of 151 consecutive patients, tumor cells were found in endothelial lined spaces. Significantly more deaths and recurrences were found among these patients compared to those without vessel invasion (26.7 versus 9.1%, P < .01).

Factors influencing the treatment of patients with stage Ia carcinoma of the cervix

A total of 122 patients with Stage Ia carcinoma of the cervix was followed for 5 to 25 years. Eight recurrences were found, four of which were located in the vagina, cervix or the bladder and four on the pelvic wall. Five of the recurrences were detected after 5 years of follow-up. Tumour cells were found in blood vessels or lymphatic channels in eight patients and five of them developed metastases. It is proposed that only tumours with a depth of stromal invasion of less than 5 mm should be treated conservatively. If blood vessels or lymphatic channels contain tumour, we would recommend a Wertheim's hysterectomy or treatment by intracavitary and external irradiation.

Sarcoidosis of the cardiac conducting system

In a consecutive series of 2.950 routine autopsies two of 13 cases with sarcoidosis had cardiac involvement, one of which showed extensive granulomatous lesions in the sinus node. It is suggested that sudden death in this 52-year-old woman was caused by cardiac sarcoid involvement, possibly by leading to sinus arrest with cardiac standstill. However, because of the lack of electrocardiographic evidence, sudden death from ventricular fibrillation can not be excluded. As sudden death is a well-known complication in sarcoidosis, all such patients should be regularly screened for cardiac involvement in order to prevent fatal arrhythmias.