Recombinant factor VIIa to treat late radiation-induced hemorrhagic cystitis: a case report

BACKGROUND

Late radiation cystitis is one of the most difficult complications of radiation therapy for pelvic malignancies.

CASE

A 29-year-old woman with a history of cervical cancer presented with radiation-induced hemorrhagic cystitis. The patient received multiple units of packed red blood cells while undergoing several intravesical treatments, including continuous bladder irrigation, 4% formalin, 0.15% AgNO3 and Mg(OH)2 with Al(OH)3. The bleeding finally was stopped by the use of intravenous recombinant factor VIIa.

CONCLUSION

When hemorrhagic cystitis related to late radiation complications is refractory to conventional management, intravenous recombinant factor VIIa may be of benefit.

Estrogen receptor alpha and beta expression in a case matched series of serous and endometrioid adenocarcinomas of the ovary

OBJECTIVE

The purpose of this study was to analyze estrogen receptor alpha and beta (ERalpha, ERbeta) expression in a stage and grade matched cohort of patients with serous and endometrioid adenocarcinoma of the ovary.

METHODS

Forty-two patients from 1991 to the present were found to have the diagnosis of endometrioid adenocarcinoma of the ovary and have tissue available for analysis. Of these 42, ten were selected for analysis. These were stage and grade matched with ten patients having serous adenocarcinoma of the ovary during the same time period. ERalpha and ERbeta mRNA was detected by a multiplex RT-PCR and amplification of random hexamer generated cDNA using a housekeeping gene (G3PD) as a control for mRNA quality and quantity. Methylation specific PCR (MS-PCR) was used to correlate methylation of the ERalpha and ERbeta CpG islands with mRNA expression status.

RESULTS

ERalpha expression was present in ten of ten endometrioid adenocarcinomas but in only five of ten serous carcinomas (chi2, p = 0.01). ERbeta expression was present in six of ten endometrioid adenocarcinomas and in four of ten serous caricinomas (chi2, p = 0.65). Methylation of the ERalpha and ERbeta CpG islands was found in tumors without mRNA expression but not in the tumors with mRNA expression (p = 0.005).

CONCLUSIONS

ERalpha expression, but not ERbeta expression, is significantly more common in endometrioid than serous adenocarcinomas of the ovary when controlled for stage and grade. The role of methylation in ER silencing may lead to potential therapeutic interventions.

Tunneled central venous catheters in a gynecologic oncology service: operative and short-term complications

PURPOSE

To determine the difference in the immediate complication rate between placement of long-term central venous catheters (LTCVCs) by the percutaneous versus jugular venous cutdown method.

METHOD

Case lists were examined to determine the number of LTCVCs placed during the designated time period. Medical records, operative reports, and chest roentgenograms were examined to extract pertinent information. Immediate complications included complications occurring in the operating room until 30 days postoperatively. Complications included misplacement of the catheter requiring an adjustment or a repeat procedure, pneumothorax, hydrothorax, or hemothorax, operative site or tunnel infection, and line migration requiring removal.

RESULTS

Five hundred and one patients had LTCVCs placed during the period of this study. This included 399 totally implantable venous access devices (TIVADs) and 102 free access venous access devices (FAVADs) with 163 placed percutaneously into subclavian veins and 338 placed by cutdown into jugular veins. There was a significant increased risk in the overall immediate complication rate for the percutaneous placement compared to venous cutdown (p < 0.001). Also, pneumothorax was more common with the percutaneous approach compared to the venous cutdown approach (p < 0.001).

CONCLUSIONS

Immediate complications, especially pneumothorax, were more common when placing catheters by the percutaneous approach as compared to the venous cutdown approach.

Vascular endothelial growth factor staining and elevated INR in advanced epithelial ovarian carcinoma

BACKGROUND

The purpose of this study was to determine whether vascular endothelial growth factor (VEGF) expression in tumors correlates with the incidence of an elevated prothrombin time (PT), specifically an international normalized ratio (INR) > or = 1.4, in patients undergoing primary surgical cytoreduction for ovarian cancer.

METHODS

INRs were obtained on all patients perioperatively. VEGF expression was determined by immunostaining of tumor specimens using published protocols.

RESULTS

One hundred patients underwent surgical cytoreduction. Sixty-seven percent of patients had postoperative INR of 1.4 or greater. INRs of greater than or equal to 1.8 were found in 5% of patients. INR elevation was independent of mean estimated blood loss (EBL) with the EBL in the patients with INRs > or = 1.4 not significantly different than the EBL in the patients with INRs < 1.4 (660 ml vs. 530 ml, P = 0.09). There was a significant correlation between elevated INR and tumor VEGF immunostaining (P < 0.005). All but one patient with an elevated INR had positive VEGF staining.

CONCLUSIONS

In conclusion, development of an elevated INR (INR > or = 1.4) is common in patients undergoing primary surgical cytoreduction. Positive tumor VEGF staining is very common in patients having a postoperative coagulopathy.

Extreme drug resistance is common after prior exposure to paclitaxel

OBJECTIVE

The platinum-free interval (PFI) is an important entity in the treatment of women with epithelial ovarian cancer. The purpose of this study was to determine on clinical samples whether a taxane-free interval (TFI), as defined by in vitro extreme drug resistance assay, existed in women previously exposed to platinum and taxane chemotherapy.

METHODS

Records were examined from 2003 to 2006 to find all patients with epithelial ovarian cancer who had previous exposure to platinum and taxane therapy. Further examination was done to find all patients who underwent secondary cytoreduction and had their tumor submitted for extreme drug resistance assay.

RESULTS

Thirty-four women meeting the above criteria were found. The mean PFI was 25 months (median 18). The mean TFI was 27 months (median 20). Over 44% of the patients have been exposed to more than just a course of platinum and a course of a taxane. In patients having a PFI of >or=12 months, 38.8% had extreme drug resistance (EDR) to carboplatin and 41.9% EDR to cisplatin. Conversely, in patients having a TFI of >or=12 months, 89.7% had EDR to paclitaxel and 82.8% EDR to docetaxel.

CONCLUSIONS

While only a small percentage have EDR to carboplatin and cisplatin after a PFI of >or=12 months, almost 90% of patients with a TFI>or=12 months showed EDR to paclitaxel in vitro.

Pelvic and para-aortic lymphadenectomy in patients with endometrioid adenocarcinoma of the endometrium

BACKGROUND

The purpose is to determine the rate of lymph node metastases in women with endometrioid adenocarcinoma of the endometrium (EAE) undergoing systematic lymphadenectomy.

METHODS

Patients (349) underwent a complete pelvic and para-aortic lymphadenectomy from caudal to the median circumflex to the level of the renal vessels.

RESULTS

Grade 1 tumors accounted for 32.7% of the tumors and 31.0% of the positive nodes, grade 2 accounted for 47.3% of the tumors (37.9% of positive nodes), and grade 3 accounted for 20.1% of the tumors and 31.0% of the positive nodes (P>0.05). Positive nodes were found in 15.8% of grade 1 tumors, 13.3% of grade 2 tumors and 25.7% of grade 3 tumors (P>0.05). Isolated para-aortic involvement without pelvic nodal involvement occurred in 29% of patients with positive nodes.

CONCLUSIONS

When complete lymphadenectomies are performed in EAE, positive lymph nodes (including isolated para-aortic lymph nodes) are common in all grades.

Nutritional assessment using prealbumin as an objective criterion to determine whom should not undergo primary radical cytoreductive surgery for ovarian cancer

BACKGROUND

The purpose of this study was to determine if serum prealbumin could be used to objectively determine which patients could not safely undergo cytoreductive surgery.

METHODS

Patients with suspected ovarian cancer in a 24-month period underwent nutritional assessment during their preoperative workup and were followed for development of postoperative complications.

RESULTS

One hundred and eight of 114 patients underwent surgical cytoreduction. Of the 108 surgical patients, 88 patients had prealbumin levels <18 mg/dl and 24 patients had prealbumin levels <10 mg/dl. Postoperative complications increased with lower prealbumin levels. All complications occurred in group of patients with prealbumin <18 mg/dl (P=0.013). A significantly increased number of complications occurred in patients with prealbumin <10 mg/dl (61.5% vs. 6.4%, P<0.001, RR 9.6). All postoperative mortality in this series occurred in patients with prealbumin <10 mg/dl (23.1% vs. 0%, P<0.001). Patients whose prealbumin started low but was able to be raised to >10 mg/dl by TPN did not have significantly increased complications or EBL compared to patients whose initial prealbumin was >10 mg/dl (18.2% vs. 4.8%, P=0.95 and 570 vs. 600 ml, P=0.87).

CONCLUSIONS

Significantly more blood loss, morbidity, and mortality occurred in patients with abnormal preoperative prealbumin. This was especially true in patients with a prealbumin <10 mg/dl. With these significantly increased risks, patients with extremely poor nutritional status (prealbumin <10 mg/dl) may be better served by neoadjuvant chemotherapy with interval cytoreductive surgery if nutrition improves.

5-Fluorouracil cardiotoxicity complicating treatment of stage IIB cervical cancer--case report

A 31-year-old female was found to have FIGO Stage IIB squamous cell carcinoma of the cervix. The patient began her prescribed radiation therapy and 5-fluorouracil radio-sensitizing chemotherapy. During the first day of infusion, she began having severe shortness of breath. Cardiac evaluation revealed acute congestive heart failure with a cardiac ejection fraction of 19%. Radiation was continued without chemotherapy. Four years later, the patient is alive and well with an ejection fraction of 53%.

CAG repeat length in exon 1 of the androgen receptor gene is related to age of diagnosis but not germ line BRCA1 mutation status in ovarian cancer

It has been postulated that androgens, through their interaction with androgen receptors (AR), may play an important role in the development of ovarian cancer. Exon 1 of the AR gene contains three highly polymorphic trinucleotide repeats. The length of the (CAG)n repeat segment 1 is inversely correlated with the transactivation function of the AR. Recent studies have shown that BRCA1 may function as an AR coregulator or coactivator and play positive roles in androgen-induced cell death in cancer cells as well as other androgen/AR target organs. We hypothesize that the AR gene, involved in endocrine signaling, may modify BRCA1-associated ovarian cancer risk. To test this hypothesis, potential associations between the (CAG)n repeat length, germ line BRCA1 mutation status, and age of diagnosis for ovarian cancer were investigated. One hundred and eleven ovarian cancer patients (27 hereditary and 84 sporadic) were included. All the cases were allelotyped for CAG repeat length and genotyped for mutations in the BRCA1 gene by direct sequencing. No association between CAG repeat length and BRCA1 mutation status was identified. Furthermore, there were no differences between hereditary and sporadic ovarian cancer in the number of (CAG)n repeats of the short allele (P= 0.336), long allele (P= 0.875), or average allele length (P= 0.550). However, ovarian cancer patients from both groups (hereditary and sporadic) who carried any AR allele of (CAG)n < or = 22 repeats were diagnosed on average 8.17 years (95% confidence interval [1.3, 15.0]) earlier than the patients whose shortest AR allele (CAG)n was >22 (P= 0.020). In conclusion, it is suggested that the CAG repeat length in AR exon 1 may affect the age of diagnosis of ovarian cancer but does so independent of germ line BRCA1 carrier status.

Neoadjuvant chemotherapy in vulvar cancer: Avoiding primary exenteration

OBJECTIVE

To determine whether neoadjuvant cisplatin and 5-fluorouracil chemotherapy can be used to preserve the anal sphincter and/or urethra in patients with advanced vulvar cancer involving these sites.

METHODS

Fourteen patients with advanced vulvar cancer (1997-2003) involving the anal sphincter and/or urethra were given 3-4 cycles of neoadjuvant chemotherapy to attempt preservation of these pelvic structures rather than undergoing a primary pelvic exenteration. Following 3 cycles, a radical vulvectomy and groin lymph node dissection were planned. All patients had lesion size documented by measurement and photograph prior to and following chemotherapy.

RESULTS

The median age was 63 years (range 39-88). Thirteen patients received a median of 3 cycles (range 2-4) of neoadjuvant chemotherapy. Ten patients received cisplatin and 5-fluorouracil, while three received cisplatin alone. The median time from diagnosis to surgery was 77 days (range 54-143). All patients with cisplatin and 5-fluorouracil chemotherapy underwent surgery except one patient who had a synchronous renal cell carcinoma and died prior to surgery. Patients receiving cisplatin alone showed no measurable response, while all patients receiving cisplatin and 5-fluorouracil demonstrated at least a partial response. Two patients had no residual invasive carcinoma on final pathology. All patients receiving cisplatin and 5-fluorouracil followed by surgery are disease-free, while two of three receiving cisplatin have progressive disease. The anal sphincter and urethra were conserved in all patients receiving cisplatin and 5-fluorouracil.

CONCLUSION

Neoadjuvant cisplatin and 5-fluorouracil in advanced vulvar cancer demonstrated a response rate of 100%. The anal sphincter and urethra were conserved in all patients receiving cisplatin and 5-fluorouracil. Responders are disease-free at this time. This response rate demonstrates superior activity of 5-fluorouracil in vulvar cancer and spares these patients the morbidity of exenteration or radiation.

Chemotherapy for ovarian cancer: an evidence-based approach

Although cytoreductive surgery is the most influential factor in treatment for ovarian cancer, chemotherapy is needed for almost all patients diagnosed with this disease. The mainstay of chemotherapy is platinum. Different platinum compounds are used for different histologies, and different combinations are used for different histologies also. We will present the data so that each reader can understand the knowledge behind chemotherapy decisions.

Sequential Intraperitoneal Topotecan and Oral Etoposide Chemotherapy in Recurrent Platinum-Resistant Ovarian Carcinoma

PURPOSE

The purpose is to investigate the safety and efficacy of i.p. topotecan and oral etoposide as salvage treatment for patients with platinum-resistant ovarian or primary peritoneal cancer.

EXPERIMENTAL DESIGN

Patients were treated with i.p. topotecan initial dose, 1 mg/m2 on days 1 to 5, followed by oral etoposide 100 mg on days 6 to 9 of a 28-day cycle for six cycles. Dose reduction of topotecan was used for severe bone marrow suppression. Peritoneal (topotecan) and plasma (topotecan and etoposide) levels were assessed at multiple time points using high-pressure liquid chromatography.

RESULTS

Twenty-two patients (mean age, 61 years) with a median of 1.5 prior treatments were enrolled. Etoposide peak plasma concentrations ranged from 1.9 to 6.9 microg/mL (mean, 3.6 microg/mL). Topotecan plasma levels rose with increasing peritoneal concentration and were detectable within 1 hour but tended to decrease rapidly to below detectable levels within 24 hours. The peak plasma concentration of topotecan was 12.82 +/- 8.55 microg/mL with a plasma half-life of 6.17 +/- 2.75 hours. A total of 104 cycles was administered; 14 patients (64%) completed all six planned cycles. All patients were evaluable for toxicity, and 21 patients were evaluable for response. The most common grade 4 toxicities were neutropenia and thrombocytopenia in eight and four patients (36 and 18%), respectively. There were no treatment-related deaths. The overall response rate was 38% [complete response, three (14%); partial response, five (24%)]. Seven patients had stable disease and six progressed while on treatment.

CONCLUSIONS

The combination of i.p. topotecan and oral etoposide is an active and well-tolerated regimen in platinum-resistant ovarian carcinoma. Additional studies investigating topotecan in combination with etoposide are warranted.

Late recurrence of juvenile granulosa cell tumor of the ovary

Juvenile granulosa cell tumor (JGCT) of the ovary, if diagnosed at an early stage, has a favorable prognosis. Recurrences are uncommon but typically occur within the first year. The patient presented here was treated with a left oophorectomy after initial presentation. Tumor recurrence in the left adnexa, diagnosed 48 months later, was treated with cytoreductive surgery followed by chemotherapy; she remains disease free 19 months after this recurrence. Late recurrences of JGCT can occur and continued close surveillance is recommended.

Nuclear size, shape, and density in endometrial carcinoma: relationship to survival at over 5 years of follow-up. Does analyzing only cells occupying the G0-G1 peak add useful information?

OBJECTIVE

The authors, using image analysis, previously demonstrated nuclear size and summed optical density to be independent prognostic indicators of recurrence in patients with endometrial carcinoma. The same tumors were analyzed by studying the optical features in the G0-G1 peak to see if this changed the values found as well as their importance as prognostic features at greater than 5 years of follow-up.

METHODS

Tumors from 74 consecutive patients, surgically treated, with endometrial cancer, were evaluated. Survival, depth of invasion, lymphvascular space invasion, FIGO stage, grade, histology were analyzed. DNA index, progesterone receptor status, as well as nuclear size (NUSZ), shape (NUSH), and summed optical density (NUSD) were evaluated. NUSZ, NUSH, and NUSD were quantified using image analysis.

RESULTS

Fifteen patients died from disease during the observation period of the study. Mean follow-up was 82 months with a median of 84 months. Forty-nine patients had stage I cancers, five stage II, 17 stage III, and three stage IV. NUSZ and NUSD were all significantly different between the original (entire cell cycle) and the re-measured (G0G1 only) values (both P < 0.001). Multivariate analysis showed both the original (P = 0.0001) and G0G1-only (P = 0.046) NUSZ and the original (P = 0.0002) and G0G1-only (P = 0.018) NUSD to be independent prognosticators of survival.

CONCLUSION

Image analysis is able to quantify cellular and nuclear parameters not otherwise quantifiable. NUSD and NUSZ correlated with traditional prognostic indicators, were demonstrated independent predictors of survival at over 5 years of follow-up. Although the re-measured NUSZ and NUSD from only the G0-G1 peak were significantly different from the original NUSZ and NUSD, they were not as valuable as prognostic factors. Nuclear size and summed optical density measured from the entire cell cycle are independent prognostic indicators of survival at greater than 5 years of follow-up. Measuring nuclear morphometric features in the G0-G1 peak only does not add any new prognostic information.

Gemcitabine associated vasculitis leading to necrotizing enterocolitis and death in women undergoing primary treatment for epithelial ovarian/peritoneal cancer

We present two patients who developed necrotizing enterocolitis following their first cycle of chemotherapy for epithelial ovarian/peritoneal cancer. After optimal cytoreductive surgery, both women received gemcitabine as part of a chemotherapy protocol. One patient developed necrotizing enterocolitis, 1 day after chemotherapy and the other 8 days after chemotherapy. The first patient succumbed to the enterocolitis despite aggressive supportive care. The second patient succumbed despite both aggressive supportive care and surgical intervention. Pathologic review for both patients revealed a drug induced vasculitis causing necrotizing enterocolitis.

Heat shock protein 27 in the placentas of women with and without severe preeclampsia

BACKGROUND

Although not fully understood, heat shock proteins (HSP) are well known stress response proteins. The purpose of this analysis was to determine whether staining for HSP27 was different between placentas from pregnancies complicated by severe pre-eclampsia with intrauterine growth restriction (IUGR) as compared to controls.

METHODS

Sterile placental tissue was collected from ten women whose pregnancies were complicated by severe preeclampsia with IUGR and from ten women with uncomplicated by severe pre-eclampsia with IUGR and from ten women with uncomplicated term pregnancies. The tissue was then stained for HSP27.

RESULTS

The median age of the patients was 27 years (mean 27, range 17-37). The median estimated gestational age at delivery was 38 weeks (mean 37, range 29-41). Overall 12 of 20 placentas stained positively for HSP27 (nuclear and/or cytoplasmic). Eight of ten placentas from women with pre-eclampsia and IUGR stained positively for HSP27 (p = 0.046).

CONCLUSION

HSP27 staining of the placenta is twice as common in patients with severe preeclampsia as compared to patients with normal term gestations. These preliminary results warrant the inauguration of a similar but larger study to examine the significance of these findings.

Evaluation of DNA methylation in the human genome: why examine it and what method to use

PURPOSE

Since its discovery 50 years ago, DNA methylation has been found to be an important part of gene regulation. Newer methods of analysis over the last decade have helped further the understanding of this epigenetic phenomenon. The purpose of this article is to describe current methods of analysis and discuss advantages and disadvantages of each and their possible roles in gynecologic malignancies.

RESULTS

The methods for analysis of DNA methylation are divided into two major categories: 1) methods which utilize chemical methods or restriction enzymes to differentially cleave at cytosine versus 5-methylcytosine sites, 2) methods which utilize sodium bisulfite (NaHSO3) to specifically convert unmethylated cytosines to uracil (thymine after PCR). This recently developed method appears to be more sensitive and allows the investigator to specifically delineate the study site(s).

CONCLUSION

DNA methylation is important in the human genome. Its role in tumorigenesis is just beginning to be understood. While relying upon newly designed methods of analysis, further understanding of this epigenetic phenomenon and its role in gene expression and tumorigenesis will be forthcoming.

Nuclear and cytoplasmic c-myc staining in endometrial carcinoma and their relationship to survival

OBJECTIVE

The role of the c-myc proto-oncogene in genomic instability is just becoming more fully understood. However, its role in endometrial cancer is essentially unknown. The objective of this study was to determine the relationship between cytoplasmic and nuclear c-myc staining, DNA index, and survival in patients with endometrial carcinoma.

METHODS

One hundred and twenty-one patients with endometrial carcinoma were studied. Image analysis was used to determine DNA index. In addition to cytoplasmic and nuclear c-myc staining and DNA index, histologic type, stage, grade, depth of invasion, lymphvascular space invasion, and peritoneal cytology were evaluated as prognostic indicators. Univariate and multivariate analyses were performed.

RESULTS

One hundred and twenty-one patients were followed for over 5 years. c-myc cytoplasmic staining was present in 75.2% of the patients' tumors, and nuclear staining was present in 66.9% (P = 0.99). DNA index was significantly higher in patients with nuclear c-myc staining and no cytoplasmic staining (DNA index 1.38) as compared to those patients whose tumors displayed cytoplasmic c-myc staining but no nuclear c-myc staining (1.18) (P = 0.016). Patients whose tumors stained positively for nuclear c-myc and negatively for cytoplasmic c-myc had significantly worse survival by Kaplan-Meier analysis (P < 0.0001). Seventeen patients died during the follow-up period of this study. By multivariate analysis, positive cytoplasmic c-myc staining with negative nuclear staining (P = 0.0076), negative cytoplasmic c-myc staining with positive nuclear staining (P = 0.011) and FIGO stage (P < 0.0001) were shown to be independent prognostic indicators predictive of survival.

CONCLUSION

Nuclear and cytoplasmic c-myc staining, as well as FIGO stage, when assessed by multivariate analysis, were demonstrated to be important factors in predicting survival in the 121 patients in this study. While increasing FIGO stage was prognostic of decreased survival, the specific location of c-myc staining was also associated with prognosis. The expression of the c-myc protein is related to survival in patients with adenocarcinoma of the endometrium.

HSP27 in patients with ovarian carcinoma: still an independent prognostic indicator at 60 months follow-up

OBJECTIVE

Heat shock protein 27 (HSP27) is produced in response to pathophysiologic stress in animal cells. The authors have previously shown that HSP27 is an independent prognostic indicator in patients with ovarian carcinoma. The present study was performed to see whether HSP27 remained an independent prognostic indicator with longer follow-up.

METHODS

One hundred and three consecutive patients with epithelial ovarian carcinoma were studied. Slides were prepared from fresh tissue. HPS27 staining was performed as previously described. Patient records were examined for FIGO stage, grade, histology, level of cytoreduction and survival.

RESULTS

One hundred and three patients were followed for a mean of 60 months. Twenty patients had FIGO Stage I disease, four Stage II, 59 Stage III, and 20 Stage IV. Immunohistochemical (IHC) staining for HSP27 was not related to histologic grade, level of cytoreduction or histologic subtype. A statistically significant decrease in HSP27 staining was found to correlate with increased FIGO stage (p = 0.008). Using cox-regression analysis, HSP27 staining (p = 0.025), stage (p = 0.0012), and level of cytoreduction (p < 0.0001) were independent predictors of survival in these patients.

CONCLUSION

Cox-regression analysis found HSP27 to be an independent indicator of prognosis and survival in patients with ovarian carcinoma who had longer follow-up. Decreased HSP27 staining was related to decreased survival. This study confirms the authors' earlier report on the importance of HSP27 as a prognostic indicator in ovarian carcinoma.