Efficacy and toxicity of very high-dose cisplatin in advanced ovarian carcinoma: 4-year survival analysis and neurological follow-up

Given the steep dose-response relationship with cisplatin, a pilot study on very high-dose cisplatin (HD-CDDP) was conducted in previously untreated patients with advanced ovarian carcinoma and postoperative residual tumor (RT). Thirty-seven patients (FIGO stages III-IV; RT> 0.5 cm) received three courses of HD-CDDP (a course of 40 mg m-2 day-1 for days 1-5, every 28 days). Twenty patients (54%) achieved clinical complete response (CR), 12 (32%) partial response (PR), and the remaining five (14%) showed stable or progressive disease (NC-P). All 20 clinically complete responders underwent second-look laparotomy and CR was confirmed in all but five cases (pathologic CR: 40%) and in 71% of patients with> 0.5-2 cm RT vs. 15% of those with> 2 cm RT (P < 0.001). The 4-year overall survival was 35% (median: 27 months, range: 7-58+), and 53% vs. 20% for patients with> 0.5-2 cm and> 2 cm RT, respectively (P = 0.01). The overall progression-free survival was 29.5% (median: 16 months, range 2-58+) and for patients with more or less than 2 cm RT it was 20 and 41.2% (P < 0.05). Pathologically complete responders received no further treatment and showed a 3-year disease-free survival of 53%. The major toxic effect was a delayed-onset peripheral neuropathy observed in all patients, five of them (13.5%) with gait disturbances requiring continuous assistance. Nevertheless, none of them became wheelchair dependent and about 90% of the alive patients recovered at the 18-month neurologic follow-up, suggesting that cisplatin damage can be reversible. Ototoxicity was detected in all patients although only 19% of patients were symptomatic. HD-CDDP showed high activity in patients with> 0.5-2 cm RT, suggesting that the adverse significance of minimal RT may be partially overcome through an intensive chemical cytoreduction. Substantial neurotoxicity and the need for intensive care represent the major drawbacks. Further studies should delineate the exact role of HD-CDDP in optimally debulked patients, and a considerable effort should be made in rapidly achieving reliable data on the value of neuroprotectors in the prevention of the dose-limiting neurotoxicity.

Significance of epidermal growth factor receptor in advanced ovarian cancer

PURPOSE

The purpose of this study was to investigate the significance of epidermal growth factor receptor (EGF-R) expression in a group of advanced ovarian carcinomas.

PATIENTS AND METHODS

The study was conducted on 72 previously untreated patients with International Federation of Gynecology and Obstetrics (FIGO) stage III-IV disease. The median follow-up was 24 months (range, 4 to 75 months). EGF-R was measured by a radioreceptorial assay. A cutoff of 1.5 fmol per milligram of protein was chosen to define EGF-R positivity. Medians and life tables obtained with the Kaplan and Meier method were analyzed by the log-rank test. The risk of progression was estimated by Cox's proportional hazards model.

RESULTS

EGF-R was detected in 54% of primary tumors. When EGF-R was analyzed in different tissue specimens of the same tumor, consistent findings were noted in 88% (seven of eight) of cases. A lower concordance rate (nine of 15; 60%) was found between primary tumors and omental metastases, with a tendency toward higher EGF-R levels in the latter. The EGF-R expression did not significantly correlate with age, stage, grading, and residual tumor after primary surgery. In the univariate analysis, stage IV disease, postoperative residual tumor diameter greater than 2 cm, presence of ascites, and EGF-R positivity were found to be significantly associated with a greater risk of disease progression. In the multivariate analysis, only the postoperative residual tumor and the EGF-R expression remained significantly associated with a high risk of progression.

CONCLUSION

Data reported here suggest that the presence of EGF-R in advanced ovarian tumor at the time of the primary surgery identifies a subset of patients with a particularly poor prognosis.

Anatomical study of para-aortic and pelvic lymph nodes in gynecologic malignancies

Between January 1986 and June 1990, systematic para-aortic and pelvic lymphadenectomy was performed in 208 women with untreated ovarian, endometrial, and cervical cancers. This study aimed to evaluate the median number of nodes collected from each pelvic and para-aortic group and to verify a new detailed nomenclature for the various lymph node groups. The para-aortic nodes were distinguished as paracaval, precaval, and retrocaval, depending on their relationship with the vena cava. Para-aortic, pre-aortic, and retro-aortic nodes were located close to the aorta. The nodes situated between the vena cava and aorta were designated intercavo-aortic. A median of 26 (range 15-48) para-aortic nodes were collected during ovarian or endometrial cancer operations. The lymphatic system of the pelvis was divided into six groups, depending on the relationship with the pelvic blood vessels. The pelvic nodes were distinguished as common, internal and external iliac, presacral, obturator, and parametrial. In cases of cervical cancer, the median number of pelvic nodes collected was 38 (range 20-88). Such anatomical study of the lymphatic system shows that a higher number of nodes than expected can be found in the retroperitoneum.

Mitomycin C and 5-fluorouracil salvage chemotherapy in platinum-resistant ovarian carcinoma

Twenty-four patients with progressing or recurrent ovarian carcinoma, all pretreated with cisplatin, were evaluated for response and toxicity to mitomycin C (MMC) and 5-fluorouracil (5-FU) chemotherapy. Eligible patients had histologically proven intra-abdominal disease (67% clinically measurable; 33% nonmeasurable), and 67% of them had progressed on prior platinum-based chemotherapy. WHO response criteria were adopted in patients with measurable disease while those with nonmeasurable lesions were considered as responding in case of nonevident disease and CA-125 values less than 35 U/dl for at least 6 months. All patients received at least 2 treatment courses (median 6, range 2-10), and 5 patients (21%) could be considered as responding: 4/8 (50%) with nonmeasurable and 1/16 (6%) with measurable disease. The overall median survival was 12 months, range 7-30+ (median follow-up: 29.5 months, range 28-30). Progression-free survival was significantly different in responders (15 months) versus nonresponders (3 months) (p = 0.0001). Toxicity was mainly represented by myelosuppression (grade I 29%; II 8% and III 4%). MMC and 5-FU did not show significant activity against large tumor burden, while a relatively good activity was detected in patients with minimal disease. The limited toxicity and possible schedule modifications have to be taken into account for further investigation on selected patients.

Recombinant alpha-2b-interferon dynamic test as a potential tool in predicting disease status during second look in ovarian cancer. A preliminary report

The circulating levels of a 90-kilodalton (KD) tumor-associated antigen were measured in the blood of 26 patients with ovarian cancer in clinical remission who received a short course of recombinant alpha-2b-interferon (rIFN-alpha-2b, 3 million U/m2/d intramuscularly for 3 days) before second-look procedures. The administration of rIFN-alpha-2b to 90-KD antigen-positive patients produced a slight increase of the marker. However, in patients without the marker but with evidence of disease, a remarkable increase above the cutoff level was observed. Less pronounced modifications of 90-KD antigen serum levels were found in patients with no disease at second look. Moreover, considering the 90-KD antigen mean percentage increase, the dynamic test with rIFN-alpha-2b was able to eliminate five of six false-negative results obtained with the 90-KD antigen basal assay alone. The sensitivity of the assay increased to 92% after IFN compared with 54% for the 90-KD antigen assay alone. An increase (greater than 100% above pretreatment titer) of 90-KD antigen levels during the test also was observed in four patients with no evidence of disease at second look. In two of these false-positive cases, recurrence of disease was observed 13 and 24 months later. At the time of this analysis, none of the patients with a negative second look and negative dynamic test had relapsed. These results suggest that the dynamic test with rIFN-alpha-2b might be a new tool to assess disease status in patients with ovarian cancer before second-look procedures.

Autologous blood stem cell harvesting and transplantation in patients with advanced ovarian cancer

We investigated the feasibility of a programme of autologous blood stem cell (ABSC) harvesting and transplantation in 13 patients with advanced ovarian cancer, previously untreated by chemotherapy or radiotherapy and entering a phase II study of high-dose cisplatin, etoposide and carboplatin with haematopoietic stem cell rescue. Prior to high-dose treatment all patients underwent two courses of cisplatin and cyclophosphamide. An 8-fold increase of the peripheral colony forming unit granulocytic-macrophage (CFU-GM) was observed during recovery from myelosuppression after the first chemotherapy course. The second course determined a 2.5-fold increase of peripheral CFU-GM. In 70% of enrolled patients (nine patients) we were able to perform ABSC harvesting by leukaphereses; in the apheresed patients we harvested an average of 20.8 x 10(4)/kg CFU-GM (range 10.9-37.0). Haematopoietic trilineage engraftment, established as the number of days necessary to reach white blood cells (WBC) greater than 1.0 x 10(9)/l, polymorphonuclear leucocytes (PMN) greater than 0.5 x 10(9)/l and platelets (PLT) greater than 50 x 10(9)/l, occurred very promptly and was sustained in the same series after high-dose cisplatin, carboplatin and etoposide, followed by autologous blood stem cell transplantation (ABSCT). In our experience we found a significant correlation (r = 0.77; P less than 0.05) between CFU-GM infused dose and the engraftment speed of PMN. We conclude that the combination of cisplatin and cyclophosphamide is effective in mobilizing haematopoietic progenitors in the peripheral blood of patients with advanced ovarian cancer, previously untreated by chemoradiotherapy. Moreover, ABSCT is capable of rapidly restoring the haematopoietic function after high-dose treatment and for this reason it represents a particularly advisable therapeutic option for the treatment of solid tumours because these patients are commonly older than 50 and can be excluded from bone marrow transplantation.

Cathepsin D assay in ovarian cancer: correlation with pathological features and receptors for oestrogen, progesterone and epidermal growth factor

Using an immunoradiometric assay, Cathepsin-D (Cath-D) concentrations were measured in the cytosol of 68 normal and neoplastic human ovarian tissues. Cath-D levels were higher in malignant tumours than in normal tissue samples (P less than 0.01) and benign tumours (P less than 0.01). In six out of seven cases, metastatic deposits showed Cath-D concentrations higher than the respective primary tumours. Using 12 of 17 pmols.mg-1 protein as cut-off levels, the Cath-D status (high or low) was not related to any pathological parameter. Moreover, no correlation was found between Cath-D levels and receptors for oestrogen, progesterone and epidermal growth factor. Our results indicate that ovarian tumours produce Cath-D. Further studies are needed to evaluate whether this protein could represent a prognostic factor for this neoplasia.

High-dose cisplatin and bleomycin neoadjuvant chemotherapy plus radical surgery in locally advanced cervical carcinoma: a preliminary report

One course of chemotherapy containing cisplatin and bleomycin as a neoadjuvant treatment was given to 26 consecutive patients with previously untreated stage IB (bulky disease)-III cervical carcinoma and followed by radical surgery. After chemotherapy responses were detected in 23 patients (5 complete and 18 partial; overall, 88%) and permitted radical surgery in 21 cases (81%). Surgery consisted of type III-IV radical hysterectomy plus systematic para-aortic and pelvic lymphadenectomy. At histologic examination, complete responses were found in 5 (19%) and partial responses in 16 (62%) cases. The average number of lymph nodes removed was 61 (range, 38-118). A lower than expected incidence of lymph node metastases was detected (2/21, 9.5%). The chemotherapy-induced toxicity was mainly represented by nausea and vomiting. Chemotherapy did not seem to complicate surgery in these circumstances, even though moderate-degree postoperative complications occurred in 48% of cases. Eighteen months median follow-up time (range, 11-23) from hystological diagnosis has been reached in the operated patients, and no recurrences have been detected so far.

Constitutive expression of leukemia inhibitory factor RNA by human bone marrow stromal cells and modulation by IL-1, TNF-alpha, and TGF-beta

Recent in vitro studies indicate that bone marrow mesenchymal elements, residing in close proximity to hematopoietic cell populations, elaborate a network of cytokines that are, at least partially, responsible for modulating the growth and maturation of the latter compartment. Leukemia inhibitory factor (LIF), a molecule with both positive and negative regulatory activities, has been implicated in murine embryogenesis and hematopoiesis. We demonstrate that cultured normal human bone marrow stromal cells constitutively express LIF message. Further, exposure of these cells to other hematopoietic modulators including interleukin 1 alpha (IL-1 alpha), interleukin 1 beta (IL-1 beta), transforming growth factor-beta (TGF-beta), and tumor necrosis factor-alpha (TNF-alpha) (but not interferon-alpha [IFN alpha]) increases the level of LIF RNA. Interestingly, cultured stromal cells derived from three of four patients with chronic myelogenous leukemia showed enhanced LIF expression. These observations suggest that LIF may participate, either alone or through interaction with other cytokines, in the bone marrow microenvironment-mediated influence on both normal and malignant hematopoietic processes.

High dose chemotherapy with cisplatin, VP16 and carboplatin with stem cell support in patients with advanced ovarian cancer

Authors treated 4 patients suffering from advanced ovarian cancer with high-dose chemotherapy and autologous peripheral blood stem cell (APBSC) or autologous bone marrow stem cell (ABM) as hematopoietic support. In three patients were collected peripheral blood stem cells using a fully automated blood cell separator during hematopoietic recovery following aplasia induced by non-intensive chemotherapy (cisplatin 200 mg/m2 and cyclophosphamide 1,500 mg/m2). Hemopoietic reconstitution of the four patients submitted to APBSC or ABM support after high-dose chemotherapy (cisplatin 100 mg/m2, VP16 650 mg/m2 and carboplatin 1,800 mg/m2) showed the low hematological toxicity of our treatment with APBSC support. Moreover, the drug combination of cisplatin and cyclophosphamide has clinical activity in ovarian cancer and it is an optimal association to mobilize and harvest large number of PBSC.

Expression of the macrophage colony-stimulating factor and its receptor in gynecologic malignancies

Recently, hematopoietic growth factors have been implicated in protean nonhematopoietic processes. In the current study, expression of macrophage colony-stimulating factor (M-CSF) and its receptor (the c-fms proto-oncogene) was investigated in 42 samples of gynecologic tissues. There were 15 samples of normal ovarian and uterine tissue or benign conditions of these organs; 11 samples of primary ovarian cancer tissue; seven samples of metastatic ovarian cancer tissue; and nine samples of primary endometrial cancer tissue. Steady state transcript levels were assessed by Northern Blot analysis. Macrophage colony-stimulating factor (M-CSF) expression was not observed in any of the specimens of benign abnormalities or of normal organs; c-fms expression was detected in two of 15 (13%) of these specimens, albeit at very low levels. In contrast, 14 (78%) of 18 ovarian tumor specimens, and five (55%) of nine endometrial tumor specimens expressed M-CSF. Similarly, 16 (89%) of 18 ovarian tumor specimens and six (67%) of nine endometrial tumor specimens expressed c-fms. Most positive malignant tissues (19 [86%] of 22) showed coexpression of M-CSF and c-fms. Of interest, M-CSF and c-fms mRNA were detected in tumor, but not in adjacent normal tissue. Furthermore, M-CSF and c-fms transcripts were produced by all metastatic tumors, including two cases in which the corresponding primary tumor from the same patient was negative. Because M-CSF mediates its effects by binding to its receptor, the increased levels of both these gene products in gynecologic malignancies suggest that an interaction between M-CSF and c-fms may participate in the development of ovarian and endometrial carcinomas and especially in progression to the metastatic state.

Neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer. Prognostic factors for response and survival

Between January 1986 and September 1988, 75 patients with locally advanced cervical carcinoma (International Federation of Gynecology and Obstetrics [FIGO] Stages IB-III) received three courses of neoadjuvant chemotherapy (NAC), including cisplatin, bleomycin, and methotrexate (PBM). Fifteen percent of patients achieved a complete response (CR) and 68% a partial response (PR). Pretreatment characteristics were analyzed for response to NAC. Significantly lower response rates were found in patients with tumor size more than 5 cm in diameter and bilateral parametrial involvement to the pelvic side wall. None of the biological parameters studied was related to chemoresponsiveness. Patients achieving CR or PR had a significantly improved 3-year survival rate compared with those who did not respond. After NAC, radical surgery was possible in all responding patients. The median number of lymph nodes removed was 60. A lower than expected incidence of lymph node metastases was detected. None of the clinical and pathologic features considered was significantly correlated with the lymph node status. Twelve of the 62 operated patients had disease recurrence. Pathologic parametrial involvement and cervical infiltration equal to or deeper than 5 mm were found to be significant prognostic factors for recurrence. A 3-year, disease-free survival of 89%, 73%, and 43% for Stage IB-IIA, IIB, and III, respectively, was found. Among the operated patients these rates increased to 100%, 81%, and 66% for Stage IB-IIA, IIB, and III, respectively. A prospective randomized trial comparing NAC and surgery with radiotherapy alone is in progress.

Effect of recombinant human interferon-alpha 2b on receptors for steroid hormones and epidermal growth factor in patients with endometrial cancer

Interferons (IFNs) may modulate oestrogen (ER), progesterone (PR) and epidermal growth factor (EGFR) receptor expression in vitro. ER, PR and EGFR levels in tumour specimens taken from 13 patients with endometrial adenocarcinomas before and after 5 days' intramuscular treatment with 5 x 10(6) U per recombinant human leucocyte interferon-alpha 2b (rh IFN-alpha 2b). After treatment, ER (P less than 0.01) and PR (P less than 0.05) levels were significantly increased with a simultaneous reduction of EGFR content (P less than 0.05). Since the expression of ER and PR characterises more differentiated hormono-sensitive tumours, while EGFR are preferentially expressed in less differentiated tumours, the increase of steroid hormone receptor levels with the reduction of EGFR expression suggests that rh IFN-alpha 2b may induce endometrial cancer cell differentiation. Moreover, the decrease of EGFR levels may explain the antiproliferative effect of IFNs.

Constitutive and induced expression of growth factors in normal and chronic phase chronic myelogenous leukemia Ph1 bone marrow stroma

Study of growth factor RNA levels in the stromal cells derived from the adherent layer of long-term bone marrow culture demonstrated constitutive expression of transforming growth factor beta 1 (TGF-beta 1) and macrophage colony-stimulating factor. These cells did not express granulocyte colony-stimulating factor, granulocyte-monocyte colony-stimulating factor, interleukin (IL) 1 alpha, IL-1 beta, IL-3, and IL-6. However, granulocyte colony-stimulating factor expression could be induced by recombinant human IL-1 beta; while IL-6 could be induced by both IL-1 beta and tumor necrosis factor-alpha. No differences could be detected between adherent layers established from normal and benign phase Ph1 chronic myelogenous leukemia bone marrow. The uninduced expression of TGF-beta 1, a potent hematopoietic cell growth inhibitor, suggests that stromal cells play an inherent role in regulating the proliferation of adjacent bone marrow hematopoietic progenitor cells. However, a defect in stromal TGF-beta 1 production cannot account for the profoundly expanded myeloid compartment in chronic phase chronic myelogenous leukemia. In contrast to the constitutive expression of TGF-beta 1 and macrophage colony-stimulating factor, hematopoietic growth factors are only expressed following a proper stimulation.

Steroid hormone receptors in carcinoma of the cervix: lack of response to an antiestrogen

Levels of estrogen (ER) and progesterone (PR) receptors were measured in 81 patients with primary cervical cancer. In 10 patients, receptor levels were evaluated before and after a short course of tamoxifen treatment. Fifty-six percent of cervical tumors contained ER, and 58%, PR. Receptor level and expression were not related to any clinical and histological characteristic. Moreover, both survival time and response to neoadjuvant chemotherapy did not correlate with the presence of ER and PR. Tamoxifen treatment did not influence ER and PR levels. Our results suggest that steroid hormone receptors are of little value in the management of cervical cancer, and that in this neoplasia, ER is probably not functional.

Recombinant alpha-2b-interferon enhances the circulating levels of a 90-kilodalton (K) tumor-associated antigen in patients with gynecologic and breast malignancies

The circulating levels of a 90-kilodalton (K) tumor-associated antigen were measured in the blood of 43 patients with gynecologic and breast malignancies who underwent a short course of recombinant alpha-2b-interferon (rIFN alpha-2b) (3 million U/m2/d intramuscularly [IM] for 3 days). Of the 43 patients, 23 showed abnormal 90-K levels (greater than 1.7 U/ml). A significant increase of antigen levels was already observed 24 hours after the first administration and persisted throughout the investigation period. Of 20 patients with 90-K levels below the normal limit, 12 went over the normal cutoff value after two rIFN alpha-2b injections. No significant modifications of 90-K levels were detected in nine women receiving rIFN alpha-2b for the treatment of genital condylomata. The serum levels of two other tumor-associated antigens, CA 125 and CA 15-3, were not modified by rIFN alpha-2b administration. The ability of rIFN alpha-2b to increase the circulating levels of 90-K might have important clinical implications for the serodetection of cancer.

Type II estrogen binding sites in human peripheral blood mononuclear cells: variations during the menstrual cycle

We have previously reported that human peripheral blood mononuclear cells (PBMC) contain type II estrogen binding sites (type II EBS). In this study, the fluctuations of type II EBS during the menstrual cycle were analyzed in 6 normally menstruating women. Approximately 3 times higher levels of type II EBS were found in the periovulatory period with respect to both follicular and luteal phases. In postmenopausal women the mean type II EBS levels were similar to those observed in the follicular phase of the cycle. However, in 3 postmenopausal patients a short course of estrogen or tamoxifen resulted in a marked increase of type II EBS levels. Tamoxifen was also found to compete with 17 beta-estradiol for type II EBS in PBMC, although to a lesser extent than diethylstilbestrol.

Endometrioid stromal sarcomas arising from ovarian and extraovarian endometriosis: report of two cases and review of the literature

Endometrioid stromal sarcomas arising from endometriosis are rare tumors. Two cases from our institution are presented and the literature is reviewed. The patients tend to be nulliparous. Presentations usually are related to the symptoms of a pelvic mass. However, extraovarian origin was frequently accompanied by hemorrhage. The tumors are usually of low histologic grade. Among 18 patients with ovarian origin, only 2 were reported dead of disease. However, 5 of 13 patients with extraovarian origin died mostly as a result of recurrent disease. Deaths generally occurred within 3 years of diagnosis. The efficacy of chemotherapy, radiotherapy, or hormonal therapy in the adjuvant or recurrent setting cannot be determined from the available reports.

Rationale for very high-dose chemotherapy with peripheral blood stem cell support in advanced ovarian cancer

Although significant progress has been made in the management of advanced ovarian cancer, the majority of patients continue to die of this disease. Most advanced ovarian cancer patients present sub-optimal residual tumour after primary surgery and their prognosis is very poor since residual disease has been confirmed as the major factor predicting response to chemotherapy and survival. Therefore, it seems worth developing treatment modalities that can produce a longer remission period. In this short review, the authors summarize the clinical and experimental evidence supporting the usefulness of high-dose chemotherapy with autologous peripheral blood stem cell transplantation in advanced ovarian cancer.

Predictive value of multiple tumor marker assays in second-look procedures for ovarian cancer

Sera from 51 ovarian cancer patients in clinical remission undergoing a second-look operation were studied. CA 125, CA 15-3, and 90K assays were performed in the week preceding surgery. Twenty-seven patients (53%) had no evidence of disease; 3 (6%) and 21 (41%) had microscopic and macroscopic disease. All patients but two with no evidence of disease had normal CA 125 serum levels, as did the three cases with microscopic disease and 6 patients with macroscopically detectable tumor. Of 17 patients with high CA 125 values, 15 (88%) were found to have persistent disease. Hence, the sensitivity and specificity of a CA 125 assay were 62 and 93%, respectively. CA 15-3 levels were low in all patients with no evidence of disease, in 2 cases with microscopic disease, and in 2 cases with residual tumor greater than 1 cm. All patients with high CA 15-3 titers had a positive second-look. The sensitivity and specificity of assay were 69 and 100%, respectively. With the 90K assay, 4 false-positive and 4 false-negative results were found and the sensitivity and specificity were 69 and 67%, respectively. However, 3 of 4 cases with a false-positive 90K assay had recurrence of disease with 7, 9, and 20 months later. Combination of the three markers increased sensitivity to 79%. These data suggest that more effective surveillance of disease status at second-look is obtained by using a combination of tumor marker assays.

Randomized clinical trial comparing systemic interferon with diathermocoagulation in primary multiple and widespread anogenital condyloma

Two hundred three patients (median age 26 years; range 18-45) with untreated multiple and widespread anogenital condyloma were randomly assigned to one of four study arms in order to compare the efficacy, toxicity, and tolerability of recombinant interferon alpha-2b with those of diathermocoagulation. Of 200 evaluable patients, 51 were treated intramuscularly (IM) with 3 x 10(6) U (3 MU)/m2 daily for 3 weeks (total dose 63 MU/m2), 50 received subcutaneous thrice-weekly injections of 3 MU/m2 for 4 weeks (total dose 36 MU/m2), 51 underwent diathermocoagulation, and 48 were not treated and were used as a control group. Six months after the end of treatment, the overall response rate (complete and partial responses) was 70%: 57 and 82% for patients receiving interferon alpha-2b (IM and subcutaneously) and diathermocoagulation, respectively, and 8% for the control group. After 6 months from therapy, no significant differences in complete response were found among the different types of treatment: 20, 20, and 35% for the two interferon groups and the diathermocoagulation group, respectively. Fifteen and two complete responders in the cauterization and interferon groups, respectively, experienced disease recurrence (P less than .01). All patients given interferon therapy complained of flu-like symptoms, which declined progressively after the first week of treatment. Fatigue, lasting as long as patients received interferon, was the most prevalent chronic side effect. We conclude that systemic recombinant interferon alpha-2b is active in treating patients with primary condyloma lesions and does so as well as cauterization.(ABSTRACT TRUNCATED AT 250 WORDS)

A primary amelanotic melanoma of the vagina diagnosed by immunocytochemistry

A case of primary malignant melanoma of the vagina is discussed. The lesion consisted of a nodule in the middle third of the vagina that was histologically suspected of being an unpigmented malignant melanoma. The melanocytic origin of the lesion was confirmed by the pattern of reactivity to a battery of human melanoma associated antigens and to class 1 and 2 histocompatibility antigens. No secondary lesions or alternative primary sites were found. The patient underwent radical hysterectomy with bilateral salpingooophorectomy, total vaginectomy and vulvectomy, radical inguinal, pelvic and paraaortic lymphadenectomy. The pathology report showed the presence of multiple neoplastic foci in the vagina. Although the removed lymph nodes were histologically free of metastases, microscopic foci of neoplastic cells were detected by immunohistochemistry in three lymph nodes. There is no evidence of recurrence at the twelfth postoperative month. Our results show that immunohistochemical techniques may usefully complement diagnostic histopathology in the diagnosis of female genital tract melanoma.

Circulating tumor markers in cervical cancer

Serum levels of CA 19-9, CA 125 and CA 15-3 were measured in 91 patients with cervical cancer (16 with intraepithelial neoplasia and 75 with invasive cancer). In 35 patients with locally advanced cervical cancer, serum marker levels were measured at monthly intervals during neo-adjuvant chemotherapy. CA 19-9 was found to be abnormally high only in advanced stages with an overall sensitivity of 7.3%. CA 125 and CA 15-3 were elevated in 31.9 and 23.1% of the patients, respectively, with a combined sensitivity of about 40%. The mean values of CA 125 and CA 15-3 were positively related to clinical stage and tumor differentiation. CA 125 and CA 15-3 values were correlated with response to chemotherapy in more than 80% of the cases. These findings suggest that CA 125 and CA 15-3 could be usefully employed in the management of cervical cancer.

Multiple serum markers in patients with endometrial cancer

Serum levels of carcinoembryonic antigen (CEA), CA 125 and CA 15-3 were measured in 47 patients with endometrial cancer and 20 with endometrial hyperplasia. Before treatment elevated serum levels of CEA, CA 125 and CA 15-3 were found in 14, 43 and 32% of cancer patients, respectively. In the 20 patients with endometrial hyperplasia, CEA and CA 15-3 values were normal, while elevated CA-125 titers were detected in 1 case. There was an increasing incidence of abnormal levels of all markers in relation to a higher tumor stage (stage I: 36%; II: 66%; III: 100%). The percentage of positive marker values increased in case of deep myometrial infiltration (greater than M1) and/or poorer tumor differentiation (greater than G1). However, only percent increase in CA 15-3 positivity was significantly higher in more infiltrating (greater than M1, 7 vs. 65%, p less than 0.01) and less differentiated (greater than G1, 0 vs. 47%, p = 0.01) tumors. These findings suggest that CA 15-3 is in some way associated with the prognostic factors of the disease. All patients except 2 with no evidence of disease after surgery had normal serum marker values. Moreover, CA 125 and CA 15-3 levels reflected the clinical course of the disease during chemotherapy and seemed to be useful for monitoring response to treatment.

Epidermal growth factor receptor expression in gynecological malignancies

Epidermal growth factor receptor (IEGF-R) levels were analyzed in 72 gynecological tumor specimens. Measurable EGR-R levels were found in a significant percentage of ovarian and uterine tumors. Moreover, all vulvar epidermoid carcinomas and uterine sarcomas analyzed were EGF-R positive. In all tumor types examined, scattered EGF-R levels were observed. Higher EGF-R levels were found in metastatic than in primary ovarian tumors. Moreover, EGF-R were found to be more expressed in less differentiated than in well-moderately differentiated endometrial tumors. Our results suggest a role of EGF or EGF-like substances in regulating the growth of gynecological malignancies, and indicate EGF-R expression as a possible prognostic factor.

Recombinant human leukocyte interferon-alpha 2b stimulates the synthesis and release of a 90K tumor-associated antigen in human breast cancer cells

We have previously reported the production of a new monoclonal antibody (MAb) (SP-2) recognizing a 90-kDa tumor-associated antigen, termed 90K, which is increased in the serum of many cancer patients. Treatment of CG5 human breast cancer cells with recombinant interferon-alpha 2b (rIFN-alpha 2b) can increase the synthesis and release, in culture medium, of the 90K. The effect of rIFN-alpha 2b was dose-related and occurred at concentrations which did not affect cell proliferation. The increase of 90K expression was due to de novo protein synthesis since cycloheximide, added within 3 hr of the beginning of rIFN-alpha 2b stimulation treatment, completely abolished the effect of rIFN-alpha 2b. The stimulatory effect of rIFN-alpha 2b was already evident after 24 hr treatment. Finally, an increase in serum 90K levels was observed in 3 patients with advanced breast cancer receiving a short course of rIFN-alpha 2b (Intron A). No effect of rIFN-alpha 2b was seen in 3 normal women. The ability of rIFN-alpha 2b to increase the synthesis and release of 90K both in vitro and in vivo may be of clinical importance in the early detection of tumors.

Measurement of a monoclonal-antibody-defined antigen (90K) in the sera of patients with ovarian cancer

Serum levels of CA125 and 90K, a new tumor-associated antigen, were measured in 73 ovarian cancer patients and 70 patients with benign gynecological conditions. Abnormally high serum CA 125 and 90K levels were found in 49% and 78% of these patients, respectively. When a combination of the two markers was used, the sensitivity increased to 86%. The percentage of 90K positivity did not significantly correlate with stage of disease or with histological type. A statistically significant correlation was found between 90K positivity rate and grade of tumor differentiation. Elevated serum CA 125 and 90K levels were present in 32% and 29% of patients with benign ovarian tumors, respectively. Only 1 case out of 26 with endometriosis had high 90K levels, compared to 7 patients with abnormal CA 125 levels. Serial measurements of 90K concentrations were found to be correlated with the clinical behaviour of the disease during chemotherapy. Moreover, rising levels of 90K preceded the clinical detection of recurrence with a median lead-time of 3 months. In 2 of these cases the serial changes in 90K values were better correlated with the course of disease than changes in CA 125 levels. Our data suggest that 90K combined with CA 125 may be applied for the detection and monitoring of ovarian cancer.

CA 15-3 as a tumor marker in gynecological malignancies

Serum levels of CA 15-3 were measured in 778 samples from 270 patients with benign and malignant gynecological conditions. Malignant tumors were present in 180 patients including 58 cases with cancer of the ovary, 47 of the endometrium, 61 of the cervix, and 14 of the vulva. The 90 cases with benign conditions included 24 patients with ovarian tumors, 28 with fibromyomatosis, 18 with endometriosis, and 20 with endometrial hyperplasia. Of 180 cancer patients, CA 15-3 serum levels were elevated (greater than 30 U/ml) in 74 cases (41%) and the frequency of abnormal marker values increased with clinical stage. Of 90 patients with benign conditions, high CA 15-3 levels were found in 5 cases (6%) with benign ovarian tumors. Elevated levels of the marker were most commonly seen in ovarian cancer patients (71%). In endometrial, cervical, and vulvar cancer abnormal CA 15-3 values occurred in 32, 26, and 14%, respectively. In endometrial cancer the percentage of positive marker levels increased with more infiltrating and/or less differentiated tumors. A positive correlation was found between residual tumor after surgery and CA 15-3 levels. Serial measurements in sera of patients who underwent chemotherapy showed a good correlation with response to treatment. CA 15-3 values were correlated with clinical course of disease in 87% of cases.

Antiproliferative effects of somatostatin and the somatostatin analog SMS 201-995 on three human breast cancer cell lines

The antiproliferative effect of somatostatin and the somatostatin analog SMS 201-995 on three human breast cancer cell lines (CG5, T 47 D, and ZR 75-1) is reported. Both peptides markedly inhibited CG5 cell growth with a maximal inhibition of about 40% as compared with control cells. The antiproliferative effect of somatostatin on T 47 D and ZR 75-1 cells was much less evident. These results suggest that somatostatin is a peptide inhibitory factor for human breast cancer cells. Possible therapeutic implications of these findings are still to be investigated.

Neoadjuvant chemotherapy and radical surgery in locally advanced cervical carcinoma: a pilot study

Neoadjuvant chemotherapy with cisplatin, bleomycin, and methotrexate was used in the primary treatment of 33 consecutive patients with locally advanced cervical carcinoma (International Federation of Gynecology and Obstetrics [FIGO] stages IB-III; tumor volume greater than 4 cm). This therapy induced responses in 25 of the 33 patients (four complete, 21 partial; overall 75.7%), thus permitting radical surgery in all these cases despite initial bulky tumor. Surgery consisted of type III-IV radical hysterectomy plus systematic para-aortic and pelvic lymphadenectomy. The average number of lymph nodes removed was 63 (range 37-117). At histologic examination, complete responses were found in four cases (12.1%) and partial responses in 14 cases (42.4%). The highest response rates were found for vaginal disease (80%), followed by cervical disease (72%) and parametrial disease (63.1%). A lower than expected incidence of lymph node metastases was detected (16%, four of 25). Chemotherapy did not seem to complicate surgery in these circumstances. The combination of cisplatin, bleomycin, and methotrexate chemotherapy and surgery did not produce severe morbidity. However, chemotherapy-induced nausea and vomiting and moderate postoperative complications did occur. These encouraging preliminary results need a longer follow-up to evaluate the influence of treatment on disease-free survival.

Growth inhibitory effect of LH-RH analogs on human breast cancer cells

The antiproliferative effect of two LH-RH agonists (Pro 9-LH-RH ethylamide and D Ser(t BU)6 Aza Gly 10-LH-RH, ICI 118630) on the human breast cancer cell line CG5 is reported. Although ineffective when used alone, both analogs inhibited in a dose-dependent fashion the growth stimulatory effect of estradiol. LH-RH analogs did not influence the growth inhibitory effect of tamoxifen and medroxyprogesterone acetate. Likewise, these compounds neither modified basal estrogen and progesterone receptor levels nor prevented estrogen-induced increase of progesterone receptor. A marked antiproliferative effect of the analogs was also seen in cells stimulated with other mitogens, such as insulin and epidermal growth factor.

CA 15-3 serum levels in ovarian cancer

Serum levels of CA 15-3, an antigen expressed by human breast carcinoma cells, were measured in 58 ovarian cancer patients, 24 patients with benign ovarian tumor and 62 patients with benign gynecological conditions. Abnormally high serum CA 15-3 levels were found in 41 of 58 patients (71%) with ovarian cancer. The percentage of CA 15-3 positivity correlated with tumor stage. Elevated serum CA 15-3 levels were found in 5 of 24 patients (20%) with benign ovarian tumor. None of the patients with benign gynecological conditions had increased serum CA 15-3 levels. Serial measurements showed CA 15-3 concentrations to be correlated with the clinical behavior of disease in 21 of 25 patients (84%). CA 15-3 serum levels were also found to be correlated with findings on second look. These results suggest that CA 15-3 may represent a useful tumor marker in ovarian cancer.