Phase II study on the combination carboplatin-celecoxib in heavily pre-treated recurrent ovarian carcinoma patients

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Background: Cyclooxygenase-2 (COX-2) has been shown to be involved in several steps of ovarian onset and progression and its overepression is associated with a poor chance of response to chemotherapy and poor prognosis in ovarian cancer. Celecoxib, an orally active selective COX-2 inhibitor, has been tested for its ability to potentiate the activity of carboplatin in treatment of heavily pretreated recurrent ovarian cancer patients. Methods: A phase II study was planned, considering the regimen active if at least 12 responses were observed among the 43 enrolled patients. Celecoxib (400 mg/die), and carboplatin (5 AUC) q28 were administered, until progression or unacceptable toxicity. Response was assessed by RECIST and also by Rustin criteria. Results: 34 pts (median age: 60 yrs, range 28–74) and an ECOG performance status (0/1/2) of (21/12/1), were enrolled. 58.8% of patients were platinum resistant (progressing during or < 6 months from primary treatment). Median number of previous chemotherapy regimens was 3 (range 2–6). Currently 27 patients are evaluable for response. The overall response rate (CR and PR) was 25.9% (2 CR, 5 PR) with stabilization of disease in 8 patients (29.6%). Four responses occurred in platinum sensitive and 3 in platinum resistant group Median time to response was 11 weeks (range 9–19) and median duration of response was 23 weeks (range 12–39). According to Rustin criteria 10 patients out of 25 (40%) were considered responsive to treatment (return of CA125 levels to normal level or >50% reduction). Overall, 143 cycles were administered with a median value of 3 cycles (range = 1–10). Moderate/severe toxicities were as follows: G3 anemia occurred in 2.3% cycles, G3 neutropenia in 4.6% cycles, G3 thrombocytopenia in 1.5% cycles, G3/4 gastrointestinal toxicity occurred in 4.6% cycles. Cutaneous diffuse erithema was observed in 2 patients, in both cases recovered with a short period of antihistaminic treatment; 2 cases of hypertension were documented, G2 hypersensitivity reactions during carboplatin infusion were observed in 4 cases. Conclusions: Celecoxib combined with carboplatin is well tolerated and has promising activity as salvage treatment in heavily pretreated recurrent ovarian cancer patients.

No significant financial relationships to disclose.

A multicentre, prospective phase 2 study of weekly schedule of carboplatin (C) plus paclitaxel (P) in first-line treatment of elderly patients (pts) with ovarian cancer (OC). The MITO (Multicentre Italian Trials in Ovarian cancer)-5 study

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Background: CP every 3 weeks is the standard for pts with OC, but elderly pts frequently receive modified schedules or single agent chemotherapy to avoid toxicity. A prospective phase 2 study was conducted to describe tolerability and activity of a weekly schedule of CP in elderly pts with OC. Methods: Pts aged ≥70 years with chemo-naive OC, stage IC-IV, ECOG PS≤2 were eligible. Treatment was C (AUC 2) + P (60 mg/m2) on days 1, 8, 15 every 4 weeks, up to 6 cycles. A 2-stage minimax design was applied. With rate of pts without unacceptable toxicity in the first 3 cycles (UT) as primary endpoint, alpha 0.05 and beta 0.10, p0=0.75, p1=0.95, ≥23/26 pts without UT were required at the final stage. Toxicity was coded with NCI-CTC and response by RECIST. Geriatric assessment was performed by ADL (Activities of Daily Living) and IADL (Instrumental ADL). Results: 26 pts were enrolled. Median age was 77 (range 70–84). PS0: 10 pts, PS1: 16 pts. 14 pts (53.8%) had ≥2 comorbidities. 32%/72% had some ADL/ IADL dependency, respectively. 23 pts (88.5%) did not suffer UT. The 3 UT recorded were g3 heart rhythm (1 pt), g3 liver (1 pt), prolonged haematological toxicity (1 pt). Other main toxicities: g3 thrombocytopenia 1 pt, g2 constipation 2 pts (8%), g1 neuropathy 4 pts (15%). Out of 13 pts with at least one measurable lesion, 4 partial responses were observed (response rate 30.8%, 95% exact CI: 9.1–61.4). Out of 6 pts with non-measurable disease and 2 pts evaluable only for Ca125, 4 complete responses were observed (50%). Conclusions: In this series of elderly OC pts, characterized by a high incidence of comorbidities and functional impairment, weekly CP has a favourable toxicity profile. In this setting, a comparison of weekly vs 3-weekly CP is advisable to compare efficacy.

No significant financial relationships to disclose.

Phase II study of oxaliplatin (OXA) and docetaxel (DTX) in recurrent ovarian cancer

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Background: We conducted a phase II study to evaluate the efficacy and safety of OXA and DTX in recurrent platinum-sensitive ovarian cancer patients. Methods: Patients received DTX 75 mg/m2 (60-min i.v.) on day 1, followed by OXA 100 mg/ m2 (120-min i.v.) on day 1 every 21 days. Results: Between October 2002 and November 2005, 30 Caucasian patients (median age: 53.5 yrs; range, 31–73) were enrolled; 7 (23.3%) patients had FIGO stage I-II disease, 22 (73.3%) had FIGO stage III, and 1 (3.3%) had FIGO stage IV disease. Sites of relapse were as follows: abdominal 3 (10.0%), pelvis 5 (16.7%), lymph nodes 10 (33.3%), peritoneal 7 (23.3%), lung 1 (3.3%), and mixed 4 (13.3%). The median PFI was 28.5 months (range 13–91). The median CA125 was 182 U/ml (range 21–5,596 U/ml). Of the 30 patients evaluable, 13 (43.3%) had complete responses and 7 (23.3%) had partial responses, for an overall response rate of 66.6%. The median time to response was 9.5 wks (range 5–32) and the median duration of response was 43 wks (range 5–124). 8 (26.7%) patients had stable disease (median duration of stabilization: 26.5 wks, range 12–43). 2 (6.7%) patients progressed while on treatment. An overall clinical benefit was observed in 93.3% of patients. All patients were evaluable for toxicity. A total of 186 courses were given, with a median of 6 cycles per patient (range 2–11). Severe toxicities (Grade 3–4 NCI-CTC) included: neutropenia in 29.4% of cycles; severe anemia and thrombocytopenia were not observed. Grade 3–4 neurotoxicity and alopecia were detected in 2.8% and 22.8% of cycles respectively. Allergic reaction was observed only in one case. Doses were reduced by 20% in 14.0% of cycles. Conclusions: In recurrent platinum-sensitive ovarian cancer patients the OXA/DTX combination is highly active with acceptable toxicity, thus making it an attractive regimen.

No significant financial relationships to disclose.

From bio-molecular and technology innovations to clinical practice: focus on ovarian cancer

Ovarian cancer (OC) still represents the most lethal of gynecological malignancies with the chance for death in 5 years exceeding the chance for life. In recent years, the development of knowledge in molecular biology of OC coupled with the new technologies offers enormous opportunity to learn about aetiology of OC, and also give us a powerful tool for early diagnosis, prognosis and treatment of this disease. In particular, small cancer specimens from patients have become extremely informative thanks to techniques such as laser capture microdissection (LCM), tissue lysate arrays (TLAs), reverse trascriptase polymerase chain reaction (RT-PCR), and mass spectrometry. All of this coupled with advancements in bioinformatics have allowed the explosion of genomics, transcriptomics and proteomics. This paper focusses on the influence that advancement in the "-omics" bio-technology will reserve in OC diagnosis, prognostic characterization, and treatment.

Ultrasound and color power Doppler in the detection of metastatic omentum: a prospective study

OBJECTIVES

To analyze prospectively the ability of ultrasound to detect metastatic omentum in patients with suspicious pelvic masses and to describe the sonographic features of metastatic omental disease.

METHODS

One hundred and eighty-four patients were evaluated preoperatively by ultrasound examination and of these 173 were used in the analysis. We defined as an ultrasound-positive examination one which visualized intra-abdominal aperistaltic solid tissue, located above the bowel loops and below the anterior peritoneal surface. Preoperative sonographic findings were compared with pathological results.

RESULTS

Sonographic detection of metastatic omentum was achieved in 104 of 173 patients (60.1%), appearing as either solid aperistaltic tissue (80.8% of cases), or as solid discrete nodules (19.2%). When considering the echostructure of the surrounding bowel loops, this tissue appeared hypoechoic in 46 (44.2%) cases and isoechoic or slightly hyperechoic in the other 58 (55.8%) cases. In the overall series, the negative and positive predictive values (NPV and PPV) and the accuracy of ultrasound examination were 92.7%, 91.3% and 91.9%, respectively. When considering only the group of ovarian tumors, the NPV, PPV and accuracy were 91.9%, 94.6%, and 93.8%, respectively.

CONCLUSION

Ultrasound examination is highly accurate in detecting metastatic omental involvement in cases with suspicious pelvic masses.

Gemcitabine in epithelial ovarian cancer treatment: current role and future perspectives

Newer agents and combinations are needed in order to improve current results in ovarian cancer treatment. Gemcitabine is a novel agent that has shown consistent activity as a single agent in the treatment of platinum-resistant ovarian cancer and a favorable toxicity profile. Because of its clinical and preclinical synergism with platinum analogs, gemcitabine has been combined with carboplatin as a convincing approach in the treatment of platinum-sensitive recurrent ovarian cancer patients. Further combination of gemcitabine and other agents, including paclitaxel, is also feasible and has been actively studied in order to establish the role of gemcitabine in the management of treated and untreated ovarian cancer patients.

Ultrasound features of different histopathological subtypes of borderline ovarian tumors

OBJECTIVE

To describe the gray-scale sonographic and color Doppler imaging features of the most common histopathological subtypes of borderline ovarian tumors.

METHODS

We analyzed retrospectively the preoperative transvaginal sonographic reports of patients with a histological diagnosis of borderline ovarian tumor. All patients were scanned consecutively by two of the investigators using transabdominal and transvaginal gray-scale imaging to assess the morphology and color Doppler to obtain indices of the blood flow. Sonographic findings were compared to histopathological data.

RESULTS

A total of 113 consecutive cases were reviewed from two referral centers for gynecological oncology. At histological examination 50 tumors (44%) were classified as being serous borderline ovarian tumors (SBOT), 61 (54%) were mucinous borderline ovarian tumors (MBOT) (42 intestinal type and 19 endocervical type), and two patients (2%) presented with borderline endometrioid tumors. SBOTs and endocervical-type MBOTs had very similar sonographic features and a smaller diameter, fewer locules (usually unilocular-solid lesions) and a higher color score than intestinal-type MBOTs. Intestinal-type MBOTs were characterized by a significantly higher percentage of lesions with > 10 locules when compared with the endocervical-type MBOTs.

CONCLUSION

Intestinal-type MBOTs have different sonographic features from other common borderline ovarian tumors.

Progression of conservatively treated endometrial carcinoma after full term pregnancy: A case report

INTRODUCTION

We describe a case of conservatively treated endometrial endometrioid (EE) adenocarcinoma which showed an aggressive clinical outcome after pregnancy.

CASE

A 30-year-old woman with a well differentiated EE adenocarcinoma decided to attempt a conservative approach and underwent progestin treatment with subsequent negative ultrasound and hysteroscopic controls. After 3 months, she conceived and at 36 weeks of gestation, a cesarean section was performed with multiple negative biopsies. Eight 8 months after delivery, an exploratory laparotomy documented disseminated poorly differentiated EE adenocarcinoma. Staging work up revealed diffuse metastatic disease. Despite chemotherapy, the patient experienced progression of disease with fatal acute respiratory syndrome due to massive neoplastic pulmonary lymphangitis.

CONCLUSION

Conservative medical management of endometrial cancer in young women willing to preserve their reproductive potential, carries on potential risks. Careful selection of cases, informed consent, and strict follow up procedures are mandatory.

Skull metastasis in primary vulvar adenocarcinoma of the Bartholin's gland: A case report

BACKGROUND

Metastatic bone involvement in vulvar squamous carcinoma is very rare. Here, we present a case of primary adenocarcinoma of the Bartholin's gland giving rise to isolated skull metastasis.

CASE

A 74-year-old woman was referred with a diagnosis of primary vulvar adenocarcinoma of the right labium minus. A right hemivulvectomy was performed with ipsilateral inguinofemoral lymphadenectomy, revealing a primary adenocarcinoma of the Bartholin's gland and metastatic involvement in 6 out of 13 lymphnodes. During chemotherapy administration, the patient started complaining of a worsening of right hypoacousis. CT scan and MRI of the brain showed the presence of a metastatic lesion on the right side of the skullbone. The diagnosis was metastatic poorly differentiated adenocarcinoma.

CONCLUSION

In adenocarcinoma of the Bartholin's gland at an advanced stage of disease, a bone scan or survey in the preoperative as well as follow up staging procedures could be useful.

Does quantitative analysis of three-dimensional power Doppler angiography have a role in the diagnosis of malignant pelvic solid tumors? A preliminary study

OBJECTIVE

To investigate the role of a simplified method for the three-dimensional (3D) quantification of tumor vascularity in the differential diagnosis of solid pelvic masses.

METHODS

Twenty-four patients with a solid pelvic mass on B-mode ultrasound evaluation underwent 3D power Doppler evaluation before surgery. The volume of interest was obtained by drawing the largest section of the mass in three orthogonal planes. The following 3D vascular parameters were calculated for all patients: relative color, average color and flow measure. Receiver-operating characteristics curve analysis was used to choose the best cut-off value. The overall agreement between the test result and the actual outcome was calculated using kappa statistics.

RESULTS

Fifteen of 24 subjects were found to have pelvic malignancy. The relative color and the flow measure were significantly higher in malignant (9.7 (8.98) and 8.95 (8.78) (median (interquartile range (IQR)), respectively) than in benign masses (2 (4.42) and 1.79 (4.71), respectively; P < 0.05) but there was no difference in the average color. The best cut-off values of relative color and flow measure were 3.2 and 2.8, respectively. The use of relative color showed a sensitivity of 80% with a specificity of 67% with an overall agreement that was higher, though only marginally so, than that of qualitative 3D power Doppler (kappa = 0.47 and 0.44, respectively).

CONCLUSIONS

In a small group of pelvic masses that appear malignant on B-mode ultrasonography, the use of 3D quantification of tumor vascularity yields a diagnostic accuracy that is similar to that of subjective evaluation of vascularity. We suspect, however, that the quantitative method will produce more consistent results between operators.

Role of pegylated liposomal doxorubicin (PLD) in epithelial ovarian cancer

Pegylated liposomal doxorubicin (PLD, Caelyx) is an emerging option for patients with recurrent ovarian carcinoma. Several phase II studies showed promising activity of PLD in recurrent ovarian cancer patients with response rate ranging from 16 to 25%. A phase III randomized trial compared PLD 50 mg/m2 day 1 every 4 weeks with Topotecan 1.5 mg/m2 daily for 5 days q 21 in recurrent ovarian cancer patients. No differences in progression free survival and overall survival were documented between treatment arms in the general population but a survival advantage was reported for platinum-sensitive subset. Our experience with PLD in the treatment of ovarian cancer is reported in this review article. Pegylated liposomal doxorubicin is effective as a second line treatment in ovarian cancer patients; comparative data are needed to establish its role in first line therapy.

Survivin expression in ovarian cancer and its correlation with clinico-pathological, surgical and apoptosis-related parameters

We investigated the association of survivin expression with prognosis and other apoptosis-related biological factors in 110 primary ovarian cancer patients admitted to the Division of Gynecologic Oncology, Catholic University of Rome. Immunohistochemistry was performed on formalin-fixed, paraffin-embedded sections by using polyclonal antibody ab469 for survivin, and mouse monoclonal antibodies (clone 124 and DO-7), for bcl-2 and p53, respectively. Cytoplasmic survivin immunoreaction was observed in 84.5% cases, while nuclear survivin immunostaining was observed in 29.1% cases. We failed to find any relationship between cytoplasmic survivin positivity rate and any of the parameters examined. Serous tumours showed a lower percentage of nuclear survivin positivity with respect to other histotypes (20.5 vs 48.6%, respectively; P-value=0.004). The percentage of nuclear survivin positivity was higher in cases subjected to primary tumour cytoreduction (43.5%), with respect to patients subjected to exploratory laparotomy (20%) (P=0.024). Bcl-2 and p53 were, respectively, expressed in 27.3 and 60.0% of the cases and their expression was not correlated with survivin status. During the follow-up period, progression and death of disease were observed in 68 (61.8%) and 53 (48.2%) cases, respectively. There was no difference in time to progression and overall survival according to survivin status in ovarian cancer patients. In conclusion, in our experience, the immunohistochemical assessment of survivin status does not seem to be helpful in the prognostic characterisation of ovarian cancer. A more in depth investigation of the complex physiology of divergent survivin variants is needed in order to clarify the biological and the clinical role of differentially located survivin isoforms.

Stem cell-based treatments for gynecological solid tumors

BACKGROUND AND OBJECTIVE

We have recently assisted to an increasing scientific interest and a new research effort in the field of stem cell-based therapy. Since the late 1980s hematopoietic stem cells (HSC) have been used to set up therapeutic strategies for the treatment of solid tumors such as gynecological cancers. In this context, different approaches have been suggested and clinically investigated.

STATE OF THE ART

In the autologous setting we can describe the well-known use of HSC as hematologic support to high-dose chemotherapy regimens, and the use of HSC as a source of dendritic cells for cancer vaccination protocols. In our institution a long-term experience has been developed in high-dose chemotherapy with autologous HSC transplantation as first-line treatment of advanced ovarian cancer, and in the use of cytokines both for HSC collection and for post-transplantation hematopoietic recovery and immune reconstitution. An alternative approach consists of allogenic HSC transplantation following either myeloablative/standard or non-myeloablative/reduced conditioning regimens, which have been proposed as new adoptive immunotherapeutic treatments for different non-hematologic malignancies.

PERSPECTIVES

Future strategies in the use of HSC in oncology comprise the possibility of HSC ex-vivo expansion, the use of umbilical cord blood HSC, and the development of HSC-based gene-therapy programs. Further investigations are expected in the new field of cancer stem cells.

Microsatellite instability is not related to response to cisplatin-based chemotherapy in cervical cancer

This study investigates whether microsatellite instability (MSI) due to defects of the mismatch repair (MMR) system could be associated with response to cisplatin-based neoadjuvant chemotherapy (NACT) and if cisplatin exposure could select MSI-positive cell clones in cervical cancer. Microsatellite analysis was performed by polymerase chain reactions using six microsatellite markers, while hMLH1 protein expression was investigated by immunohistochemistry. We found that 1 tumor out of 20 (5%) NACT-responding patients and 1 tumor out of 18 (6%) nonresponding patients showed MSI. The analysis of tumor specimens collected after NACT revealed no change in the banding pattern as compared to each corresponding pre-NACT tumor at each locus tested. hMLH1 staining was observed in at least > or =80% of cells in all tumors examined except the two exhibiting MSI. Our data showed that MSI due to defects of the MMR system seems not to play a crucial role in the biology of human cervical cancer cells and that MSI seems not to be related to response to chemotherapy. Moreover, cisplatin exposure did not seem to select for MMR-deficient tumor clones in cervical cancer.

Microsatellite instability is not related to response to cisplatin-based chemotherapy in cervical cancer

This study investigates whether microsatellite instability (MSI) due to defects of the mismatch repair (MMR) system could be associated with response to cisplatin-based neoadjuvant chemotherapy (NACT) and if cisplatin exposure could select MSI-positive cell clones in cervical cancer. Microsatellite analysis was performed by polymerase chain reactions using six microsatellite markers, while hMLH1 protein expression was investigated by immunohistochemistry. We found that 1 tumor out of 20 (5%) NACT-responding patients and 1 tumor out of 18 (6%) nonresponding patients showed MSI. The analysis of tumor specimens collected after NACT revealed no change in the banding pattern as compared to each corresponding pre-NACT tumor at each locus tested. hMLH1 staining was observed in at least ≥80% of cells in all tumors examined except the two exhibiting MSI. Our data showed that MSI due to defects of the MMR system seems not to play a crucial role in the biology of human cervical cancer cells and that MSI seems not to be related to response to chemotherapy. Moreover, cisplatin exposure did not seem to select for MMR-deficient tumor clones in cervical cancer

Phase II Study of Pegylated Liposomal Doxorubicin in Heavily Pretreated Epithelial Ovarian Cancer Patients

OBJECTIVE

Pegylated liposomal doxorubicin (PLD) has shown promising activity in the treatment of recurrent ovarian cancer but skin toxicity remains the dose-limiting toxicity of the drug. The aim of this study was to investigate whether a different treatment schedule may improve the toxicity profile, especially in terms of dermatological and mucosal toxicity.

METHODS

It is an open-label phase II study in a population of heavily pretreated ovarian cancer patients. PLD was administered at the dose of 35 mg/m2 q21 until disease progression or unacceptable toxicity.

RESULTS

Thirty-seven heavily pretreated (median number of previous chemotherapy regimens 2, range 1-6) ovarian cancer patients were enrolled. All patients received at least two courses of chemotherapy and all were evaluated for response. No one showed complete response, while five partial responses (13.5%), 16 stabilizations of disease (48.6%) and 14 progressions of disease (37.8%) were observed. The median time to response was 12 weeks (range 8-16). The median duration of response was 22.8 weeks (range 4-68), the median duration of stabilization of disease was 17.6 weeks (range 4-28). Palmar plantar erythrodysesthesia (PPE) occurred in 8 patients (21.6%) and was of grade 3 in one patient (2.8%). Grade 1 stomatitis occurred in 3 patients (8.1%). Grade 3-4 neutropenia occurred in only 4 patients (10.8%).

CONCLUSIONS

PLD at the dose of 35 mg/m2 q21 seems to translate into an acceptable skin toxicity profile with a response rate comparable to others obtained with a standard schedule.

Sonographic features of decidualized ovarian endometriosis suspicious for malignancy

The discovery of an ovarian mass during pregnancy is often a difficult issue because of the risk related to surgical intervention during pregnancy. Moreover, ultrasound examination is often unable to provide a definitive diagnosis. A case of decidualized ovarian endometriosis is presented to highlight the challenges in this diagnosis. We report the transvaginal ultrasound findings, including color Doppler examination, magnetic resonance characteristics and tumor marker longitudinal evaluation during the first trimester of pregnancy, as well as the final histological characteristics of the lesion. Decidualization is a rare occurrence in ovarian endometriosis and must be differentiated from malignant transformation.

Color Doppler velocimetry and three-dimensional color power angiography of cervical carcinoma

OBJECTIVES

To investigate the blood flow within invasive cervical carcinoma by transvaginal two-dimensional (2D) color spectral Doppler and three-dimensional (3D) color power angiography and to correlate these parameters with the clinicopathological characteristics.

METHODS

Seventy-four patients with invasive cervical carcinoma were enrolled for the analysis. Squamous cell carcinoma serum antigen levels (SCC) were obtained for all the patients. Sections of all malignant tissues were analyzed for tumor expression of cyclooxygenase-2 (COX-2). All patients underwent color and spectral Doppler examination and 44 patients had 3D color power angiography. Color spectral Doppler parameters (color score, lowest resistance index (RI), highest peak systolic velocity (PSV)) and 3D color power angiography indices (relative color, average color, flow measure) of FIGO I/II cervical cancers were compared with those obtained in a control group of 24 patients with a normal uterine cervix. Pulsed Doppler parameters and the 3D vascular indices were compared with clinicopathological parameters, SCC serum antigen levels and tumor COX-2 expression.

RESULTS

At color Doppler analysis 72 patients (97%) showed intralesional detectable vessels. Color spectral Doppler and 3D-derived parameters were significantly different in FIGO I/II cervical cancers compared with those in women with a normal cervix. A significantly higher color score (P = 0.0008), lower RI (P = 0.032) and higher PSV (P = 0.004) were associated with a tumor diameter > or =4 cm compared with smaller tumors. The highest PSV was significantly higher in patients with FIGO stage III/IV compared with FIGO stage I/II (P = 0.0069). There was a direct correlation between PSV and SCC (r = +0.44, P = 0.003). The median relative color was significantly higher in patients with a higher color score (P = 0.0006). No statistically significant correlations were found between 3D color power angiography parameters and the clinicopathological characteristics or between the 3D vascular parameters and biological factors.

CONCLUSIONS

Alterations of 3D ultrasound-derived vascular indices were found in patients with cervical cancer compared with those with a normal cervix. Moreover, some vascular indices proved to be associated with tumor size. The assessment of a possible clinical role of 2D and 3D ultrasound-derived vascular indices in cervical cancer deserves further investigation.

Epidermal growth factor-responsive laryngeal squamous cancer cell line Hep2 is more sensitive than unresponsive CO-K3 one to quercetin and tamoxifen apoptotic effects

Epidermal growth factor receptor (EGFR) plays a role in laryngeal squamous cell carcinoma (SCC) development and progression. The flavonoid quercetin (Q) and the antiestrogen tamoxifen (TAM) inhibit proliferation of both primary laryngeal SCC and laryngeal carcinoma cell lines, through still uncharacterized mechanisms. We studied Q and TAM inhibitory effect on epidermal growth factor (EGF)-stimulated Hep2 and CO-K3 laryngeal squamous cell lines. Q and TAM (0.1-1.0 microM) induced more apoptosis in EGF growth-stimulated than in unstimulated Hep2 cells. EGF neither stimulated CO-K3 cell growth nor enhanced Q and TAM-induced apoptosis. Mitogen-activated protein kinase (MAPK) analysis revealed that in Hep2 cells, but not in CO-K3 cells, EGF induced a time-dependent phosphorylation of p42, p44, p38, and p46. In Hep2 cells, but not in CO-K3 cells, Q and TAM produced, upon EGF treatment, a twofold increase of p38 and p46 and an enhancement of p42 and p44 dephosphorylation, suggesting a requirement of EGFR. The enhancing effect was due to a p38 and p46 dephosphorylation delayed kinetics. An antiphosphorylated p38 antibody prevented Q and TAM inhibitory effect on p42 and p44 phosphorylations, suggesting that the EGF-dependent increase in Q and TAM apoptotic effect on Hep2 cells could depend on the p38 inhibition of the survival kinases p42 and p44. In SCC, EGFR overexpression is an early event from dysplasia to neoplasia. We conclude that the capacity of Q and TAM to increase apoptosis in EGFR-activated cells makes these compounds possible chemopreventive drugs in subjects at risk of developing laryngeal cancer.

Phase II study of liposomal doxorubicin and gemcitabine in the salvage treatment of ovarian cancer

In total, 70 patients were enrolled into this phase II study, to evaluate the activity of the pegylated liposomal doxorubicin (PLD) and gemcitabine (GEM) combination in recurrent ovarian cancer patients. PLD, 30 mg m⁻², was administered on day 1 by 60′ i.v. infusion, followed by GEM, 1000 mg m⁻², given by 30′ i.v. on days 1 and 8; cycles were repeated every 21 days. In all, 67 patients are so far evaluable for response. Seven complete responses (10.4%, 95% CI: 3.1–17.7), 16 partial responses (23.9%, 95% CI: 13.7–34.1), 26 disease stabilisations (38.8%, 95% CI: 27.1–50.5) and 18 progressions (26.9%, 95% CI: 16.3–37.5) have been registered. Within the resistant population (n=36), the response rate was 25% (95% CI: 10.9–39.1). Within the group of platinum-sensitive patients (n=31), the response rate was 45.2% (95% CI: 27.7–62.7). A total of 443 courses are evaluable for toxicity. Grade 3–4 hematological toxicity was registered in 30 patients (42.8%), mainly represented by neutropenia (35.6%); palmar-plantar erythrodysesthesia affected 24 patients (34.2%), but it was of grade 3 in only seven of them (10%).

Phase III multicenter randomized trial of amifostine as cytoprotectant in first-line chemotherapy in ovarian cancer patients

BACKGROUND

A phase III multicenter randomized trial has been designed in order to address whether amifostine (WR-2721, Ethyol), an organic thiophosphate cytoprotector, can protect ovarian cancer patients from toxicity induced by carboplatin-paclitaxel chemotherapy.

PATIENTS AND METHODS

Patients were randomly assigned to receive carboplatin [area under the curve (AUC) 5 mg.min/ml] and paclitaxel (175 mg/m(2)) with (arm A) or without (arm B) amifostine (910 mg/m(2)) every 21 days for six cycles.

RESULTS

One-hundred and eighty-seven patients were accrued: 93 patients in arm A and 94 patients in arm B. There was no difference in terms of erythrocytopenia between the two arms; grade 3-4 thrombocytopenia was higher in arm A (3.3% versus 0.6%; P = 0.0010). There was no significant reduction of grade 3-4 leukopenia in arm A (11.8% versus 13.8%). The incidence of grade 3-4 neutropenia was lower in arm A (31.3% versus 37.9%; P = 0.03), as was the incidence of severe mucositis (4.7% versus 15.4% in arm A versus arm B, respectively; P <0.0001). Finally, amifostine appears to be protective against neurotoxicity (grade 3-4 neurotoxicity 3.7% versus 7.2%; P = 0.02). With a median follow-up of 24 months (range 2-41), time to progression was similar between the two groups.

CONCLUSIONS

We showed that amifostine can exert some protection from the cumulative toxicity associated with this regimen. The results need to be confirmed in other randomized trials with this combination.

Radiofrequency bipolar coagulation for radical hysterectomy: technique, feasibility and complications

This study describes the surgical technique and intra- and postoperative complications associated with the use of a radiofrequency bipolar coagulator in a series of 18 Piver type III-IV radical hysterectomies performed in cervical cancer patients. Preliminary vessel-by-vessel dissection of the lateral parametria was possible in 17 out of 18 (94%) cases, and a direct application of a radiofrequency bipolar coagulation instrument was performed to coagulate the posterior and anterior parametrial tissues in all cases. We were able to easily coagulate isolated vessels up to 5 mm of maximal diameter. In no case were clamps or hemoclips necessary to complete hemostasis. We did not observe any parametrial vessel damage or heat-related injury of the surrounding normal tissue. The median size of the parametria removed was 44 mm (range 31-58) and nodes were detected in 15 cases (83%). Median operative time and estimated blood loss for the whole procedure including systematic pelvic and aortic lymphadenectomy was 250 min (range 200-410) and 550 ml (range 400-2500), respectively. Median follow-up time was 9 months (range 5-13). No complications specifically related to the use of radiofrequency coagulation were found. In conclusion the radio-frequency coagulation with this instrument appears to be a safe technique that is particularly useful in reducing blood loss and operative time without affecting radicality in patients undergoing radical hysterectomy.

Radiofrequency bipolar coagulation for radical hysterectomy: Technique, feasibility and complications

This study describes the surgical technique and intra- and postoperative complications associated with the use of a radiofrequency bipolar coagulator in a series of 18 Piver type III-IV radical hysterectomies performed in cervical cancer patients. Preliminary vessel-by-vessel dissection of the lateral parametria was possible in 17 out of 18 (94%) cases, and a direct application of a radiofrequency bipolar coagulation instrument was performed to coagulate the posterior and anterior parametrial tissues in all cases. We were able to easily coagulate isolated vessels up to 5 mm of maximal diameter. In no case were clamps or hemoclips necessary to complete hemostasis. We did not observe any parametrial vessel damage or heat-related injury of the surrounding normal tissue. The median size of the parametria removed was 44 mm (range 31–58) and nodes were detected in 15 cases (83%). Median operative time and estimated blood loss for the whole procedure including systematic pelvic and aortic lymphadenectomy was 250 min (range 200–410) and 550 ml (range 400–2500), respectively. Median follow-up time was 9 months (range 5–13). No complications specifically related to the use of radiofrequency coagulation were found. In conclusion the radio-frequency coagulation with this instrument appears to be a safe technique that is particularly useful in reducing blood loss and operative time without affecting radicality in patients undergoing radical hysterectomy.

Cyclooxygenase-2 (COX-2) expression in locally advanced cervical cancer patients undergoing chemoradiation plus surgery

PURPOSE

To investigate whether cyclooxygenase-2 (COX-2) could be a marker of clinical outcome in cervical cancer patients undergoing concomitant chemoradiation plus surgery.

METHODS AND MATERIALS

The study included 33 locally advanced cervical cancer patients; all underwent neoadjuvant chemoradiation, and responsive patients underwent radical surgery. Immunohistochemistry was performed with rabbit antiserum against COX-2.

RESULTS

COX-2 integrated density values (IDVs) in the tumor component ranged from 1.4 to 72.3 (median 15.0); in stromal inflammatory cells, COX-2 IDVs ranged from 1.4 to 96.0 (median 16.0). A statistically significant inverse relation was found between the COX-2 IDVs of the tumor vs. the stromal inflammatory component (r = -0.52, p = 0.0017). When the ratio between COX-2 IDV in the tumor vs. the stromal compartment was <or=1, it was considered to indicate cervical tumor with COX-2 expression in the tumor component lower or equivalent to COX-2 expression in the stroma. According to the chosen cutoff value, 17 (51.5%) of 33 were scored as having a high (>1) tumor/stroma COX-2 IDV ratio. Patients with a high tumor/stroma COX-2 IDV ratio had a shorter disease-free survival than did those with a low tumor/stroma COX-2 IDV ratio (p = 0.030). Similarly, those with a high tumor/stroma COX-2 IDV ratio had a shorter overall survival (p = 0.033).

CONCLUSION

The assessment of COX-2 status in both the tumor and the stromal compartment could provide additional information in the prognostic characterization of cervical cancer patients administered concomitant chemoradiation plus surgery.

Expression of cyclooxygenase-2 (COX-2) in tumour and stroma compartments in cervical cancer: clinical implications

This study aims at investigating the relationship between cyclooxygenase-2 expression in tumour vs stroma inflammatory compartment and its possible clinical role. The study included 99 stage IB-IV cervical cancer patients: immunostaining of tumour tissue sections was performed with rabbit antiserum against cyclooxygenase-2. CD3, CD4, CD8, CD25, Mast Cell Tryptase monoclonal antibodies were used to characterise stroma inflammatory cells in nine cervical tumours. An inverse relation was found between cyclooxygenase-2 levels (cyclooxygenase-2 IDV) of tumour vs stroma compartment (r=-0.44, P<0.0001). The percentage of cases showing high tumour/stromal cyclooxygenase-2 IDV ratio was significantly higher in patients who did not respond to treatment (93.3%) with respect to patients with partial (60.5%), and complete (43.7%) response (P= 0.009). Cases with a high tumour/stroma cyclooxygenase-2 IDV ratio had a shorter overall survival rate than cases with a low tumour/stroma cyclooxygenase-2 IDV (P<0.0001). In the multivariate analysis advanced stage and the status of tumour/stroma cyclooxygenase-2 IDV ratio retained an independent negative prognostic role. The proportion of CD3(+), CD4(+), and CD25(+) cells was significantly lower in tumours with high tumour/stroma cyclooxygenase-2 IDV ratio, while a higher percentage of mast cells was detected in tumours showing high tumour/stroma cyclooxygenase-2 IDV ratio. Our study showed the usefulness of assessing cyclooxygenase-2 status both in tumour and stroma compartment in order to identify cervical cancer patients endowed with a very poor chance of response to neoadjuvant therapy and unfavourable prognosis.

Increased cyclooxygenase-2 (COX-2) expression is associated with chemotherapy resistance and outcome in ovarian cancer patients

BACKGROUND

Cyclooxygenase-2 (COX-2) expression is associated with aggressive clinicopathological parameters and unfavourable prognosis in several human malignancies. The aim of this study was to investigate the expression of COX-2 and its association with clinicopathological parameters, response to treatment, and clinical outcome in ovarian cancer patients.

PATIENTS AND METHODS

COX-2 expression was analysed by immunohistochemistry in 87 primary ovarian carcinomas from patients with measurable disease after primary laparotomy.

RESULTS

COX-2 immunoreaction was observed in 39 (44.8%) cases, and did not differ in distribution according to age, FIGO stage, debulking at time of surgery, presence of ascites, histotype or tumour grade. Both in patients cytoreduced at first surgery and in those undergoing only explorative laparotomy, the percentage of COX-2 positivity was significantly higher in non-responding than in patients responding to treatment (P = 0.043 and P = 0.0018, respectively). In multivariate analysis, only COX-2 positivity and older age retained an independent role in predicting a poor chance of response to treatment. There was no significant difference of clinical outcome according to COX-2 status in patients undergoing primary debulking while, in the subgroup of patients who underwent explorative laparotomy, COX-2-positive cases showed a shorter time to progression (P = 0.025) and overall survival (P = 0.025).

CONCLUSIONS

The assessment of COX-2 status could provide additional information in order to identify ovarian cancer patients with a poor chance of response to chemotherapy and potentially candidates for more individualised treatments.

Cyclooxygenase-2 (COX-2), epidermal growth factor receptor (EGFR), and Her-2/neu expression in ovarian cancer

OBJECTIVES

Cyclooxygenase-2 (COX-2) seems to be involved in critical steps of cancer onset and progression. Abnormalities of epidermal growth factor receptor (EGFR) and Her-2/neu have been actively investigated in ovarian cancer and associated with unfavorable clinical outcome. The involvement of COX-2 in ErbB family pathways has been proposed. We investigated by immunohistochemistry the expression of COX-2, EGFR, and Her-2/neu in a series of advanced primary ovarian cancers.

METHODS

The study included 76 consecutive stage IIIC-IV ovarian cancer patients with measurable disease after first surgery. Immunohistochemistry was performed on paraffin-embedded sections with rabbit antiserum against COX-2, murine monoclonal antibody (MoAb) 300G9 against Her-2/neu, and monoclonal antibody 108 against EGFR.

RESULTS

No association among COX-2, EGFR, and HER-2/neu was found. COX-2 positivity was found in a statistically significant higher percentage of unresponsive cases (80.0%) than in patients responding to chemotherapy (35.7%) (P = 0.0008). The association between COX-2 positivity and poor chance of response to treatment was retained in multivariate analysis. In the subgroup of patients who underwent explorative laparotomy COX-2-positive cases showed a shorter overall survival (P = 0.049).

CONCLUSIONS

COX-2 could represent a possible new marker of sensitivity to platin-based chemotherapy in ovarian cancer. The lack of association of COX-2 with EGFR or Her-2/neu suggests that the ability of COX-2 to predict tumor sensitivity to chemotherapy is not dependent on EGFR or Her-2/neu status and could be independently associated with prognosis. In this context, the availability of agents able to specifically interfere with COX-2, Her-2/neu, or EGFR tyrosine kinase is of potential interest.

Growth inhibitory effects and radiosensitization induced by fatty aromatic acids on human cervical cancer cells

Evidences have been reported that phenylacetic (PA) and phenylbutyric (PB) fatty aromatic acids can exert tumor growth inhibition in vitro and in vivo. Moreover, clinical trials also showed some activity for these drugs to modulate the expression of genes implicated in tumor growth, metastasis, immunogenicity, and to potentiate the efficacy of cytotoxic agents. The aim of the study was to examine the effects of PA and PB on the growth as well as sensitization to cisplatin and radiation in human cervical cancer cells. The effects of PA and PB on the proliferative activity and apoptosis induction in cervical tumor tissue was investigated. Both PA and PB exhibited a time- and dose-dependent antiproliferative activity in SW756 and ME180 cell lines: after 72-h treatment, the IC50 (concentration able to inhibit 50% of cell growth) of PB was 1.9 +/- 0.2 mM and 1.5 +/- 0.2 mM in SW756 and ME180 cells, respectively, while the IC50 of PA was 13.0 +/- 1.7 mM and 10.0 +/- 1.2 mM in SW756 and ME180 cells, respectively. In tumor tissue biopsies obtained from patients affected by squamous cervical cancer, both drugs resulted in a marked reduction of the percentage of bromodeoxyuridine-labeled cells compared with untreated samples [19.0 +/- 1.63% in untreated tissues with respect to 1.30 +/- 0.54% and 4.20 +/- 2.50% of stained cells after treatment with PA (30 mM) (P < 0.0001) and PB (5 mM) (P < 0.0001), respectively]. Moreover, analysis of the staining with M30 monoclonal antibody revealed that PA (30 mM) and PB (5 mM) were able to produce a marked increase in the number of stained apoptotic nuclei with respect to untreated samples. Finally, PB and PA were shown to enhance the sensitivity of SW756 to radiation and to exert an additive effect when combined with cisplatin. A significant reduction of the processed form of p21ras and rhoB proteins in the membrane fraction of cells exposed to PA and PB was observed. When farnesol, which is able to circumvent the enzymatic step inhibited by PA and PB, was added to the medium only a partial reversal of the growth inhibition and potentiation of sensitivity to radiation induced by PA and PB were found. In conclusion, the growth inhibitory properties of fatty aromatic acids suggest that these molecules could represent the prototype of a new class of compounds with some therapeutic potential in cervical cancer.

Increased cyclooxygenase-2 expression is associated with chemotherapy resistance and poor survival in cervical cancer patients

PURPOSE

To investigate the expression of cyclooxygenase (COX-2) and its association with clinicopathologic parameters and clinical outcome in patients with cervical cancer.

PATIENTS AND METHODS

The study included 84 patients with stage IB to IVA cervical cancer. Patients with early-stage cases (n = 21) underwent radical surgery, whereas patients with locally advanced cervical cancer (LACC) (n = 63) were first administered neoadjuvant cisplatin-based treatment and subjected to surgery in case of response. Immunohistochemical analysis was performed on paraffin-embedded sections with rabbit antiserum against COX-2.

RESULTS

COX-2--integrated density values in the overall population ranged from 1.2 to 82.3, with mean plus minus SE values of 27.4 plus minus 2.4. According to the chosen cutoff value, 36 (42.9%) of 84 patients were scored as COX-2 positive. COX-2 levels were shown to be highly associated with tumor susceptibility to neoadjuvant treatment. COX-2 showed a progressive increase from mean plus minus SE values of 19.9 plus minus 8.0 in complete responders through 31.5 plus minus 3.5 in partial responses to 44.8 plus minus 3.9 in patients who were not responsive (P =.0054). When logistic regression was applied, only advanced stage and COX-2 positivity retained independent roles in predicting a poor chance of response to treatment. COX-2--positive patients had a shorter overall survival (OS) rate than COX-2--negative patients. In patients with LACC, the 2-year OS rate was 38% in COX-2--positive versus 85% in COX-2--negative patients (P =.0001). In the multivariate analysis, only advanced stage and COX-2 positivity retained independent negative prognostic roles for OS.

CONCLUSION

The assessment of COX-2 status could provide additional information to identify patients with cervical cancer with a poor chance of response to neoadjuvant treatment and unfavorable prognosis.

Prognostic significance of cyclooxygenase-2 in laryngeal squamous cell carcinoma

Epidermal growth factor receptor (EGFR) overexpression is an unfavorable prognostic marker in laryngeal squamous cell carcinoma (SCC). EGFR stimulates cyclooxygenase-2 (COX-2) expression in normal human keratinocytes and squamous carcinoma cells. Based on these observations a prognostic role of COX-2 expression in laryngeal SCC can be hypothesized. Consequently, COX-2 expression was studied in laryngeal SCC (median follow-up = 47 months; range: 2-87 months) by quantitative immunohistochemistry (n = 61) and EGFR by binding assay (n = 51). Well-differentiated regions of laryngeal SCC revealed strong COX-2 immunostaining, whereas histologically normal areas neighboring tumor as well as poorly-differentiated tumors were negative. Immunohistochemical results were confirmed by Western blot analyses. Cox's regression analysis showed that the combination of low levels of COX-2 integrated density and high levels of EGFR covariates provided strong prediction, at 5-year follow-up, of both poor overall survival (chi(2) = 12.905; p = 0.0016) and relapse-free survival (chi(2) = 9.209; p = 0.01). In vitro studies on CO-K3 cell line, obtained from an EGFR positive, COX-2 negative poorly-differentiated laryngeal SCC, revealed that EGF stimulation failed to induce COX-2 expression and PGE2 production suggesting a change in EGFR signaling pathway. These findings indicate that COX-2 is overexpressed in less aggressive, low grade laryngeal SCC, whereas its expression is lost when tumors progress to a more malignant phenotype.

Human papillomavirus infection and epidermal growth factor receptor expression in primary laryngeal squamous cell carcinoma

PURPOSE

This study was designed to add new data about laryngeal carcinogenesis, a multistep process in which chemical and/or viral agents induce and promote successive alterations in growth factor-linked signal transmission pathways, genetic instability, and mutations in key genes involved in cell growth control. Epidemiological evidence suggests that human papillomavirus (HPV) infection may be associated with the development of laryngeal cancer.

EXPERIMENTAL DESIGN

In this report, we have analyzed the prevalence of HPV infection and epidermal growth factor receptor (EGFR) expression in a series of 42 laryngeal squamous cell carcinomas by PCR with HPV consensus primers and by a radioligand receptor assay, respectively.

RESULTS

HPV DNA was detected in 15 of 42 (35.7%) tumors, and it belonged almost exclusively to the highly oncogenic HPV-16, HPV-18, and HPV-33 genotypes. At analysis by Mann-Whitney nonparametric statistical test, EGFR level was found to be significantly higher in HPV-infected than in HPV-negative cases (T = 440; P = 0.002). EGFR overexpression (EGFR-positive status >6 fmol/mg protein, the arbitrary cutoff value chosen) was found in 20 of 42 (47.6%) tumors, and it was associated with HPV infection in a statistically significant extent (chi(2) = 4.686; P = 0.03).

CONCLUSIONS

Viral oncoproteins have been shown to induce a perturbation of the cell response to signals for growth and differentiation; these findings confirm that enhanced EGFR expression and activation in laryngeal squamous cell carcinoma may occur also as a consequence of HPV infection and support the hypothesis of an involvement of HPV infection in laryngeal carcinogenesis.

The role of growth factor administration and T-cell recovery after peripheral blood progenitor cell transplantation in the treatment of solid tumors: results from a randomized comparison of G-CSF and GM-CSF

BACKGROUND

Peripheral blood progenitor cell (PBPC) transplantation (PBPCT) combined with post-PBPCT administration of myelopoietic growth factors is a valid therapeutic intervention to rapidly restore hematopoiesis after the delivery of intensive, myeloablative cancer chemotherapy. On the other hand, the best growth factor regimen to potentiate PBPC-mediated immunohematopoietic recovery has yet to be determined.

STUDY DESIGN AND METHODS

In a randomized evaluation, the effects produced by post-PBPCT G-CSF and GM-CSF on myeloid/lymphoid recovery and transplant outcome in women with chemosensitive cancer were compared. Thirty-seven ovarian cancer patients and 34 breast cancer patients ranging in age from 24 to 60 years were treated with carboplatin, etoposide, and melphalan (CEM) high-dose chemotherapy and then randomly assigned to receive G-CSF (5 microg/kg subcutaneously) or GM-CSF (5 microg/kg subcutaneously) until Day 13 after PBPCT. Patients were compared in regard to hematopoietic recovery, posttransplant clinical management, and immune recovery. Finally, clinical outcome was estimated as time to progression and overall survival.

RESULTS

Hematopoietic recovery and posttransplant clinical management were comparable in both the G-CSF and GM-CSF series. Conversely, significantly higher T-cell counts were observed in G-CSF-treated patients during the early and late posttransplant follow-up. Patients who received G-CSF showed a significantly longer median time to progression. A parallel analysis revealed that patients in whom a higher CD3+ count was recovered had a significantly longer overall survival and time to progression.

CONCLUSION

The enhancement of post-PBPCT T-cell recovery observed in G-CSF-treated patients encourages the use of G-CSF to ameliorate immune recovery, which seems to play a role in post-PBPCT control of disease in cancer patients. GM-CSF might be administered to prolong immunosuppression after autologous PBPCT for autoimmune diseases or allogeneic PBPCT.

Prognostic significance of cyclooxygenase-2 in laryngeal squamous cell carcinoma

Epidermal growth factor receptor (EGFR) overexpression is an unfavorable prognostic marker in laryngeal squamous cell carcinoma (SCC). EGFR stimulates cyclooxygenase-2 (COX-2) expression in normal human keratinocytes and squamous carcinoma cells. Based on these observations a prognostic role of COX-2 expression in laryngeal SCC can be hypothesized. Consequently, COX-2 expression was studied in laryngeal SCC (median follow-up = 47 months; range: 2-87 months) by quantitative immunohistochemistry (n = 61) and EGFR by binding assay (n = 51). Well-differentiated regions of laryngeal SCC revealed strong COX-2 immunostaining, whereas histologically normal areas neighboring tumor as well as poorly-differentiated tumors were negative. Immunohistochemical results were confirmed by Western blot analyses. Cox's regression analysis showed that the combination of low levels of COX-2 integrated density and high levels of EGFR covariates provided strong prediction, at 5-year follow-up, of both poor overall survival (chi(2) = 12.905; p = 0.0016) and relapse-free survival (chi(2) = 9.209; p = 0.01). In vitro studies on CO-K3 cell line, obtained from an EGFR positive, COX-2 negative poorly-differentiated laryngeal SCC, revealed that EGF stimulation failed to induce COX-2 expression and PGE2 production suggesting a change in EGFR signaling pathway. These findings indicate that COX-2 is overexpressed in less aggressive, low grade laryngeal SCC, whereas its expression is lost when tumors progress to a more malignant phenotype.

Systematic pelvic and aortic lymphadenectomy in elderly gynecologic oncologic patients

BACKGROUND

Retroperitoneal lymph node dissection is a fundamental step in the surgical management of patients with pelvic gynecologic malignancies, but its applicability to geriatric patients is controversial. The objective of this study was to evaluate whether pelvic and aortic lymphadenectomy in elderly patients with gynecologic malignancies can be a safe procedure in terms of morbidity and mortality.

METHODS

In a retrospective case-control study, the authors compared morbidity, mortality, and surgical data in a series of elderly patients (age > 70 years) with endometrial and ovarian carcinoma who underwent surgery. Patients were divided into two groups: Cases were 36 elderly patients who underwent surgery and pelvic and/or aortic lymphadenectomy and were matched with 72 controls, who were patients who underwent surgery without lymphadenectomy.

RESULTS

Cases showed a significantly longer median operative time than controls (median, 162 minutes [range, 85-330 minutes] vs. median, 100 minutes [range 20-310 minutes], respectively; P = 0.003). No significant difference between the two groups in terms of blood loss, blood transfusions, intraoperative complications, duration of ileus, reintervention required, or postoperative hospital stay were observed. One patient in the control group died. The type and frequency of severe postoperative complications in the two groups were not substantially different.

CONCLUSIONS

Pelvic and aortic lymphadenectomy was performed safely in elderly patients age > or = 70 years with endometrial and ovarian carcinoma without an increase in morbidity and mortality. Advanced chronologic age alone should not be considered a contraindication to full surgical treatment in these patients.

Is there a place for a less extensive radical surgery in locally advanced cervical cancer patients?

OBJECTIVE

The aim of this study was to assess the association among the pathological status of different lymph node groups and parametrium in a single institutional population of 103 locally advanced cervical cancer (LACC) cases who underwent surgery after a neoadjuvant approach. A series of 29 early cervical cancer patients was also included in the analysis.

METHODS

Eighty-two LACC patients with documented clinical response to neoadjuvant treatment and 29 early stage cases underwent radical surgery. The operative technique consisted of a type II-V radical hysterectomy and systematic pelvic lymphadenectomy (median number of lymph nodes removed 46; range 5-140). Sixty-four cases were submitted to para-aortic lymphadenectomy up to the level of the inferior mesenteric artery (median number of lymph nodes removed 13; range 1-37).

RESULTS

Two subgroups of lymph nodes were defined: lower pelvic lymph nodes (LPN), including obturator and external iliac nodes, and upper pelvic nodes (UPN) including common iliac, presacral, and internal iliac nodes. Metastatic UPN involvement showed a strict association with LPN involvement: in LACC cases, 6 of 7 (86%) positive UPN cases had tumor disease at the LPN level. The single positive UPN case with negative LPN was intraoperatively identified by palpation and frozen section. Similarly, in early cervical cancer patients, 100% of positive UPN cases showed metastatic involvement at the LPN level. Sixty-three of 70 (90%) LACC patients with negative histological parametrium had negative LPN. Among 12 cases with metastatic involvement of parametrium, 5 cases (41.7%) had positive LPN. In early stage cervical cancer, 23 of 27 (85%) cases with negative parametrium showed no lymph nodal involvement. Intraoperative palpation of the parametrium could identify all cases with parametrial involvement not predicted by LPN status.

CONCLUSIONS

These data offer the basis for tailoring the extent of radical surgery in LACC patients, through the selection of those lymph node stations likely to provide reliable information on the pathological status of UPN and parametrium.

Tamoxifen modulates the expression of Ki67, apoptosis, and microvessel density in cervical cancer

PURPOSE

The aim of the study was to investigate if a short-term administration of high-dose Tamoxifen (Tam) could affect the expression of biologically relevant biochemical parameters in cervical cancer tissue.

EXPERIMENTAL DESIGN

The study was conducted in 24 patients with histologically confirmed cervical tumors. Biopsies were obtained by colposcopy on day 0 in all patients, who then received either 80 mg/die or 160 mg/die for 5 consecutive days until the second biopsy was obtained. Immunohistochemistry was performed with antiestrogen receptor (ER), anti-Ki67, anticaspase cleavage product of keratin 18 (M30), and anti-CD31 monoclonal antibodies.

RESULTS

Eleven (45.8%) of 24 cervical tumors were ER positive. The percentage of Ki67-positive tumor cells in pre-Tam biopsies was significantly higher than the percentage in the corresponding posttreatment biopsies (z = 4.29, P = 0.0001). No difference in the pretreatment percentage of Ki67-positive cells according to ER status was found. The percentage of M30 positivity was higher in post-Tam than in pre-Tam biopsies. Microvessel density values in pre-Tam biopsies were significantly higher than corresponding values in posttreatment tissues (z = -3.72, P = 0.0002). The reduction in the percentage of Ki67-positive tumors was significantly (z = 3.58, P = 0.0003) higher in ER-positive than in ER-negative tumors, whereas no difference in Tam-induced reduction of microvessel density values according to ER status (z = -0.18, P = 0.85) was found. Tam treatment did not induce any change of M30 positivity in ER-positive tumors, whereas in ER-negative tumors, it produced a significant (P = 0.015) increase in the percentage of M30-positive cells in post-Tam versus pre-Tam biopsies.

CONCLUSIONS

A short-term treatment with Tam at doses 4-8-fold higher than those in conventional schemes is associated with modifications of biological parameters associated with tumor cell proliferation, apoptosis, and neoangiogenesis in cervical cancer.

GLUT-1 expression in ovarian carcinoma: association with survival and response to chemotherapy

BACKGROUND

Cancer cell growth is an energy-related process supported by an increased glucose metabolism. The objective of this study was to investigate the association of GLUT-1 with response to chemotherapy and outcome in patients with ovarian carcinoma.

METHODS

Histologic sections of formalin fixed, paraffin embedded specimens from 113 primary ovarian carcinomas were stained for GLUT-1 by using polyclonal GLUT-1 antibody (Dako Co., Carpinteria, CA) and the labeled streptavidin biotin procedure. Intensity of GLUT-1 staining was compared with disease free survival (DFS), chemotherapy response, and other clinicopathologic characteristics.

RESULTS

GLUT-1 cytoplasmic membrane staining was observed in 89 of 104 (85.6%) malignant tumors. Poorly differentiated tumors showed a trend to overexpress the GLUT-1 protein compared with the more differentiated counterparts (27.6% vs. 8.7%; P = 0.08). Patients who experienced a complete clinical response to chemotherapy were more frequently GLUT-1 positive than GLUT-1 negative (80% vs. 51.5%; P = 0.036). In multivariate analysis of advanced stage disease, residual tumor (P = 0.0001) and high GLUT-1 expression levels (P = 0.028) were the only independent variables that maintained a significant association with response to chemotherapy (P = 0.0001; chi-square = 38.13). In the subgroup of Stage III-IV (International Federation of Gynecology and Obstetrics patients showing a complete clinical response, GLUT-1 overexpression was associated with a shorter DFS. The median time to progression was 30 months in GLUT-1 strongly positive cases (> 50% of cancer cells positive) versus 60 months in GLUT-1 weakly positive cases (< or = 50% of cancer cells positive; P = 0.024).

CONCLUSIONS

GLUT-1 status is an independent prognostic factor of response to chemotherapy in advanced stage ovarian carcinoma. Moreover, patients overexpressing GLUT-1 show a significantly shorter DFS. These results suggest that the assessment of GLUT-1 status may provide clinically useful prognostic information in patients with ovarian carcinoma.

Chemoprevention of DMBA-induced mammary cancer in rats by dietary soy

This study was designed to assess the potential chemopreventive effect of the administration of a standardized soy extract, SOYSELECT, on 7,12-Dimethylbenz[a]anthracene (DMBA)-induced mammary tumors in rats. Three groups, 24 females each, were used. Animals were fed either a phytoestrogen-free diet alone (control) or the same diet supplemented with 0.35% or 0.7% of soy extract. Treatment started at weaning and continued to the end of the study (24 weeks after DMBA administration). At day 50 of age all animals received via oral gavage 80 mg/kg DMBA. Only tumors subsequently classified as adenocarcinomas were considered for data evaluation. In rats on the soy diet, mammary tumors took a longer period of time to develop as compared to control rats. However, at the end of the study, no relevant difference in tumor incidence and multiplicity was observed among the groups. The most significant changes were seen between control and soy-treated groups when tumor dimension and results from histopathologic examination were considered. The latter, in fact, showed a dose-dependent reduction in the percentage of poorly differentiated tumors in treated animals. This change was statistically significant in animals receiving 0.7% soy. In addition, assessment of estrogen and progesterone receptor (ERalpha, PR) levels, revealed a significant reduction in the percentage of ERalpha and PR positive tumors in animals receiving 0.7% dietary soy, when compared to controls. Interestingly, genistein and daidzein plasma levels determined at the end of the study were within the range of those detected in people consuming large amounts of soyfoods.

High-dose chemotherapy as a consolidation approach in advanced ovarian cancer: long-term results

The aim of this study was to assess the long-term impact of high-dose chemotherapy (HDC) as consolidation in a large series (n = 55) of advanced chemosensitive ovarian cancer patients who were optimally cytoreduced at time of first surgery or at interval debulking surgery (IDS). HDC consisted of carboplatin (600 mg/m(2) days 1 and 2), etoposide (450 mg/m(2) days 1 and 2) and melphalan (50 mg/m(2), days 3 and 4). The primary endpoint of the study was the assessment of time to progression (TTP) and overall survival (OS). In September 2000 the overall population had a median follow-up of 55 months (range 17--137) and a TTP of 35 months with a 5-year TTP rate of 35% (CI 95%: 21--49) whereas OS averaged 75 months with a 5-year OS of 59% (CI 95%: 45--73). In patients achieving optimal primary cytoreduction the median TTP was 44 months with a 5-year rate of 43% (CI 95%: 26--60). In the same series the 5-year OS rate was 62% (CI 95%: 45--79) (median OS = 75 months). In patients who were optimally cytoreduced at the time of IDS the median TTP was 25 months and the 5-year TTP rate was 22% (CI 95%: 3--41) and median OS was 46 months with a 5-year OS rate of 50% (CI 95%: 27--73). HDC with hematopoietic support could represent an effective approach for the treatment of advanced optimally cytoreduced ovarian cancer patients with chemosensitive disease. Patients who underwent IDS because of unresectable tumors at the time of first surgery had the greater survival benefit from HDC.

Expression of bcl-2, bax-xL, and bcl-xS in endometrial and cervical tissues

We assessed the protein expression levels of bcl-2, bax, bcl-xL, and bcl-xS in a group of 51 endometrial cancers and 8 normal samples as well as in 59 cervical neoplasms and in 15 normal cervical tissues. Neoplastic endometria (median, 1.30 absorbance units [AU]; range, 0.13-7.26 AU) had slightly higher bcl-2 levels than did normal tissue (median, 0.83 AU; range, 0.29-1.90 AU; P < .068), whereas bcl-2 was lower in neoplastic (median, 3.59 AU; range, 0.13-19.86 AU) than in normal cervical samples (median, 8.45 AU; range, 2.09-15.04 AU; P < .010). Bcl-xL levels were higher in endometrial carcinoma (median, 1.23 AU; range, 0.03(4.29 AU) than in normal tissues (median, 0.56 AU; range, 0.46-1.48 AU; P < .048), whereas no significant difference was observed in cervical tissues. Bax levels did not show any variation in either system. The protein bcl-xS was marginally detectable in only a few samples. In endometrial carcinoma, bcl-2 and bcl-xL levels were correlated inversely (r = -0.27; P < .054), whereas in cervical cancer, they were correlated directly (r = +0.40; P < .002). The different expression patterns of bcl-2 family members in endometrial and cervical tissues confirm the hypothesis of a strictly tissue-specific regulation of these proteins.

Topotecan and gemcitabine in platinum/paclitaxel-resistant ovarian cancer

24 patients were enrolled into a phase I-II study conducted to determine the maximum tolerated doses of topotecan-gemcitabine in sequential combination and the response rate in platinum/paclitaxel resistant ovarian cancer patients. A total of 83 courses are evaluable, with a median number of three cycles administered per patients (range 2-7). Topotecan was administered on days 1-5 by 30 min i.v. infusion immediately after gemcitabine given by 30 min i.v. on days 1 and 3; cycles were repeated every 28 days. The starting doses were topotecan 0.7 mg/m(2) and gemcitabine 200 mg/m(2). Following dose levels were 08/400; 0.9/600; 0.9/800 for topotecan and gemcitabine, respectively. The maximum tolerated dose (MTD) was reached at dose level 3, the dose-limiting toxicity being represented by febrile neutropenia and thrombocytopenia. After the MTD was reached, granulocyte-colony-stimulating factor was administered in 27% of cycles. Mild and manageable was non hematological toxicity. All patients are so far evaluable for response. Among them 2 complete responses (8.3%; 95% CI: 2.6-19), 1 partial response (4.2%; 95% CI: 3.8-12), 9 no change (37.5%; 95% CI: 18-56.8) and 12 progressions (50%; 95% CI: 30-70) have been registered. Based on these data, there is no evidence that combining topotecan and gemcitabine is better than using either of the two drugs used separately.