Carcinosarcoma of the ovary

The objective of this study was to evaluate the treatment and outcome in patients with ovarian carcinosarcoma. The Tumor Board Registry was reviewed for patients with ovarian carcinosarcoma treated at our institution from June 1993 to December 2004. The medical records were retrospectively analyzed with emphasis on cytoreduction, cytotoxic regimens, progression-free interval, and survival. Twenty-two patients were identified. All but two presented with advanced stage disease. The median survival for the entire cohort was 38 months. Median survival was 46 months for 18 optimally debulked (<1 cm) patients and 27 months for four suboptimally debulked (>1 cm) patients. Six patients were treated with optimal cytoreduction and adjuvant cisplatin (40 mg/m(2)x 1 day) and ifosfamide (1200 mg/m(2)/day x 4 days) every 28 days. Median progression-free interval in the cisplatin and ifosfamide group was 13 months, and median survival was 51 months. The combination of carboplatin (AUC 5) and taxol (175 mg/m(2)) every 21 days was administered to four patients as first-line chemotherapy following optimal cytoreduction. In the carboplatin and taxol group, median progression-free interval was 6 months and median survival was 38 months. The difference in survival between the cisplatin and ifosfamide group and the carboplatin and taxol group was not statistically significant (P= 0.48). In conclusion, patients with ovarian carcinosarcoma usually present with advanced stage disease. Treatment consists of optimal cytoreduction and chemotherapy. The most effective cytotoxic regimen remains to be determined. First-line cisplatin and ifosfamide or carboplatin and taxol can achieve survival rates observed in epithelial ovarian cancer.

Neoadjuvant chemotherapy lessens surgical morbidity in advanced ovarian cancer and leads to improved survival in stage IV disease

OBJECTIVES

To compare the survival and peri-operative morbidities of patients with advanced epithelial ovarian cancer (EOC, stage IIIC and IV) who were treated with primary debulking surgery (PDS) followed by adjuvant platinum-based chemotherapy, or neoadjuvant chemotherapy followed by cytoreductive surgery (NAC).

METHODS

172 patients with advanced EOC diagnosed at YNHH (1998-2005) were retrospectively reviewed. 109 patients were treated with PDS and 63 patients were treated with NAC [37 received carboplatin/paclitaxel (CP), 26 received carboplatin/cyclophosphamide (CC)].

RESULTS

NAC patients had significantly less intra-operative blood loss, operating time, units of transfusion, and shorter hospital stay (p<0.05). Optimal cytoreduction was achieved in 95% NAC patients, versus 71% of PDS group (p<0.001). Three patients in the NAC group (5%) versus 27 patients (25%) in the PDS group required aggressive surgery in addition to standard cytoreduction. Within the NAC group, overall survival (OS) is improved in patients who received CP compared to CC (83 vs. 26 months, p=0.008). Patients with extra-abdominal disease who received CP as NAC had improved progression-free survival (PFS) and OS when compared to the PDS group with stage IV disease (15 vs. 9 months, p=0.015; 31 vs. 20 months, p=0.032, respectively).

CONCLUSION

This study demonstrates that NAC is associated with less peri-operative morbidity, less need for further aggressive surgery, and similar survival. Additionally, in patients with extra-abdominal disease, NAC is associated with an improved PFS and OS. Therapy with platinum and taxane should be the treatment of choice in NAC.

Inflammatory bowel disease and the lung: is there a link between surgery and bronchiectasis?

PURPOSE

One-third of patients with inflammatory bowel disease (IBD) has extracolonic manifestations. Inflammatory bowel-associated pulmonary disease is one of the less commonly recognized and more recently described manifestations. Here, we report the experience of our patients with inflammatory bowel-associated bronchiectasis.

METHODS

A retrospective analysis of case notes of patients with IBD and respiratory manifestations was undertaken. Relevant demographic, clinical, radiological, and pulmonary physiology laboratory results were reviewed.

RESULTS

Ten patients with IBD and bronchiectasis were identified. Eight developed respiratory symptoms after surgery for IBD. Five of the ten had ulcerative colitis. Their lung function abnormality is mild to moderate in severity. Small airways disease (forced expiratory flow between 25-75% is <50%) was evident in seven of the ten patients.

CONCLUSIONS

This preliminary study supports an association between surgery for IBD and development of symptomatic lung disease, particularly bronchiectasis, in susceptible patients. The pulmonary manifestations of IBD in some patients may only become clinically significant after surgery and the withdrawal of medical treatment.

Atypical presentations of carboplatin hypersensitivity reactions: Characterization and management in patients with gynecologic malignancies

OBJECTIVES

Carboplatin skin testing (ST) can help identify patients with platinum hypersensitivity (PH), however, we have encountered patients who do not immediately test positive yet exhibit subtle or delayed allergy symptoms prior to PH. We describe the "atypical platinum reactions" (APH) of 14 patients and our experience with skin testing and desensitization.

METHODS

Retrospective chart review was performed on carboplatin-treated patients. Patients with +ST, PH or APH were offered desensitization, and the number of successful additional treatments was recorded.

RESULTS

A total of 73 ST were administered to patients receiving their >6th carboplatin cycle. 19 +ST and 10 PH with -ST were identified. 14 APH were identified including delayed +ST conversions and allergy symptoms. The median onset and duration of symptoms after treatment were 6 and 3.5 days respectively. 12 APH patients had ST on their next cycle, seven of which were immediately positive. ST was positive in 36% of those tested, resulting in a negative predictive value of 76%. The median number of carboplatin cycles received prior to ST conversion, PH or APH was eight. 29% of patients with a +ST, PH, or APH had a prior history of systemic allergic reaction to other medications or allergens. Desensitization and dose escalation were successful in 14/20 patients (70%) for an average of 1.9 cycles/patient.

CONCLUSIONS

ST will not identify all patients with carboplatin-associated reactions. Careful questioning regarding symptoms in between chemotherapeutic cycles may identify patients who will benefit from desensitization, allowing continuation of treatment and prevention of life-threatening adverse events.

TLR-4 signaling promotes tumor growth and paclitaxel chemoresistance in ovarian cancer

Evidence suggests that an inflammatory profile of cytokines and chemokines persisting at a particular site would lead to the development of a chronic disease. Recent studies implicate bacterial infection as one possible link between inflammation and carcinogenesis; however, the crucial molecular pathways involved remain unknown. We hypothesized that one possible upstream signaling pathway leading to inflammation in carcinogenesis may be mediated by Toll-like receptors (TLR). We describe for the first time an adaptive mechanism acquired by ovarian cancer cells that allows them to promote a proinflammatory environment and develop chemoresistance. We propose that the TLR-4-MyD88 signaling pathway may be a risk factor for developing cancer and may represent a novel target for the development of biomodulators. Our work explains how bacterial products, such as lipopolysaccharide, can promote, directly from the tumor, the production of proinflammatory cytokines and the enhancement of tumor survival. In addition, we provide new evidence that links TLR-4 signaling, inflammation, and chemoresistance in ovarian cancer cells.

Malignant Transformation of Myomas: Myth or Reality?

The possibility that a fibroid may actually be a smooth muscle tumor of uncertain malignant potential or a leiomyosarcoma often dictates the clinical management of rapidly growing fibroids. This article provides a clinicopathologic background regarding uterine leiomyosarcomas and answers common questions that obstetricians and gynecologists have about the management of rapidly growing fibroids and leiomyosarcoma. The clinician must be aware that the infrequent occurrence of uterine leiomyosarcomas makes it difficult to establish absolutely firm recommendations for the diagnosis and management of this disease, particularly with regard to fertility preservation. Nevertheless, this article addresses major issues that a clinician might face in the evaluation of a smooth muscle tumor of the uterus that clinically may be malignant.

Improved survival in surgical stage I patients with uterine papillary serous carcinoma (UPSC) treated with adjuvant platinum-based chemotherapy

OBJECTIVE

Uterine papillary serous carcinoma (UPSC) is an aggressive form of endometrial cancer characterized by a high recurrence rate and a poor prognosis. Prior studies evaluating treatment of UPSC have been limited by small numbers of patients and inclusion of partially staged patients. The purpose of this study was to evaluate the efficacy of adjuvant platinum-based chemotherapy and vaginal cuff radiation in a large cohort of surgical stage I UPSC patients.

METHODS

We retrospectively reviewed 74 stage I patients with UPSC who underwent complete surgical staging at our institution between 1987 and 2004.

RESULTS

Stage IA patients were divided into two groups: patients with no cancer in the hysterectomy specimen (defined as no residual uterine disease) and patients with cancer in the hysterectomy specimen (defined as residual uterine disease). Stage IA patients with no residual uterine disease had no recurrences, regardless of adjuvant therapy (n = 12). Stage IA patients with residual uterine disease who were treated with platinum-based chemotherapy had no recurrences (n = 7). However, 6 of 14 (43%) stage IA patients with residual uterine disease who did not receive chemotherapy recurred. The 15 patients with stage IB UPSC who received platinum-based chemotherapy had no recurrences but 10 of the 13 (77%) stage IB patients who did not receive chemotherapy recurred. One of the 7 patients with stage IC UPSC who received platinum-based chemotherapy recurred and 4 of the 5 (80%) stage IC patients who did not receive chemotherapy recurred. Overall platinum-based chemotherapy was associated with improved disease-free survival (P < 0.01) and improved overall survival (P < 0.05) in patients with stage I UPSC. None of the 43 patients who received radiation to the vaginal cuff recurred locally, but 6 of the 31 (19%) patients who were not treated with vaginal radiation recurred at the cuff.

CONCLUSIONS

Platinum-based chemotherapy improves the disease-free and overall survival of patients with stage I UPSC and vaginal cuff radiation provides local control. Stage IA UPSC patients with no residual uterine disease can be observed but concomitant platinum-based chemotherapy and vaginal cuff radiation (referred to as chemoradiation) should be offered to all other stage I UPSC patients.

Synthesis and biological evaluation of benzodioxanylpiperazine derivatives as potent serotonin 5-HT(1A) antagonists: the discovery of Lecozotan

A series of benzodioxanylpiperazine derivatives possessing a 4-aryl amide substituent was prepared and evaluated for 5-HT(1A) affinity and functional antagonist activity in vitro and in vivo. All of the compounds in this series possessed high affinity for the human 5-HT(1A) receptor and many displayed potent antagonist activity in vitro and varying degrees of intrinsic activity in vivo. Compound 11c (Lecozotan) was selected for further development and is currently in clinical trials.

Melanocortin subtype-4 receptor agonists containing a piperazine core with substituted aryl sulfonamides

The biological activity for a set of melanocortin-4 receptor (MC4R) agonists containing a piperazine core with an ortho-substituted aryl sulfonamide is described. Compounds from this set had binding and functional activities at MC4R less than 30 nM. The most selective compound in this series was >25,000-fold more potent at MC4R than MC3R, and 490-fold more potent at MC4R than MC5R. This compound also reduced food intake after oral dosing at 25, 50, and 100 mg kg(-1) in fasted mice.

Discovery of Potent, Orally Available Vanilloid Receptor-1 Antagonists. Structure−Activity Relationship of N-Aryl Cinnamides

The vanilloid receptor-1 (TRPV1 or VR1) is a member of the transient receptor potential (TRP) family of ion channels and plays a role in regulating the function of sensory nerves. A growing body of evidence demonstrates the therapeutic potential of TRPV1 modulators, particularly in the management of pain. As a result of our screening efforts, we identified (E)-3-(4-tert-butylphenyl)-N-(2,3-dihydrobenzo[b][1,4]dioxin-6-yl)acrylamide (1), an antagonist that blocks the capsaicin-induced and pH-induced uptake of (45)Ca(2+) in TRPV1-expressing Chinese hamster ovary cells with IC(50) values of 17 +/- 5 and 150 +/- 80 nM, respectively. In this report, we describe the synthesis and structure-activity relationship of a series of N-aryl cinnamides, the most potent of which (49a and 49b) exhibit good oral bioavailability in rats (F(oral) = 39% and 17%, respectively).

Patients with uterine papillary serous cancers may benefit from adjuvant platinum-based chemoradiation

OBJECTIVE

The coexistence of minimal uterine disease and extrauterine metastases is common in patients with uterine papillary serous carcinoma (UPSC). Only complete surgical staging accurately depicts the extent of this disease. The purpose of this study was to evaluate different therapeutic options in surgically staged patients.

METHODS

We retrospectively reviewed all patients with UPSC histologically limited in the uterus to the endometrium treated at our institution between 1987 and 2002.

RESULTS

Twenty-three (45%) cases were International Federation of Gynecology and Obstetrics (FIGO) stage IA, seven (15%) were stage IIIA, one (2%) was stage IIIC, and nine (18%) stage IV. Additionally, 11 of these 51 patients (21%) were diagnosed with two cancers: a stage IA UPSC and concomitant advanced stage serous cancer of the ovary, fallopian tube, or peritoneum. Stage IA patients with no cancer in the hysterectomy specimen (defined as no residual uterine disease) had no recurrences (n = 10) regardless of treatment. There was a trend toward increased survival in stage IA patients with residual uterine disease who were treated with chemoradiation (concomitant vaginal brachytherapy and platinum-based chemotherapy). There were no recurrences in patients with locoregional disease (stages IA-IIIA) who received chemoradiation. All patients with advanced stage UPSC (stage IIIC or IV or two primary cancers) did poorly regardless of treatment.

CONCLUSION

Our findings suggest that stage IA patients with no residual uterine disease may be observed. Stage IA patients with residual uterine disease may benefit from chemoradiation. More effective treatment needs to be identified for advanced stage UPSC.

Synthesis of novel melanocortin 4 receptor agonists and antagonists containing a succinamide core

A novel series of piperazines appended to a succinamide backbone were synthesized and found to have a high affinity for the melanocortin-4 receptor (IC(50)s ranging from <0.1 to 200 nM). Both agonists and antagonists of MC4R were prepared by modifying the groups attached to the right-hand side of the succinamide. This series also exhibits a high level of selectivity (up to 7000-fold) over mouse MC1R and human MC3R.

Design of a new peptidomimetic agonist for the melanocortin receptors based on the solution structure of the peptide ligand, Ac-Nle-cyclo[Asp-Pro-DPhe-Arg-Trp-Lys]-NH(2)

The solution structure of a potent melanocortin receptor agonist, Ac-Nle-cyclo[Asp-Pro-DPhe-Arg-Trp-Lys]-NH(2) (1) was calculated using distance restraints determined from 1H NMR spectroscopy. Eight of the lowest energy conformations from this study were used to identify non-peptide cores that mimic the spatial arrangement of the critical tripeptide region, DPhe-Arg-Trp, found in 1. From these studies, compound 2a, containing the cis-cyclohexyl core, was identified as a functional agonist of the melanocortin-4 receptor (MC4R) with an IC(50) and EC(50) below 10 nM. Compound 2a also showed 36- and 7-fold selectivity over MC3R and MC1R, respectively, in the binding assays. Subtle changes in cyclohexane stereochemistry and removal of functional groups led to analogues with lower affinity for the MC receptors.

Structure-activity relationship of (1-aryl-2-piperazinylethyl)piperazines: antagonists for the AGRP/melanocortin receptor binding

Agouti-related protein (AGRP) is an endogenous antagonist of the melanocortin action.(1) In the hypothalamus, melanocortin peptide agonists act as satiety-inducing factors that mediate their action through the melanocortin-4 receptor (MC4R) whereas AGRP is an opposing orexigenic agent. Novel inhibitors of the AGRP/MC4 binding based on (piperazinylethyl)piperazines were prepared, and their structure-activity relationship was established.

Pseudodextrocardia in bronchiectasis

Bronchiectasis is a chronic inflammatory pulmonary disorder characterized by chronic productive cough, recurrent bronchial sepsis and haemoptysis, with airflow obstruction and progressive tissue destruction. Kartagener's syndrome, associated with dysfunctional cilia, sinusitis and situs inversus, is a rare cause of bronchiectasis (Marwah and Sharman, 1995). This article reports two cases where patients had been erroneously diagnosed as having Kartagener's syndrome based on misinterpretations of chest radiographs.

Admissions with chronic obstructive pulmonary disease after publication of national guidelines

BACKGROUND

The British Thoracic Society (BTS) published guidelines on managing acute exacerbations of chronic obstructive pulmonary disease (AECOPD) in 1997.

AIM

To audit admissions with AECOPD and to see how well these guidelines were adhered to. Methods All patients admitted were identified and 50 selected for audit.

RESULTS

The mean age was 72 years and 52% were female. Admission C reactive protein (CRP) and white cell count (WCC) were 49 (12.7) mg/l and 10.97 (0.64) x 10(9)/l respectively. Six were acidotic and 16 hypercapnoeic. Median length of stay (LOS) was six days. Twenty-one fulfilled admission criteria. Thirty-seven had > or = 2 Anthonisen criteria. Nine had spirometry performed. Correlations were seen between appropriateness of admission score and pH (r=-0.41, p=0.01) and LOS (r=-0.43, p=0.002) and between Anthonisen criteria score and age (r=0.33, p=0.018). Symptom score correlated with PaO2 (r=-0.38, p=0.02), LOS (r=0.27, p=0.06) and age (r=0.38, p=0.007). LOS correlated with PaCO2 (r=0.33, p=0.04).

CONCLUSION

Admissions are chiefly comprised of an ill, elderly population. Careful adherence to guidelines could result in fewer admissions.

Use of similarity measures for quality control of benthic diatom samples

A method for evaluating the similarity of replicate benthic diatom samples based on the Bray-Curtis similarity measure is described. This technique may be useful as part of quality control procedures where objective performance measures are required. Levels of similarity > 60% typically indicate good agreement between the primary analyst and auditor. However, an evaluation of 57 comparisons indicated that achievable levels of similarity were dependent upon the species diversity of the sample, with samples with high species diversity typically having lower levels of similarity than samples with low species diversity. Whilst a threshold value of 60% is adequate for most samples, a stiffer threshold of 70% should be applied to samples with very low levels of diversity.

1,2,5-Thiadiazole derivatives are potent and selective ligands at human 5-HT1A receptors

Amino acid derivatives of 1,2,5-thiadiazol-3-yl-piperazine related to (+)-WAY-100135 and WAY-100635 are potent 5-HT1A receptor agonists and antagonists, which have selective affinity for 5-HT1A receptors versus alpha1 and dopamine (D2, D3, and D4) receptors.