Prophylactic oophorectomy: clinical considerations

Ovarian cancer usually remains clinically silent until it is far advanced, and is associated with significant morbidity and mortality. In view of the modest impact of adjuvant treatments on survival, much effort is devoted to early detection programs and prevention strategies. However, the usefulness of early detection programs remains to be established, with only one randomized study indicating improved median survival in screened individuals. At present, oral contraceptives and prophylactic oophorectomy are the only options for prevention of ovarian cancer. Indications for prophylactic oophorectomy either as a primary procedure, or secondary to abdominal surgery, will vary according to the estimated risk, and to the individual's perception of that risk. Genetic screening allows better identification of pre-symptomatic individuals who would benefit the most from prophylactic oophorectomy. Data concerning the benefit of prophylactic surgery, and the safety of established or innovative hormone replacement therapies in individuals at risk, are encouraging.

p53 and WAF1 polymorphisms in Jewish-Israeli women with epithelial ovarian cancer and its association with BRCA mutations

OBJECTIVE

To investigate whether polymorphic p53 and WAF1 alleles are associated with clinical, demographic and histopathological features and BRCA mutation in women with ovarian cancer.

DESIGN

A cross-sectional study.

POPULATION

Two hundred and twenty-one nonselected Israeli women with epithelial ovarian cancer.

METHODS

DNA was analysed for known polymorphisms in intron 3 (a 16 nucleotide single repeat) and intron 6 (a G to A change at nucleotide 13,494) of the p53 gene, the S31R polymorphism in the WAF1 gene, and for three predominant Jewish mutations in the BRCA genes (185delAG and 5382insC in BRCA1, and 6174delT in BRCA2).

MAIN OUTCOME MEASURE

The rate of polymorphic p53 and WAF1 alleles and their association with BRCA mutation, ethnic origin, age and stage at diagnosis, and family history of cancer.

RESULTS

Of the tested women, 72 (32.6%) were either BRCA1 (n = 57) or BRCA2 (n = 15) mutation carriers. Sixty-eight of 213 (31.9%) were heterozygous for intron 3 polymorphism, 67/193 (34.7%) for intron 6 polymorphism, and 22/154 (14.3%) for S31R of the WAF1 gene. The p53 and WAF1 polymorphism rate did not differ between BRCA mutation carriers and noncarriers. No significant association between specific p53 or WAF1 genotypes, and clinical, histopathological or demographic variables was observed.

CONCLUSION

In Jewish-Israeli women with sporadic and familial ovarian cancer, p53 or WAF1 polymorphisms do not seem to affect the phenotype.

Immunohistochemical analyses of sporadic and familial (185delAG carriers) ovarian cancer in Israel

A single germ line mutation in BRCA1, (185delAG) is detected in a substantial portion of Jewish Israeli patients with ovarian cancer. Whether disease phenotypes differ in BRCA1 mutation carriers and sporadic cases is presently a subject for debate. To gain insight into this issue, we analysed tumours from 65 Jewish women with ovarian cancer, 29 (45%) were 185delAG BRCA1 mutation carriers, and 36 (55%) were non-carriers of any of the predominant Jewish mutations in BRCA1 or BRCA2 (sporadic). In 19/29 mutation carriers (66%) diagnosis was made prior to age 60 years, compared with 14/36 (39%) of the non-carriers (P=0.03; Yates corrected P=0.06). Low malignant potential ('borderline') tumours were detected less frequently among carriers (2/29; 7%) than non-carriers (9/36; 25%) (P=0.03; one tail P=0.05). Immunohistochemical analysis in invasive carcinoma (n=54) showed that 17/27 carriers (63%) and 18/27 non-carriers (67%) had positive nuclear staining with a p53 antibody. In 4/27 carriers (15%) and 3/25 non-carriers (12%), 25% or more of the tumour cells stained positive for Ki-67, an insignificant difference. Results were not altered by including borderline tumours (n=11) in these analyses. We conclude that the rate of TP53 inactivation and proliferative index in ovarian cancer, are similar for 185delAG BRCA1 mutation carriers and sporadic cases.

Expression of carbohydrate antigens in advanced-stage ovarian carcinomas and their metastases-A clinicopathologic study

OBJECTIVE

Up-regulated expression or loss of expression of various carbohydrate antigens on the surface of cancer cells has been associated with a metastatic phenotype and poor survival in epithelial malignancies of different origins. The object of this study was to investigate the expression of carbohydrate antigens in two groups of patients diagnosed with advanced-stage ovarian carcinoma-one with an extremely favorable outcome and the other with a uniformly poor survival.

METHODS

Sections from 76 paraffin-embedded blocks (primary ovarian carcinomas and metastatic lesions) from 45 patients diagnosed with advanced-stage ovarian carcinomas (FIGO stages III-IV) were immunohistochemically stained using five monoclonal antibodies for Lewis(y) (Le(y))(two antibodies), Sialyl Lewis(x) (Slex), Tn, and Sialyl Tn (STn) antigens. Patients were divided in two groups based on outcome. Long-term survivors (21 patients) and short-term survivors (24 patients) were defined using a double cut-off of 36 months for disease-free survival (DFS) and 60 months for overall survival (OS). Staining results for primary tumors and metastases were analyzed separately.

RESULTS

Mean follow-up period was 70 months. The mean values for DFS and OS were 109 and 125 months for long-term survivors and 3 and 25 months for short-term survivors. Staining for all four antigens was seen in the majority of cases (range = 72-96%) and tended to be comparable in primary tumors and their metastases. However, absence of immunoreactivity for STn was seen in 9/38 (24%) metastatic lesions and only 1/38 (3%) primary tumors. This finding did not reach statistical significance (P > 0.05). A combined pattern of membranous and cytoplasmic staining was predominant in the majority of cases. Enhanced staining for Le(y) and STn was detected in the invasive front of some tumors, while Slex and Tn immunoreactivity did not relate to cell location. Primary tumors and metastatic lesions of long-term survivors displayed immunoreactivity patterns that were comparable to those of short-term survivors. In the evaluation of survival curves, more diffuse staining for Slex showed marginal correlation with poor survival (P = 0.05), while a trend toward poorer survival was seen in tumors that were more extensively stained for Le(y) and Tn (P > 0.05).

CONCLUSIONS

Le(y), Slex, STn, and Tn antigens are widely expressed in primary ovarian carcinomas and their metastases. Altered expression of Sialyl Tn is observed with tumor progression in a fraction of ovarian carcinomas. Expression of membrane carbohydrate residues is prevalent in tumors of both long-term and short-term survivors and does not appear to be a strong predictor of disease outcome. However, larger studies are needed to further elucidate the role of these molecules in ovarian carcinogenesis.

Expression of topoisomerase II and Ki-67 in cervical carcinoma--clinicopathological study using immunohistochemistry

AIM

To study the correlation between the expression of topoisomerase II and Ki-67 antigen and disease outcome in cervical squamous cell carcinomas.

EXPERIMENTAL DESIGN

Forty-nine cervical carcinomas, 10 cases of high-grade cervical intraepithelial neoplasia (CIN II-III) and 5 control cervices were stained by monoclonal antibodies for topoisomerase II and Ki-67 (MIB-1 clone). Nuclear counts were correlated with patient age, tumor stage, histological grade and survival.

RESULTS

Thirteen patients died of disease, 35 remained free of disease, and one patient was lost to follow up. Ki-67 counts were higher in CIN lesions, when compared to both invasive carcinomas and control cervices. Topoisomerase II counts were comparable for CIN and invasive tumors. No immunoreactivity for topoisomerase was detected in control cases. Neither stage nor grade was associated with nuclear counts using either marker. In multivariate survival analysis, stage (p=0.001), grade (p=0.03) and older patient age (p=0.02) predicted poor survival. Ki-67 counts predicted survival with borderline significance (p=0.07), while topoisomerase II counts were not related to survival.

CONCLUSION

Ki-67 and topoisomerase II counts do not appear to have a significant role in the prediction of survival in cervical squamous cell carcinoma.

MMP-2 and TIMP-2 expression correlates with poor prognosis in cervical carcinoma--a clinicopathologic study using immunohistochemistry and mRNA in situ hybridization

OBJECTIVE

The spread of malignant neoplasms is closely associated with matrix and basement membrane degradation, mediated by various classes of proteolytic enzymes. Matrix metalloproteinases (MMP) appear to have a key role in the sequence of events that lead to local invasion and metastasis. The present study evaluated the role of matrix metalloproteinase-2 (MMP-2), tissue inhibitor of metalloproteinases-2 (TIMP-2), and membrane-type metalloproteinase (MT1-MMP) in cervical neoplasia.

METHODS

We have analyzed 49 uterine cervical squamous cell carcinomas, 10 cases of high-grade cervical intraepithelial neoplasia (CIN II-III), and 10 control cervices for the presence of MMP-2, TIMP-2, and MT1-MMP using in situ hybridization. MMP-2 protein expression was evaluated using immunohistochemistry. Results were analyzed for possible correlation with disease outcome.

RESULTS

MMP-2, TIMP-2, and MT1-MMP mRNA were localized to both stromal and tumor cells. However, an intense signal for MMP-2 was detected almost exclusively in tumor cells and was uniformly absent from CIN lesions and control cervices. Conversely, intense signals for TIMP-2 and MT1-MMP were detected in both stromal and tumor cells of invasive carcinomas, more often for the former. As with MMP-2, they were absent from CIN lesions. MMP-2 protein expression was enhanced in tumor cells compared to CIN cases and controls, significantly compared to the latter (P = 0.01). The presence of both MMP-2 and TIMP-2 mRNA in tumor cells correlated with advanced stage (P = 0.003 for MMP-2, P = 0.002 for TIMP-2) and with poor survival (P = 0.003 for MMP-2, P = 0.002 for TIMP-2) in univariate analysis. In addition, their presence in tumor cells intercorrelated (P = 0.002). In multivariate survival analysis, MMP-2 presence retained its association with survival (P = 0.004), in addition to patient age (P = 0.027) and advanced stage (P = 0. 0002).

CONCLUSIONS

Both MMP-2 and TIMP-2 have a key role in extracellular matrix invasion in cervical carcinoma, largely through their elaboration by tumor cells. The presence of mRNA for both proteins is interrelated and is associated with poor survival.

Macrophage infiltration and angiogenesis in cervical squamous cell carcinoma--clinicopathologic correlation

BACKGROUND

The role of angiogenesis and inflammatory cell response in predicting disease outcome was evaluated in various malignant tumors. However, the data relating to cervical cancer remains equivocal. This study evaluates the prognostic significance of microvessel counts and peritumoral macrophage infiltrates in squamous cell carcinoma of the uterine cervix.

METHODS

Seventy-five cervical squamous cell carcinomas were stained immunohistochemically by two endothelial markers- anti-CD31 and Ulex Europaeus lectin I (UEA-I), and the macrophage- specific marker anti-CD68. Microvessel and macrophage counts were performed using a grid at X200 and X400 magnification, respectively, in areas of maximal density ('hot spots'). Five fields were scanned. Microvessel counts were correlated with macrophage density, and both were correlated with patient age, tumor stage, histological grade, and survival.

RESULTS

Microvessel counts were comparable for ulex lectin (mean 6.8+/-4.8/field) and CD31 (8.7+/-5.3/field), and results by both markers correlated (p<0.001). Counts by both markers correlated with tumor stage, being higher in stages Ib-II compared to stage III-IV tumors (p<0.05). No correlation with age, grade, or survival was found. Macrophage counts (mean 13.1+/-12.3 cells/field) did not correlate with any of the clinical parameters studied or with microvessel counts.

CONCLUSIONS

Microvessel counts and macrophage density do not correlate with survival in cervical cancer. Neither do they appear to be inter-related. The association between elevated microvessel counts and localized disease may reflect peak angiogenic stimuli by neoplastic cells. We hypothesize that the beneficial role of macrophages in cellular immunity may be opposed by the elaboration of growth factors in the vicinity of neoplastic cells.

Expression of matrix metalloproteinase-9 in squamous cell carcinoma of the uterine cervix-clinicopathologic study using immunohistochemistry and mRNA in situ hybridization

OBJECTIVE

Invasion of the extracellular matrix and blood vessels by malignant neoplasms, with subsequent distant dissemination, is a key event in tumor progression. This process appears to be mediated largely through the action of matrix metalloproteinases (MMPs), a family of proteolytic enzymes produced by both stromal and tumor cells. The role of gelatinases (MMP-2 and MMP-9) in basement membrane and matrix degradation was described in various tumors. We studied MMP-9 protein expression in cervical intraepithelial neoplasia (CIN) and squamous cell carcinoma using immunohistochemistry and detected MMP-9 mRNA using in situ hybridization.

METHODS

Fifty squamous cell carcinomas, 10 cases of CIN II-III, and 10 normal cervices were stained for MMP-9, using a monoclonal antibody. The presence of MMP-9 mRNA was studied using in situ hybridization. Results were correlated with patient survival during a follow-up period of up to 167 months (average, 41 months).

RESULTS

Immunohistochemical staining of tumor cells for MMP-9 was noted in 36/50 (72%) carcinomas and 5/10 (50%) CIN lesions, but was uniformly absent from the nonneoplastic epithelium adjacent to tumors and from control cervices. Peritumoral staining of stromal cells was observed in 27/50 (54%) carcinomas, but only in 3/10 (30%) CIN lesions and 1/10 (10%) control cervices. The presence of MMP-9 mRNA was detected in tumor cells in 39 (78%) carcinomas and 8 (80%) CIN lesions, but only in 4 (40%) control cervices. An intense signal for MMP-9 mRNA was observed most frequently in carcinomas. MMP-9 mRNA was detected in stromal cells in the majority of cases. However, an intense signal was observed only in stromal cells around invasive tumors. In survival analysis, age (P = 0.016), grade (P = 0. 016), and stage (P = 0.001) showed independent correlation with poor survival. Neither MMP-9 protein expression nor an intense signal for MMP-9 mRNA was associated with poor survival, although the latter was observed more frequently in neoplastic cells of lethal tumors (8/14 tumors vs 11/36 nonlethal tumors).

CONCLUSIONS

MMP-9 mRNA and protein expression are elevated in tumor and stromal cells of both high-grade CIN and invasive squamous cell carcinoma of the uterine cervix. Thus, MMP-9 is possibly an early marker of tumor progression in squamous lesions of the cervix. An intense stromal signal for MMP-9 mRNA characterizes some invasive carcinomas. Expression of MMP-9 in cervical carcinoma cells is present in both lethal and nonlethal tumors, consistent with the key role of this proteolytic enzyme in invasion, and does not appear to predict disease outcome.

Macrophage infiltration and angiogenesis in cervical squamous cell carcinoma--clinicopathologic correlation

BACKGROUND

The role of angiogenesis and inflammatory cell response in predicting disease outcome was evaluated in various malignant tumors. However, the data relating to cervical cancer remains equivocal. This study evaluates the prognostic significance of microvessel counts and peritumoral macrophage infiltrates in squamous cell carcinoma of the uterine cervix.

METHODS

Seventy-five cervical squamous cell carcinomas were stained immunohistochemically by two endothelial markers- anti-CD31 and Ulex Europaeus lectin I (UEA-I), and the macrophage- specific marker anti-CD68. Microvessel and macrophage counts were performed using a grid at X200 and X400 magnification, respectively, in areas of maximal density ('hot spots'). Five fields were scanned. Microvessel counts were correlated with macrophage density, and both were correlated with patient age, tumor stage, histological grade, and survival.

RESULTS

Microvessel counts were comparable for ulex lectin (mean 6.8+/-4.8/field) and CD31 (8.7+/-5.3/field), and results by both markers correlated (p<0.001). Counts by both markers correlated with tumor stage, being higher in stages Ib-II compared to stage III-IV tumors (p<0.05). No correlation with age, grade, or survival was found. Macrophage counts (mean 13.1+/-12.3 cells/field) did not correlate with any of the clinical parameters studied or with microvessel counts.

CONCLUSIONS

Microvessel counts and macrophage density do not correlate with survival in cervical cancer. Neither do they appear to be inter-related. The association between elevated microvessel counts and localized disease may reflect peak angiogenic stimuli by neoplastic cells. We hypothesize that the beneficial role of macrophages in cellular immunity may be opposed by the elaboration of growth factors in the vicinity of neoplastic cells.

Expression of metalloproteinases endometrial stromal sarcoma: immunohistochemical study using image analysis

AIM

To investigate the expression of matrix metalloproteinases (MMP), a group of proteolytic enzymes with a central role in extracellular matrix invasion and degradation, in stromal sarcomas.

METHODS

11 endometrial stromal sarcomas (four low grade tumours, seven high grade) were stained for MMP-2, MMP-3, and MMP-9 using immunohistochemical stains. The surgical material consisted of nine hysterectomy specimens and two pelvic recurrences. Three hysterectomy specimens, removed for leiomyomas, were studied as controls. Staining area was evaluated using image analysis.

RESULTS

Age at the time of diagnosis ranged from 21 to 67 years. Four of the 11 patients (three with high grade tumours and one with a low grade tumour) died of the disease, six remained free of disease, and one was lost to follow up. Staining for MMP-2, MMP-3, and MMP-9 was more diffuse in high grade tumours than in low grade tumours and controls. Staining for MMP-3 and MMP-9 was more pronounced in high grade than in low grade tumours (p = 0.04; p = 0.05). Staining for MMP-9 was significantly greater in all stromal sarcomas than in controls (p < 0.001 for high grade tumours v controls; p < 0.01 for low grade tumours v controls). Diffuse staining for MMP-2, exceeding 90% of the tumour area, was observed in three of seven high grade tumours but in no low grade tumours. There was no apparent correlation between staining for any of the three enzymes and survival.

CONCLUSIONS

Both low and high grade endometrial stromal tumours express matrix metalloproteinases. MMP-3 and MMP-9 are expressed more diffusely in high grade than in low grade tumours. In the individual case, diffuse staining for MMP-2 appears to best characterise the high grade tumours. Thus staining for MMP-2 may aid in differentiating high grade from low grade tumours, and MMP-9 in differentiating normal endometrial stroma from low and high grade endometrial stromal sarcomas. MMP expression does not appear to predict disease outcome in endometrial stromal sarcoma.

Intraperitoneal pressures and clinical parameters of total paracentesis for palliation of symptomatic ascites in ovarian cancer

OBJECTIVE

The present study was designed to prospectively evaluate the intraperitoneal pressure, as well as clinical and hemodynamic effects of total paracentesis, as palliation of symptomatic ascites in ovarian cancer patients.

METHODS

Prospective study of 35 sequential total paracenteses was performed using a Veres cannula on patients with advanced recurrent ovarian cancer with symptomatic tense ascites. Relevant clinical symptoms and patient well-being were evaluated. Vital signs, abdominal parameters, and hydrostatic intraperitoneal pressure were recorded before, during, and after the procedure.

RESULTS

Intraperitoneal pressure dropped from 30 +/- 7 cmH2O before paracentesis to 13 +/- 6 cmH2O after the procedure (P < 0.0001). Marked symptomatic improvement was observed in all patients (89% complete relief, 11% partial relief), while all the patients tolerated the procedure well without any complications. The mean volume of ascitic fluid removed was 4800 ml. Mean respiratory rate and mean heart rate were both significantly decreased following the procedure (29.3 to 21.4 respirations per min and 101.5 to 93.6 beats per min, respectively). Mean systolic blood pressure mildly decreased (6.6 mmHg), while the mean diastolic blood pressure did not significantly change. None of the patients presented signs or symptoms of hypovolemia during or after the total paracentesis.

CONCLUSIONS

Measurement of intraperitoneal pressures during total paracentesis for tense ascites in ovarian cancer patients indicated that the severity of symptoms correlated with the intraperitoneal pressure prior to paracentesis, but not with the volume of ascites. Intraperitoneal pressures measured following total paracentesis in patients with ovarian cancer were similar to the baseline intraperitoneal pressure measured in patients undergoing peritoneal dialysis.

Expression of extracellular matrix proteins in cervical squamous cell carcinoma--a clinicopathological study

AIM

To evaluate the intracellular and peritumoral expression of matrix proteins in squamous cell carcinoma of the uterine cervix using immunohistochemistry.

METHODS

71 squamous cell carcinomas and 10 controls were stained for laminin, fibronectin, and collagen IV. Cytoplasmic staining in tumour cells and peritumoral deposition of matrix proteins were evaluated. The association between staining results and patient age, tumour stage, histological grade, and survival was studied.

RESULTS

Positive cytoplasmic staining for laminin, fibronectin, and collagen IV was observed in 17 (23.9%), 27 (38%), and 10 (14.1%) cases, respectively. Staining for laminin was most pronounced in the invasive front of tumour islands, while for fibronectin and collagen IV it appeared to be diffuse. Peritumoral staining for laminin and collagen IV was detected in 12 cases (16.9%). Early stage (Ia1-Ia2) tumours were uniformly negative for all three proteins. Cytoplasmic staining for laminin correlated with positive staining for fibronectin and collagen IV, and with the presence of a peritumoral deposition of collagen IV and laminin. There was no correlation with any of the three markers between staining results and patient age, stage, grade, or survival.

CONCLUSIONS

Expression of extracellular matrix proteins in some cervical squamous cell carcinomas might reflect the enhanced ability of these tumours to modify the peritumoral stroma. This ability seems to be absent in early stage tumours. The correlation between intracytoplasmic and peritumoral expression of matrix proteins supports the evidence of their synthesis by tumour cells. However, this property did not correlate with disease outcome in this study.

Expression of metalloproteinases and their inhibitors in adenocarcinoma of the uterine cervix

Metalloproteinases (MMPs), a family of enzymes that participate in extracellular matrix degradation and remodeling, may play a role in tumor invasion and metastasis and have been correlated with tumor behavior and survival. The action of MMPs is regulated by tissue inhibitors of MMPs (TIMPs). Adenocarcinomas of the uterine cervix are neoplasms that primarily affect young women and are associated with human papillomavirus (HPV). Eighteen cervical adenocarcinomas and 5 controls were immunohistochemically analyzed for the expression of MMP-2, MMP-3, MMP-9, and their inhibitors, TIMP-1 and TIMP-2, in tumor cells and peritumoral stromal cells. These cells were also studied for the presence of MMP-2, MMP-9, and TIMP-2 mRNA by in situ hybridization (ISH). HPV status was studied using ISH for HPV 16 and 18. MMP-2 and -9 were expressed immunohistochemically in tumor cells in 17 of 18 tumors, MMP-3 in 5, TIMP-1 in 3, and TIMP-2 in 1. Stromal cells of most tumors expressed all the above proteins. The normal endocervical epithelium was uniformly negative for MMP-2, MMP-3, MMP-9, and TIMP-2, and variably expressed TIMP-1. Intense signals for MMP-2, MMP-9, and TIMP-2 mRNA were less frequently detected by ISH in tumor cells and peritumoral stromal cells and were absent in normal endocervical epithelium. All tumors contained HPV DNA 16, 18, or both. MMP and TIMP expression did not correlate with tumor type, grade, or HPV type. MMPs and their inhibitors are present in most cervical adenocarcinomas, independent of tumor grade or subtype, but with the exception of TIMP-1, they are not expressed in nonneoplastic endocervical epithelium. This finding might be helpful in the diagnosis of endocervical adenocarcinomas. HPV is prevalent in cervical adenocarcinomas, but its role in determining tumor behavior remains unclear.

Ulex Europaeus lectin and anti-CD31 staining in squamous cell carcinoma of the uterine cervix: potential prognostic markers

Seventy-five squamous cell carcinomas of the uterine cervix and 10 controls were stained for Ulex Europaeus lectin 1 (UEA-1) and anti-CD31, and the results were analyzed with respect to patient age, clinical stage, tumor grade, and survival during a follow-up period of 1 to 13 years. The patients' mean age at the time of diagnosis was 47.8 years (range, 27 to 83). Seventeen patients died of disease, 2 had disease recurrence, and 51 patients remained free of disease; 5 patients were lost to follow-up. Twenty-eight cases (37.3%) showed focal membranous staining for UEA-1 and 9 cases (12%) showed a diffuse pattern; 38 cases (50.7%) were UEA-1 negative. Poor survival was related to diffuse membranous UEA-1 immunoreactivity (p = 0.02), age (p = 0.014), grade (p = 0.02), and stage (p = 0.0002). CD31-positive neoplastic cells displayed a cytoplasmic pattern. Fifteen cases (20%) had diffuse staining and another 15 (20%) stained focally; 45 cases (60%) were CD31-negative. The adjacent nonneoplastic epithelium and all 10 controls were uniformly negative for CD31. Variable staining of the endocervical epithelium and weak or negative staining of ectocervical epithelium for UEA-1 were observed. However, the epithelium in all controls was negative for UEA-1. Poor survival was related to both focal and diffuse staining for CD31 (p = 0.01 and p = 0.03, respectively). Staining by both UEA-1 and anti-CD31 retained its correlation with survival after exclusion of stage la tumors.

Rates of Jewish ancestral mutations in BRCA1 and BRCA2 in borderline ovarian tumors

BACKGROUND

Germline mutations in the BRCA1 and BRCA2 genes are known to be associated with an increased risk of breast and epithelial ovarian cancers. Two specific mutations, 185delAG-BRCA1 and 6174delT-BRCA2, have been detected in a substantial proportion (20%-60%) of unselected Ashkenazi Jewish patients--i.e., Jewish patients of Eastern/Northern European descent--with invasive ovarian cancer and in a measurable proportion (2%) of the general Ashkenazi Jewish population. However, uncertainty exists concerning the heritable basis of borderline ovarian tumors and whether these tumors represent an early form of ultimately invasive disease. To gain insight into these issues, we determined the rates of 185delAG-BRCA1 and 6174delT-BRCA2 mutations in patients with borderline ovarian tumors.

METHODS

Analysis of 185delAG-BRCA1 and 6174delT-BRCA2 germline mutations was performed by use of a heteroduplex formation assay in samples from 46 consecutive patients with borderline ovarian tumors and 59 consecutive patients with invasive epithelial ovarian cancers. Forty-eight samples were also analyzed by restriction enzyme analysis for the presence of the 5382insC-BRCA1 mutation, a mutation detected in 2.2% of Ashkenazi Jewish patients with breast, but not ovarian, cancer.

RESULTS

One (2.2%) of the 46 patient with borderline tumors was identified as a carrier of the 185delAG-BRCA1 mutation, and no patients were found to carry the 6174delT-BRCA2 mutation. Nineteen (32%) of the 59 patients with invasive ovarian cancer were found to carry one of these two mutations; 17 carried 185delAG-BRCA1 and two carried 6174delT-BRCA2 (chi2 test with continuity correction, P = .00028). None of the patients analyzed for 5382insC-BRCA1 were found to carry the mutation. In one high-risk family that included 185delAG-BRCA1 carriers, a single patient with stage IIIc borderline ovarian tumor did not carry the mutation.

CONCLUSIONS

Invasive epithelial and borderline ovarian tumors appear to differ in their genetic predisposition and in the molecular mechanisms underlying their genesis.

CD44 expression in uterine cervical intraepithelial neoplasia and squamous cell carcinoma: an immunohistochemical study

CD44 is an integral membrane glycoprotein, functioning as the receptor for hyaluronic acid. CD44 is expressed on epithelial, mesenchymal, lymphoid, and glial cells. CD44 distribution, pattern of staining, and isoform types are altered in neoplastic conditions, including cervical dysplasia and carcinoma. We have studied CD44 expression by immunohistochemistry in 49 patients with cervical intraepithelial neoplasia (CIN) I, II, III invasive squamous cell carcinoma of the uterine cervix and controls. Only membranous staining was considered positive. Diffuse membranous staining was observed in all controls and CIN I cases, but only in 7/10, 3/10, and 4/9 cases of CIN II, CIN III and squamous cell carcinoma, respectively. The remaining cases showed either complete lack of staining, only focal membranous staining or only diffuse inconsistent (weak/cytoplasmic/fragmented) staining. Three invasive carcinomas showed both areas of membranous staining and areas of inconsistent staining in the same section. No correlation was observed between tumor grade and CD44 pattern of staining. Human papillomavirus (HPV) was found in 24/29 high-grade intraepithelial lesions and carcinomas. HPV expression did not correlate with CD44 staining. In conclusion, CD44 expression was found to be reduced in more than 50% of high-grade intraepithelial neoplastic lesions and invasive carcinomas. This might be associated with the loss of cellular adhesion characteristics of pre-invasive and invasive lesions. HPV presence did not seem to influence CD44 expression.

Borderline tumors of the ovary: fertility treatment, conservative management, and pregnancy outcome

BACKGROUND

Ovarian tumors of borderline malignancy have a less aggressive behavior and tend to occur at a younger age than their invasive counterparts. The role and extent of fertility-sparing conservative treatments is under continuous evaluation.

METHODS

The current study was a retrospective review of 82 patients with confirmed borderline tumors diagnosed over a 25-year period, with special focus on fertility-associated issues.

RESULTS

Follow-up was available for 96% of the patients, for a total of 357 women-years of follow-up. Thirty-nine patients underwent conservative management. Of these, only three patients had a contralateral recurrence. Two of the three again opted for conservative management and were without evidence of disease at last follow-up. Seventeen patients did benefit from contralateral ovarian dissection either by cystectomy or oophorectomy because of contralateral benign or borderline disease. Eleven patients had received or were scheduled to receive ovulation induction. Five patients were diagnosed during the evaluation, and another two were diagnosed so soon after the initiation of ovulation induction that a causative relationship appeared to be unlikely. Six patients were diagnosed during ongoing pregnancies. Twenty-two pregnancies were achieved in 15 patients after conservative treatment. No influence of the disease or its treatment on the pregnancy (or vice versa) was observed during a mean follow-up of 69 months.

CONCLUSIONS

Data are accumulating that indicate conservative fertility-sparing disease management is adequate treatment for patients with borderline tumors. Available data indicate that in these patients fertility, pregnancy outcome, and survival remain excellent.

Expression of matrix proteins in uterine cervical neoplasia using immunohistochemistry

OBJECTIVE

Neoplastic cells of various tumors are capable of modifying extracellular matrix, and can reduce basement membrane components and express matrix proteins and mRNA. Findings in cervical cancer cells have been consistent concerning their ability to reduce basement membrane, but there is a lack of consensus concerning the expression of matrix proteins in the neoplastic cells. We have investigated the expression of matrix proteins in the subepithelial basement membrane, in blood vessels and in the epithelial cells using immunohistochemistry.

STUDY DESIGN

A total of 49 cases, including normal cervix, Cervical Intraepithelial Neoplastia (CIN) grades, I, II and III, and invasive squamous cell carcinoma, were stained for fibronectin (FN), laminin (LN) and collagen IV (C IV) and analyzed by immunohistochemistry. Subepithelial and peritumoral basement membrane staining for C IV was scored as 0, 1, 2 or 3 (0, absent; 1, weak and discontinuous; 2, weak or discontinuous; 3, strong and diffuse). Vascular basement membrane staining by all three markers was interpreted as positive or negative. Staining of normal epithelium, CIN lesions and invasive carcinoma cells was evaluated with all three markers.

RESULTS

Subepithelial basement membrane staining was graded as score = 3 in all normal cervices, in contrast to 9/10, 2/10, 1/10 and 0/9 cases of CIN I, CIN, II, CIN III and invasive carcinoma, respectively. Remaining cases showed variable degrees of basement membrane loss. In 6/10 CIN III cases and 8/9 carcinomas, staining was absent (score = 0). Blood vessels stained positive for FN, LN and C IV in all cases studied. Epithelial cells were LN-positive in only one case of CIN II and FN-positive in only two cases of CIN III. Conversely, 3/9 carcinomas were LN-positive, 6/9 were FN-positive and 2/9 were C IV-positive, including two cases positive for all three markers. Staining pattern was cytoplasmic, mainly in the periphery to tumor islands.

CONCLUSIONS

Invasive squamous cell carcinomas of the cervix are capable of expressing matrix proteins that are usually absent in normal squamous cervical cells or preinvasive lesions. Secretion or degradation of these proteins could facilitate tumor invasion of stroma and vessels. In addition, basement membrane dissolution becomes pronounced in CIN II-III lesions, being complete in most invasive carcinomas, probably reflecting the ability of pre-invasive neoplastic cells to degrade basement membrane components with metalloproteases.

Advances in the biology of gynecologic cancer

This review discusses recent insights into the roles of the p53 tumor-suppressor gene and growth factors in the development of ovarian cancer and describes the genes implicated in familial ovarian cancer syndromes related to the MSH2 (Lynch II) and BRCA1 (breast and ovarian cancer) genes. Evidence of the monoclonality of ovarian cancer, which contrasts with data supporting the polyclonal origin of primary peritoneal carcinoma, is presented. Finally, the roles of the human papillomavirus and the HIV virus in the etiology of cervical cancer are analyzed in view of the growing importance of this HIV-associated cancer and the poor outcome in these patients.

Interleukin 10: ability to minimize postoperative intraperitoneal adhesion formation in a murine model

OBJECTIVE

To determine the ability of interleukin 10 (IL-10) to suppress postoperative intraperitoneal adhesion formation.

DESIGN

Randomized, controlled trial.

SETTING

University animal research facility.

ANIMALS

Six-week-old Swiss Webster mice undergoing a standardized intraperitoneal operative procedure.

INTERVENTIONS

Animals were randomized to "surgery" or "no surgery" and then further randomized to receive intraperitoneal injections of 1 mL phosphate-buffered saline (PBS) or 1 microgram/kg IL-10 in 1 mL PBS. Vehicle-only doses were given immediately after surgery and then every 24 hours for a total of four injections. Interleukin 10 injections were similarly given but with an added preoperative injection 30 minutes before surgery in one half of the animals.

MAIN OUTCOME MEASURE

Adhesion formation.

RESULTS

Animals treated with vehicle or IL-10 but not undergoing surgical intervention had no intraperitoneal adhesions. Animals undergoing surgery who were treated with IL-10, with or without a preoperative dose, had significantly lower postoperative adhesion scores than did control animals who postoperatively received PBS only.

CONCLUSION

Interleukin-10 is effective at limiting postoperative intraperitoneal adhesion formation with minimal evident systemic side effects.

Cytokine-induced modulation of tumor suppressor gene expression in ovarian cancer cells: up-regulation of p53 gene expression and induction of apoptosis by tumor necrosis factor-alpha

OBJECTIVE

Our purpose was to determine the effect of tumor necrosis factor-alpha on anti-oncogene expression and to investigate the relationship between the up-regulation of the p53 tumor suppressor gene and tumor necrosis factor-alpha-mediated apoptosis in epithelial ovarian cancer cell lines.

STUDY DESIGN

By means of Northern blot techniques p53 messenger ribonucleic acid expression was assayed in ovarian cancer cells. Tumor cells explanted from patients into Balb/c nude mice were exposed to supernatants from activated monocytes, activated T cells, or the recombinant cytokines interleukin-6 and tumor necrosis factor-alpha. Time- and dose-dependence of p53 up-regulation was measured. Induction of programmed cell death (apoptosis) by tumor necrosis factor-alpha was quantitated by means of a deoxyribonucleic acid fragmentation assay.

RESULTS

Detectable levels of messenger ribonucleic acid for p53 were seen in ovarian cancer cells. Tumor necrosis factor-alpha induced a significant up-regulation of p53 messenger ribonucleic acid levels in ovarian cancer cells grown in nude mice and in vitro, whereas interleukin-6 did not. The maximum level of induction was 8 hours, and the up-regulation of p53 was dose dependent. In addition, tumor necrosis factor-alpha induced a dose-dependent increase in deoxyribonucleic acid fragmentation.

CONCLUSION

Tumor necrosis factor-alpha induced up-regulation of p53 tumor suppressor gene expression in epithelial ovarian cancer cell lines, together with the induction of cell death by apoptosis.

Upregulation of T cell receptor gamma chain transcription by interleukin-2

Signals involved in TcR gene rearrangement and expression are poorly understood. The ability of interleukin 2 to control TcR gamma gene expression was examined. Precursor thymocytes grown in the presence of IL-1 and Con A develop to CD3+ T cells that express either the TcR alpha/beta or gamma/delta complex on the cell surface (1). We show here that a major subpopulation of these cells are CD4-/CD8-, gamma/delta cells expressing only low levels of TcR gamma transcripts, compared to TcR delta mRnA or to TcR gamma mRNA of gamma/delta cells grown from precursor thymocytes with IL-2 and Con A. The cells cultured with IL-1 and lectin then strongly reacted to IL-2 by upregulating the steady-state level of TcR gamma mRNA. Our findings indicate that IL-2 upregulates TcR gamma transcription by transcriptional regulatory effects in this in vitro system.

Presence of interleukin 10 (IL-10) in the ascites of patients with ovarian and other intra-abdominal cancers

Typically, ovarian cancer remains restricted to the peritoneal cavity. Because of this unique localization, the study of ovarian cancer is particularly suitable for immune analysis and for the development of immunotherapy. Here we report that peritoneal fluid from patients with ovarian or other intra-abdominal cancers contained significantly elevated levels of interleukin 10 (IL-10) (542 +/- 77 pg/ml, N = 35), compared with peritoneal fluid from patients with benign gynecological conditions (34.2 +/- 7.5 pg/ml, N = 63) (P < 0.001). Peritoneal fluid IL-10 levels did not correlate with histology, tumor stage, grade, or prognosis. IL-10 levels were also elevated in the serum of patients with intra-abdominal cancer (1353 +/- 906, N = 8). Established ovarian cancer cell lines (N = 5) did not produce any detectable IL-10. Investigation of the cell surface phenotype of the cells in the peritoneal cavity indicated the presence of significant amounts of activated immune cells. The presence of cytokines such as IL-10 in the peritoneal cavity of ovarian cancer bearing patients could be important in the growth and development of cancer, more specifically, in relation to host immune responsiveness.

[Immunology of pregnancy]

The fetus expresses paternally inherited gene products and tissue-specific differentiation antigens. Hence, it can be considered as a semi-allogeneic graft towards which the maternal immune response is characterized by tolerance instead of rejection. As such, the pregnancy represents a challenge to the laws of transplantation. For the immunologist, the question is not why some women miscarry, but rather, why most women do not miscarry? A bulwark of proscriptive or inhibitory influences must be built to ensure an absence of anti-fetal reactivity. The mechanisms underlying the induction of tolerance are poorly understood. Failure to obtain an adequate maternal immune response might be responsible for some forms of miscarriages, especially recurrent spontaneous abortions. Increased knowledge of those mechanisms could have implications in various fields, such as infertility, transplantation and oncology.

[Immunotherapy of recurrent spontaneous miscarriages (idiopathic abortive disease): preliminary results]

Recurrent spontaneous abortion (greater than or equal to 3 spontaneous miscarriages) represents an entity defined by negative criteria (absence of anatomical, hormonal, autoimmune and chromosomal abnormalities). The immune hypothesis is corroborated by the successes (greater than or equal to 80 %) of specific (paternal leucocytes) or non-specific (intravenous gammaglobulins) immunotherapeutic trials. Studies on the mechanisms of action of those two methods will afford information on the pathogenesis of this condition.