Randomized trial of recombinant human interleukin-3 versus placebo in prevention of bone marrow depression during first-line chemotherapy for ovarian carcinoma

PURPOSE

To determine whether recombinant human interleukin-3 (rhIL-3) reduces bone marrow depression and improves chemotherapeutic schedule adherence in ovarian cancer patients receiving first-line combination chemotherapy.

PATIENTS AND METHODS

In a randomized multicenter study, 185 patients received carboplatin (dose based on projected area under the concentration-time curve [AUC]=4) and cyclophosphamide (750 mg/m2) day 1, every 3 weeks for six cycles. Patients were randomized to receive rhIL-3 (5 microg/kg) or placebo once daily subcutaneously on days 3 to 12.

RESULTS

Adherence to chemotherapeutic regimen, mean chemotherapy cycle length, tumor response rate, and median survival at 24 months did not differ between groups. The number of side effects-primarily allergic reactions, flu-like symptoms and fever-were higher in the rhIL-3 group, which resulted in 21 discontinuations compared with one in the placebo group. Compared with placebo, the rhIL-3 group had higher platelet counts day 1 of cycles 2 to 6. The number of patients with World Health Organization (WHO) grade IV thrombocytopenia or number of platelet transfusions did not differ. Leukocyte counts differed only in cycles 1 and 2 between groups. The leukocyte nadir occurred earlier in the rhIL-3 (day 12) than in the placebo group (day 15, P=.006). Leukocytes and neutrophils were only higher in the rhIL-3 group day 1 of cycle 2. In cycles 4 and 5, more patients with WHO grade IV neutropenia received rhIL-3 (P < .005). Eosinophil counts were higher day 1 of cycles 2 to 6 in the rhIL-3 group (P < .0001).

CONCLUSION

rhIL-3 had stimulatory hematopoietic effects. This did not result either in reduction of platelet transfusions or in improvement of chemotherapeutic schedule adherence. There were more side effects in the rhIL-3 group than in the placebo group. rhIL-3 at 5 microg/kg/d is, therefore, not of clinical benefit in this chemotherapeutic regimen.

Controlled multicentre study of the influence of subcutaneous recombinant human erythropoietin on anaemia and transfusion dependency in patients with ovarian carcinoma treated with platinum-based chemotherapy

This randomised controlled multicentre trial evaluated the effectiveness of recombinant human erythropoietin (rhEPO) in preventing anaemia and reducing the need for blood or erythrocyte transfusion in 122 ovarian cancer patients receiving platinum-based chemotherapy. The patients were randomly allocated to receive rhEPO 150 U/kg or 300 U/kg subcutaneously, three times a week, or open control. Patients also received up to 6 cycles of carboplatin or cisplatin, alone or in combination with other cytotoxic agents. Intention-to-treat analysis showed that 39.4% of patients in the control group received at least one blood transfusion, compared with 9.2% of patients treated with rhEPO. Patients treated with rhEPO experienced a significantly longer time to first erythrocyte transfusion than the control group and were less likely to experience nadir haemoglobin levels < 10 g/dl (P < 0.001 and < 0.05, respectively). A haemoglobin decrease < 1 g/dl during the first chemotherapy cycle, as well as a low baseline serum erythropoietin concentration, predicted a low transfusion need in rhEPO-treated patients but not in controls. During the study, 103 patients suffered at least one adverse event, but no serious, and only nine non-serious adverse events were considered possibly related to rhEPO therapy. These results indicate that treatment with rhEPO prevents anaemia, it reduces the need for blood or rhEPO erythrocyte transfusion in patients with ovarian cancer receiving platinum-based chemotherapy, and it is well tolerated. A starting dose of 150 U/kg of rhEPO, three times a week, may be recommended.

Immunohistochemical analysis of p53 protein in uterine sarcomas

This study was undertaken to evaluate the frequency and prognostic significance of p53 protein accumulation in uterine sarcomas. Immunostaining for p53 protein was performed on formalin-fixed, paraffin-embedded sections from 158 patients with verified uterine sarcomas using monoclonal p53 antibody (DO-1). Antigen retrieval was performed with microwave oven technique. Nuclear p53 protein accumulation was demonstrated in 45% of the cases, more often in carcinosarcomas (73%) than in leiomyosarcomas (38%) and endometrial stromal sarcomas (27%). A significant correlation was found between p53 protein accumulation and malignancy grade (P = 0.003), mitotic count (P = 0.007), and DNA ploidy (P = 0.007), but not to FIGO stage (P = 0.6). The 5-year survival was not influenced by level of p53 protein accumulation. In Cox multivariate analysis, free resection margins at primary surgery (P < 0.0001), tumor diameter (P = 0.002), malignancy grade (P = 0.0004), and age at diagnosis (P = 0.0001) were found to be of independent prognostic significance while p53 protein accumulation had no significance (P = 0.022). Our results indicate that p53 alterations may play an important role in the carcinogenesis of uterine sarcomas, but in our study p53 protein accumulation had no impact on prognosis.

Ten-year results of a randomised trial comparing cisplatin with cisplatin and cyclophosphamide in advanced, suboptimally debulked ovarian cancer

176 eligible patients with advanced suboptimally operated ovarian carcinoma were randomly allocated to receive either cisplatin 75 mg/m2 or cisplatin 50 mg/m2 and cyclophosphamide 500 mg/m2 (CP) every 28 days for six courses. The overall clinical response rates (complete response plus partial response) were 52 and 63% for CP and cisplatin, respectively (non-significant). Including results obtained by second-look laparotomy, we did not observe a statistically significant difference in response rates in the two treatment groups. Median progression-free survival was 10 and 11.9 months for CP and cisplatin, respectively (non-significant). No significant difference was observed in overall survival, with a median of 19.4 and 21.5 months for CP and cisplatin, respectively. Thirty-seven platinum-resistant and 27 platinum-sensitive tumours were treated with carboplatin or cisplatin as second-line therapy. Response rates to platinum second-line therapy were 6 and 50% for resistant and sensitive tumours, respectively (P < 0.001). This difference in response rate was also confirmed by survival analysis. Patients with platinum-sensitive tumours survived longer when they were treated with platinum-containing chemotherapy (P = 0.005). Median survival was 22.8 and 8.5 months after initiation of second-line treatment for the platinum-containing and platinum-free regimens, respectively. In summary, we observed in suboptimally operated ovarian carcinoma patients similar response rates, progression-free interval, and overall survival for equitoxic cisplatin and CP. However, the doses of cisplatin and cyclophosphamide chosen were substantially lower than current standard doses of CP. Our study demonstrates, therefore, that a suboptimal dose of CP is as effective as optimal dose monotherapy cisplatin. Patients with recurrences considered as platinum-sensitive had a significantly higher response rate and improved survival when retreated with platinum-containing therapy.

A review of caveats in statistical nuclear image analysis

A large body of the published literature in nuclear image analysis do not evaluate their findings on an independent data set. Hence, if several features are evaluated on a limited data set over-optimistic results are easily achieved. In order to find features that separate different outcome classes of interest, statistical evaluation of the nuclear features must be performed. Furthermore, to classify an unknown sample using image analysis, a classification rule must be designed and evaluated. Unfortunately, statistical evaluation methods used in the literature of nuclear image analysis are often inappropriate. The present article discusses some of the difficulties in statistical evaluation of nuclear image analysis, and a study of cervical cancer is presented in order to illustrate the problems. In conclusion, some of the most severe errors in nuclear image analysis occur in analysis of a large feature set, including few patients, without confirming the results on an independent data set. To select features, Bonferroni correction for multiple test is recommended, together with a standard feature set selection method. Furthermore, we consider that the minimum requirement of performing statistical evaluation in nuclear image analysis is confirmation of the results on an independent data set. We suggest that a consensus of how to perform evaluation of diagnostic and prognostic features is necessary, in order to develop reliable tools for clinical use, based on nuclear image analysis.

An evaluation of prognostic factors in uterine carcinosarcoma

The traditional clinical and histopathological prognostic variables and DNA ploidy were analyzed in 46 patients with histologically verified uterine carcinosarcoma. Twenty-three tumors were of the homologous and 23 of the heterologous type. Evaluable flow cytometric DNA histograms from paraffin-embedded tumor tissue were obtained in 39 patients. The overall 5-year cancer related survival was 31%. All tumors were of high malignancy grade. In univariate analysis of survival, extrauterine spread of tumor (P = 0.007), age (P = 0.008), and tumor diameter (P = 0.04) obtained statistical significance. Tumors with components of serous or clear cell carcinomas had a less favorable prognosis (P = 0.017). There was no difference in survival between patients with homologous and heterologous tumors (P = 0.39). Mitotic count, vessel invasion, and DNA ploidy did not obtain prognostic significance. In Cox multivariate analysis, extrauterine spread of tumor (P = 0.004) and age (P = 0.004) were found to be the most important prognostic factors followed by content of serous or clear cell carcinoma components (P = 0.027).

TP53 protein accumulation and gene mutation in relation to overexpression of MDM2 protein in ovarian borderline tumours and stage I carcinomas

Three hundred and seventy-four early-stage ovarian tumours, including 27 borderline tumours and 347 stage I carcinomas, were investigated immunohistochemically for overexpression of the TP53 and MDM2 proteins. TP53 (p53) and MDM2 alterations were detected in 15 and 4 per cent of borderline tumours, and in 50 and 13 per cent of stage I carcinomas, respectively. Mutations in the TP53 gene (exons 5-8) were demonstrated in 29 of the 50 stage I carcinomas studied, using denaturing gel electrophoresis followed by direct sequencing. TP53 overexpression was seen less often in tumours of mucinous and endometrioid type than in tumours of other histological types and more often in moderately and poorly differentiated than in well differentiated tumours. MDM2 protein overexpression was seen more often in clear cell carcinoma than in tumours of other histological types. These results indicate that TP53 abnormalities play a crucial role, and MDM2 abnormalities a minor role, in the development of early-stage ovarian carcinoma. There was no significant association between TP53 or MDM2 alterations and survival in multivariate analysis.

Microsatellite instability in cervical and endometrial carcinomas

Microsatellite instability has been found preferentially in tumours associated with the hereditary non-polyposis-colorectal-cancer (HNPCC) syndrome. This phenotype, manifested as new alleles at microsatellite loci, and often the result of a defective mismatch-repair gene, is seen as allelic mobility shifts during electrophoretic runs. We examined possible alterations at 8 dinucleotide loci mapping to 6 different chromosomes in endometrial cancers (n = 20) and cervical cancers (n = 82). Overall instability was found in 30% of the endometrial cancers and in 6% of the cervical cancers, including 3 (15%) and 2 (2%) tumours, respectively, unstable at more than one locus. In contrast to the endometrial cancer sub-group, the affected cervical cancers were characterized by one or two new alleles at one or few loci. By DNA ploidy measurements 5 diploid endometrial cancers were microsatellite-unstable vs. one diploid of 6 unaltered cases (p = 0.015; Fisher's exact test). Our data confirm that a sub-set of diploid sporadic endometrial cancers are characterized by a mutator phenotype similar to that found in colorectal cancer. In contrast, among cervical cancers, not characterized by the HNPCC-tumour spectrum, this mutator phenotype is seen infrequently, and positive cases appear to display only minor alterations.

TP53 protein accumulation and gene mutation in relation to overexpression of MDM2 protein in ovarian borderline tumours and stage I carcinomas

Three hundred and seventy-four early-stage ovarian tumours, including 27 borderline tumours and 347 stage I carcinomas, were investigated immunohistochemically for overexpression of the TP53 and MDM2 proteins. TP53 (p53) and MDM2 alterations were detected in 15 and 4 per cent of borderline tumours, and in 50 and 13 per cent of stage I carcinomas, respectively. Mutations in the TP53 gene (exons 5-8) were demonstrated in 29 of the 50 stage I carcinomas studied, using denaturing gel electrophoresis followed by direct sequencing. TP53 overexpression was seen less often in tumours of mucinous and endometrioid type than in tumours of other histological types and more often in moderately and poorly differentiated than in well differentiated tumours. MDM2 protein overexpression was seen more often in clear cell carcinoma than in tumours of other histological types. These results indicate that TP53 abnormalities play a crucial role, and MDM2 abnormalities a minor role, in the development of early-stage ovarian carcinoma. There was no significant association between TP53 or MDM2 alterations and survival in multivariate analysis.

Early detection of familial ovarian cancer

When ovarian cancer is detected at an early stage, prognosis is good, which has led to discussion of a screening programme. The aim of this study was to identify and examine women at high risk of familial ovarian cancer, and to evaluate the inclusion criteria and the diagnostic methods for early detection of ovarian cancer. We report the first round screening findings in a prospective study of 180 women (mean age 43.4 years) considered to be at high risk of ovarian cancer based on family history. They were subjected to gynaecological examination with transvaginal ultrasound (TVU), CA125 and breast examination. Of these, 13 women with oestrogen receptor positive breast cancer had therapeutic oophorectomy and the ovaries were histologically examined. Among 180 women examined, nine ovarian cancers (among them two found at oophorectomy because of breast cancer) (mean age 49.0 years), seven benign tumours of the ovary (mean age 48.1 years), one cancer of the cervix, and four breast cancers were diagnosed. The prevalence of ovarian cancers (5%) was significantly more than in any previous series. TVU as a diagnostic method proved useful and detected 7/9 cancers, whereas CA125 was elevated in 4/9 cancers. To our knowledge, this is the first programme which has successfully delineated a high risk group and prospectively demonstrated their high prevalence of ovarian cancer. Possible biases are discussed.

The prognostic significance of surgery, tumor size, malignancy grade, menopausal status, and DNA ploidy in endometrial stromal sarcoma

To evaluate the prognostic significance of DNA ploidy in endometrial stromal sarcoma, the traditional clinical and histopathological prognostic variables and DNA ploidy in 48 patients with histologically verified endometrial stromal sarcoma were analyzed. Evaluable flow cytometric DNA histograms from paraffin-embedded tissue from the tumor were obtained in 47 patients. In univariate analysis, malignancy grade (P < 0.001), cellular atypia (P < 0.001), tumor diameter (P = 0.001), and mitotic count (P = 0.002) were highly significant. Also menopausal status (P = 0.011), FIGO stage (P = 0.035), and free resection margins at primary surgery (P = 0.026) obtained significance, while vessel invasion and age did not. DNA ploidy was not significant. In Cox multivariate analysis, free resection margins at primary surgery were found to be the most important prognostic factor (P < 0.001), followed by malignancy grade (P = 0.002), tumor diameter (P = 0.019), and menopausal status (P = 0.019). DNA ploidy did not obtain significance. Free resection margins at primary surgery, malignancy grade, tumor diameter, and menopausal status are important prognostic factors in endometrial stromal sarcoma.

Evaluation of the prognostic significance of cathepsin D, epidermal growth factor receptor, and c-erbB-2 in early cervical squamous cell carcinoma. An immunohistochemical study

BACKGROUND

This study evaluated the prognostic significance of immunohistochemical staining for cathepsin D, epidermal growth factor receptor (EGFR), and c-erbB-2 in patients with early cervical squamous cell carcinoma.

METHODS

This retrospective analysis comprised 132 patients, all subjected to radical hysterectomy with bilateral pelvic lymphadenectomy for International Federation of Gynecology and Obstetrics (FIGO) Stage IB cervical squamous cell carcinoma. Immunohistochemical staining was correlated with various histopathologic and morphologic characteristics (i.e., tumor size, grade of differentiation, vessel invasion, invasion into parametria, and lymph node metastasis) and relapse free survival.

RESULTS

Positive staining for cathepsin D was observed in 47% of tumors, more frequent in tumors giving rise to lymph node metastases. The relapse free survival was lower for patients with cathepsin D positive tumors. Overexpression of EGFR was observed in 25.8% of the tumors. There was no correlation with any of the histopathologic variables investigated. Relapse free survival was lower for patients with tumors overexpressing EGFR. Immunohistochemical staining for c-erbB-2 was observed in 12.1% of tumors with no correlation with relapse free survival. In multivariate analysis, immunostaining of cathepsin D and EGFR obtained independent prognostic significance, and considered together (both negative, one positive, or both positive) was the strongest prognostic factor after tumor size.

CONCLUSIONS

Immunohistochemical staining for cathepsin D and EGFR is useful as a tool for evaluation of tumor aggressiveness in patients with early cervical squamous cell carcinoma.

Human papilloma virus has no prognostic significance in cervical carcinoma

The prognostic significance of the detection of HPV (human papilloma virus) DNA in cervical carcinoma was evaluated in 223 cases treated from January 1988 to November 1989. HPV DNA was detected by PCR (polymerase chain reaction) on fresh tumour specimens obtained before therapy was started. HPV DNA of any type was detected in 93.3% of all tumours, HPV16 was the predominant type and was detected in 69% of cases. HPV18 was more frequent in adeno- and adenosquamous carcinoma than in squamous cell carcinoma and occurred more often in poorly differentiated tumours than in more highly differentiated tumours. Patients with HPV negative tumours were on average older than patients with tumours containing HPV. Neither presence of HPV DNA nor HPV type had prognostic significance. In 63 women with early stage tumours submitted to surgery, no difference was found in the frequency of lymph node metastasis, vessel invasion or prognosis related to HPV type. We conclude that neither the presence nor the type of HPV DNA had any prognostic significance in cervical carcinoma.

Evaluation of the prognostic significance of nm23/NDP kinase protein expression in cervical carcinoma: an immunohistochemical study

The objective of this study was to evaluate the prognostic significance of immunohistochemical staining for nm23/nucleoside diphosphate (NDP) kinase in cervical carcinoma. A retrospective analysis of 176 patients with cervical carcinoma FIGO stage IB treated with radical hysterectomy and pelvic lymphadenectomy from 1987 to 1990 was conducted. Immunohistochemical staining using the polyclonal nm23-H1/NDP kinase A antibody was correlated to various histopathological and morphological characteristics (tumor size, histologic type, grade of differentiation, vessel invasion, invasion into parametria, and lymph node metastasis) and relapse-free survival. For controls, sections were obtained from 10 hysterectomy specimens with normal cervical epithelium. Staining for nm23/NDP kinase was observed in 90% of control cases and in 70.5% of cases of cervical carcinoma, more frequent in squamous and adenosquamous cell carcinoma than in adenocarcinoma and more frequent in poorly differentiated than in more highly differentiated tumors. There were no differences related to size of tumor or invasion into vessels or parametria or occurrence of lymph node metastasis. The relapse-free survival was lower for patients with squamous cell and adenosquamous tumors with positive immunostaining for nm23/NDP kinase than for those with negative tumors when evaluated in univariate analysis. In multivariate analysis with tumor size, vessel invasion, invasion into parametria, grade of differentiation, and lymph node metastasis included, this difference was no longer significant. In patients with adenocarcinoma no difference was found. In conclusion, we did not find immunostaining for nm23/NDP kinase to be a useful indicator for prognosis in cancer of the uterine cervix.

Malignant melanoma of the vulva FIGO stage I: Evaluation of prognostic factors in 43 patients with emphasis on DNA ploidy and surgical treatment

Forty-three cases of malignant melanoma of the vulva FIGO stage I, primary treated from 1956 to 1987, have been reviewed. Initial surgery was local excision in 14 patients, vulvectomy in 14, and radical vulvectomy with inguinal lymph node dissection in 15. Recurrent disease was seen in 27 (63%) patients. The 5-year corrected survival was 63%; 10-year survival was 52%. Independent prognostic factors for disease-free and long-term survival were angioinvasion and DNA nondiploidy. Tumor thickness was of prognostic importance in univariate analysis, but did not obtain independent significance. Initial surgical modality did not influence long-term survival, but affected disease-free survival significantly. Local excision carried the greatest risk of local recurrence, but in some of these patients secondary surgery was successful. Because radical surgery did not improve long-term prognosis, wider local excision or vulvectomy seems to be the recommended surgical approach.

Cisplatin/5-fluorouracil treatment of recurrent cervical carcinoma: a phase II study with long-term follow-up

OBJECTIVE

To evaluate the response rate and corrected survival in patients with recurrent cervical carcinoma (RCC) treated with 100 mg/m2 cisplatin (CDDP) i.v. on Day 1 and 1000 mg/m2 5-fluorouracil (5-FU) i.v. on Days 1 to 5.

METHODS

A phase II study of CDDP/5-FU in RCC was initiated in 1986. Up to December 1991, a total of 72 patients were enrolled. Of these, 65 were evaluable for response.

RESULTS

The overall response rate was 49%. For 9 patients with complete remission, the median duration of response was 16 months, range 6 to 79+. The corresponding figures for 26 patients with partial remission were 10 months, range 3 to 80 months. By multivariate analysis, FIGO stage, disease-free interval, WHO performance status, and number of lesions at recurrence were independent prognostic variables. Twenty-two percent of the patients survived for more than 2 years and 9% for more than 5 years. Toxicity was tolerable. Leucopenia, ototoxicity, and neurotoxicity were the main problems.

CONCLUSION

A high response rate (49%) was observed with CDDP/5-FU treatment in patients with RCC with 9% of the patients surviving for more than 5 years.

A phase II study of carboplatin and hexamethylmelamine as induction chemotherapy in advanced epithelial ovarian carcinoma

27 patients with ovarian cancer FIGO stages IIc-IV were treated with carboplatin 7 x (glomerular filtration rate + 25) mg given intravenously on day 1 and hexamethylmelamine (HMM) 150 mg/m2 orally on days 2-15, every 28 days. 3 patients were not evaluable for response. Clinical response was seen in 17 patients (71%), with six (25%) complete and 11 (46%) partial responses. The median progression-free survival was 15.6 months and the median cancer-related survival was 21.3 months. 4 patients (15%) experienced grade 3 mental depression; none had peripheral neuropathy above grade 1. The haematological toxicity was moderate, none had grade 4 leucopenia, but 4 (15%) had grade 4 thrombocytopenia. Carboplatin plus HMM had few side-effects and a high response rate with a survival comparable to other platinum-based combinations.

No prognostic impact of flow-cytometric measured DNA ploidy and S-phase fraction in cancer of the uterine cervix: a prospective study of 465 patients

In a prospective study of 465 patients with invasive carcinoma of the uterine cervix, the prognostic impact of flow cytometric parameters (ploidy level and fraction of S-phase cells) and clinical variables was evaluated. Median follow-up time was 57 (32-80) months. A total of 230 patients died of cervical cancer during follow-up. Ploidy level had no prognostic significance, neither when analyzed as diploid against nondiploid nor when utilizing different cutoff levels for DNA index (1.3, 1.5, and 1.7). The fraction of S-phase cells (SPF) could be evaluated in 91% of the diploid cases but in only 22% of nondiploid cases. SPF had no prognostic impact. In multivariate analysis, FIGO stage was the only independent prognostic factor (P < 0.001). There was no difference between squamous cell, adeno, and adenosquamous carcinomas. A radical hysterectomy with pelvic lymphadenectomy was performed in 123 cases in stage I-IIA. In this subgroup, tumor size (P = 0.001), infiltration into the parametria (P = 0.005), vessel invasion (P = 0.008), and metastasis to the common iliac nodes (P = 0.013) obtained independent statistical significance in multivariate analysis, while ploidy level had no significance. Neither DNA ploidy nor S-phase analyses should be used in treatment planning.

The prognostic significance of residual disease, FIGO substage, tumor histology, and grade in patients with FIGO stage III ovarian cancer

Survival was evaluated in 455 patients with FIGO stage III invasive ovarian cancer managed between 1983 and 1991. Median follow-up was 73 months. The prognostic significance of clinical and histopathological variables was evaluated. In Cox multivariate analysis, FIGO substage was an independent prognostic factor with a relative hazard (RH) of 1.2 and 1.7 for substage IIIB and IIIC, respectively (P = 0.013). Size of residual disease after surgery was a stronger factor with an RH of 1.2 and 2.4 for residual disease of 0 to 2 cm and more than 2 cm, respectively (P < 0.001). Histologic type had prognostic significance because patients with endometrioid tumors did best, those with mixed, serous, and unclassified tumors had an RH of 1.5 to 1.9, and those with mucinous and clear cell tumors had an RH of 5.4 to 7 (P < 0.001). Grade, ascites, and age had also independent significance. Grade had an RH of 2.5 for grade 2 plus 3 (P < 0.001), ascites had an RH of 1.4 (P 0.018), and age had an RH of 1.7 and 2.4 for age 40 to 70 years and above 70 years, respectively (P < 0.001).

Malignant melanoma of the vulva. Evaluation of prognostic factors with emphasis on DNA ploidy in 75 patients

BACKGROUND

To the authors' knowledge, the potential prognostic value of DNA ploidy in vulvar melanoma has not been evaluated in previous series.

METHODS

Clinical data and follow-up information were retrieved from the hospital records of 75 patients treated from 1956 to 1987. Histopathologic specimens were reviewed for histologic type, depth of invasion, vessel invasion, and ulceration. Flow cytometric DNA measurements were performed on paraffin embedded samples.

RESULTS

Forty-three patients had International Federation of Gynecology and Obstetrics Stage I disease, 14 Stage II, 8 Stage III and 10 Stage IV. Sixty-five patients were treated by surgery, six by radiotherapy, and four patients with advanced disease received no therapy. The surgical procedure was local excision in 17 patients, vulvectomy in 22, and radical vulvectomy with inguinal lymph node dissection in 26. Five- and 10-year corrected survival rates were 46% and 37%, respectively. Recurrences were seen in 43 (66%) of the patients treated by surgery. Independent prognostic factors for corrected survival in the entire group of 75 patients were inguinal lymph node metastases (P = 0.016), angioinvasion (P = 0.027), tumor localization to clitoris, and multifocal tumors (P = 0.043). For the 65 patients treated by surgery, independent prognostic factors for disease free survival were angioinvasion (P < 0.001), age at diagnosis (P = 0.003), DNA ploidy (P = 0.004), and ulceration (P = 0.027). The independent prognostic factors for long term survival were tumor localization to clitoris (P = 0.018), DNA ploidy (P = 0.045), and inguinal lymph node involvement (P = 0.053). Radical surgery did not improve disease free or long term survival.

CONCLUSIONS

DNA ploidy is an independent factor that predicts prognosis in patients with vulvar melanoma, and should be considered together with previously known factors. Radical surgery does not improve prognosis and is not recommended when the inguinal lymph nodes are clinically negative.

The prognostic significance of stage, tumor size, cellular atypia and DNA ploidy in uterine leiomyosarcoma

To analyze the significance of DNA ploidy in uterine leiomyosarcoma, the traditional clinical and histopathological prognostic variables and DNA ploidy were studied in 70 patients with histologically verified uterine leiomyosarcoma. Evaluable flow cytometric DNA histograms from paraffin-embedded tissue from the tumor were obtained in 58 patients. In univariate analysis tumor diameter, FIGO stage and presence of residual disease after primary surgery were highly significant (p < 0.001) and also DNA ploidy (p = 0.043), age (p = 0.017), and menopause status (p = 0.028) obtained significance. Cellular atypia was almost significant (p = 0.056), while mitotic count, malignancy grade and vessel invasion were not. In Cox's multivariate analysis, FIGO-stage was found to be the most important prognostic factor (p < 0.001), followed by cellular atypia (p = 0.007) and tumor diameter (p = 0.016). DNA ploidy did not obtain significance when categorized as diploid/non-diploid. Patients with tumors with multiple aneuploid cell populations had a very poor prognosis. When categorized as multiple aneuploidy versus all other ploidy groups, DNA ploidy obtained marginal significance in multivariate analysis (p = 0.054). Tumor diameter, stage and cellular atypia are important prognostic parameters in uterine leiomyosarcomas.

Flow cytometric DNA ploidy and S-phase heterogeneity in advanced ovarian carcinoma

BACKGROUND

The prognostic significance of flow cytometric DNA ploidy and S-phase fraction (SPF) in ovarian cancer has been controversial. In the current study, the authors analyzed tumor heterogeneity in respect to DNA index DI and SPF.

METHODS

Flow cytometric variation in DI and SPF among representative fresh tumor material from the primary tumor, metastasis, and malignant effusions from the same patient was analyzed.

RESULTS

One hundred thirty-two samples from 47 patients were analyzed, and 119 samples from 42 patients were evaluable. Stable DI between different samples was found in 34 patients, whereas heterogeneity was found in 8 patients (19%). The metastases showed stable DNA content. The malignant effusion samples often lacked tumor cells. The representative ones were often DNA diploid. In 21% of the aneuploid samples, the SPF could not be analyzed. In 38% of the aneuploid samples, the stem line constituted less than 15% of measured nuclei. In these samples, a negative correlation between SPF and percentage of aneuploid cells was found, making SPF unreliable. Correct SPF measurement was thus possible in only 41% of the aneuploid samples, and in these tumors, SPF values varied considerably among different samples from the same patient, illustrated by a median SPF difference of 11% (range, 0-28%).

CONCLUSIONS

Tumor DI heterogeneity existed in 19% of tumors. SPF depended on the amount of aneuploid cells in case of small stem lines and varied considerably, making its use as a prognostic factor doubtful. To ensure that all tumor stem lines are represented, at least two biopsy specimens from any solid tumor should be analyzed.

Evaluation of deoxyribonucleic acid ploidy and S-phase fraction as prognostic parameters in advanced epithelial ovarian carcinoma: a prospective study

OBJECTIVE

Our goal was to study the prognostic value of deoxyribonucleic acid ploidy and S-phase fraction in advanced ovarian carcinoma.

STUDY DESIGN

Prognostic factors for corrected survival were evaluated in a prospective study including 169 patients with stage III and IV ovarian cancer treated between 1985 and 1990.

RESULTS

A total of 79% of the tumors were deoxyribonucleic acid aneuploid. Deoxyribonucleic acid aneuploidy was associated with grade of differentiation. S-phase fraction could be calculated in all deoxyribonucleic acid euploid tumors and 76% of the deoxyribonucleic acid aneuploid tumors. By multivariate analysis deoxyribonucleic acid ploidy, histologic type and grade, age, International Federation of Gynecology and Obstetrics stage, and amount of residual tumor were independent prognostic variables for corrected survival. On the basis of Cox regression a relative risk for the individual patient could be calculated.

CONCLUSION

Deoxyribonucleic acid ploidy gives additive prognostic information and is a useful parameter for dividing patients with advanced ovarian cancer into risk groups for treatment decisions.

A randomised study of cisplatin versus thiotepa as induction chemotherapy in advanced ovarian carcinoma

Between 1980 and 1984, a total of 171 patients with advanced epithelial ovarian carcinoma and residual tumour after surgery were randomly assigned to treatment groups receiving either cisplatin or thiotepa. The objective of the study was to evaluate the regimes with regard to response and survival. The two groups were well balanced with respect to age, FIGO stage, histology, grade and residual tumour after surgery. In the cisplatin group, 66% responsed to treatment compared to 38% in the thiotepa group (P < 0.00005). The median progression-free survival was 10.5 months and 6.3 months, respectively. The corrected survival was somewhat, but non-significantly, higher in the cisplatin group than in the thiotepa group, with an 8-year corrected survival of 10.6 and 7.4%, respectively. In a multivariate analysis, based on progression-free survival with FIGO stage, residual tumour after surgery, histological type and grade as covariables, treatment with thiotepa had a relative risk of 1.64 compared to cisplatin (95% confidence interval 1.17-2.30, P = 0.004).