Para-aortic nodal metastases in cervical cancer: a blind spot in the International Federation of Gynecology and Obstetrics staging system: current diagnosis and management

In cervical cancer, para-aortic nodal (PALN) metastases at presentation is a strong indicator of poor prognosis. Despite this, International Federation of Gynecology and Obstetrics staging system does not require evaluation of lymph node involvement and does not incorporate clinically detected PALN into the staging system. In the USA, despite screening, a significant number of women still present at an advanced stage often with nodal metastases. While the presence of PALN metastases often indicates occult systemic disease, it is possible with modern therapies to provide long-term control of disease in a percentage of patients. We review the epidemiology, diagnosis and treatment of PALN metastases in cervical cancer outlining advances in modern imaging and combined modality therapies (surgery, chemotherapy and radiation therapy).

Abstract 5605: Spectral karyotyping characterization of ovarian adenocarcinomas and corresponding cell lines and xenografts

Ovarian cancer is the 9th leading cancer and the 5th cause of cancer deaths in women in the USA. To understand tumor biology, identify oncogenic driver pathways and verify response to drugs, numerous in vitro (cell lines) and in vivo (xenograft in mouse) models have been developed and extensively used. In this study, we aimed to cytogenetically characterize ovarian carcinomas and their respective in vitro and in vivo models to investigate how representative the models are of their originating source.

Ascitic fluid was collected from 10 women with previously untreated high grade serous papillary adenocarcinomas of the ovary that presented with malignant ascites (stage 3). Ascitic fluid was subjected to differential centrifugation and plating to enrich for the tumor cell population (TCP). The TCP cells were cultured and considered permanent cell lines (CLP) when grew continuously without evidence of a non-malignant component and could be recovered from cryopreservation. TCP cells were also inoculated intraperitoneally into athymic nude mice and tumors harvested and cryopreserved (XCP). Eight pairs of TCP and CLP and two triplets of TCP, CLP and XCP specimens were characterized by spectral karyotyping (SKY), for a total of 22 specimens.

Highly rearranged karyotypes were detected in all specimens. All matched pairs and triplets were obviously related, sharing most of the structural (SA) and numerical (NA) abnormalities identified. Numerous examples of evolution from simple to complex chromosomal rearrangements and of multiple rearrangements originating from a single breakpoint were detected. For 9 patients, TCP and CLP specimens had the same ploidy level (near-2n in 4, near-3n in 3 and near 4n in 2); for one patient, the ploidy changed from near-2n (TCP) to near-4n (CLP). The 2 xenografts had same ploidy as their matched TCP and CLP specimens. In individual analyses, specific SA accounted for <10% of total SA in 8 specimens, for 10-30% in 8 and for >30% in 6. Specific NA accounted for <10% of total NA in 13 specimens, for 10-30% in 6 and for >30% in 3. In the TCP-CLP analyses, 3 pairs were very similar, differing by <10% of specific abnormalities; 5 pairs differed by 10-30% and 2 pairs by >30%. Higher frequency of abnormalities was detected in the TCP specimen for 4 pairs, and in the CLP for 3 pairs. One xenograft was very similar to both TCP and CLP, while the other was closer to the CLP.

In conclusion, the ovarian adenocarcinomas were highly rearranged chromosomally and highly heterogeneous. In vitro (CLP) and in vivo (XCP) models maintained a core of the TCP's SA and NA but also displayed unique events, quantitatively and qualitatively variable in distinct tumors, indicating evidence of ex vivo tumor cell selection or progression events. These findings have implications for using established tumor models in research, as well as for potentially identifying the driver rearrangements in specific tumors.

Citation Format: Marileila Varella-Garcia, Isabel M. Bernal, Sakshi Mahale, Evelyn M. Musselwhite, Victor Stastny, Mahboubeh Papari-Zareei, Jayanthi Lea, Tito Woodburn, Patrick Reynolds, Adi F. Gazdar. Spectral karyotyping characterization of ovarian adenocarcinomas and corresponding cell lines and xenografts. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5605. doi:10.1158/1538-7445.AM2014-5605

Stabilization media increases recovery in paucicellular cerebrospinal fluid specimens submitted for flow cytometry testing

BACKGROUND

Flow cytometric immunophenotpying (FCI) of cerebrospinal fluid (CSF) and other paucicellular fluids has been demonstrated to have increased sensitivity in detection of lymphoma and leukemia when compared to cytomorphology [(1) de Graaf et al., Cytometry Part B 2011, 80B:271-281; (2) Szamosi et al., CLSI Document H56-A-Body Fluid Analysis for Cellular Composition; Approved Guideline, Wayne, PA: Clinical and Laboratory Standards Institute, 2006; (3) Kraan et al., Flow Cytometric Immunophenotyping of Cerebrospinal Fluid. Current Protocols in Cytometry, Hoboken, NJ: Wiley, 2008]. However, low cellularity has been an historical problem with these samples. Several studies indicate that immediate addition of a stabilization media (e.g., RPMI with fetal calf serum (FCS)) to CSF improves the cell yield for FCI [(1) de Graaf et al.]. Such stabilization medias can, however, significantly increase cost.

METHODS

We compared FCI results in CSF stabilized with RPMI 1640 (without additional additives) to results obtained using non-stabilized CSF. Samples were processed according to published CLSI guidelines [(2) Szamosi et al.].

RESULTS

About 98/105 (93%) CSF specimens stabilized with RPMI had adequate numbers of viable cells (>100) for performing FCI. About 65/217 (30%) CSF specimens without stabilization had adequate numbers of viable cells for analysis (70% either quantity not sufficient (QNS) or specimen viability below analytical limits).

CONCLUSIONS

Utilizing RMPI without FCS as a stabilization media results in increased cell yield and improved FCI results. We have found FCS is not required to achieve high quality results in FCI of paucicellular CSF specimens.

Oxygenation in cervical cancer and normal uterine cervix assessed using blood oxygenation level-dependent (BOLD) MRI at 3T

Hypoxia is reported to be a biomarker for poor prognosis in cervical cancer. However, a practical noninvasive method is needed for the routine clinical evaluation of tumor hypoxia. This study examined the potential use of blood oxygenation level-dependent (BOLD) contrast MRI as a noninvasive technique to assess tumor vascular oxygenation at 3T. Following Institutional Review Board-approved informed consent and in compliance with the Health Insurance Portability and Accountability Act, successful results were achieved in nine patients with locally advanced cervical cancer [International Federation of Gynecology and Obstetrics (FIGO) stage IIA to IVA] and three normal volunteers. In the first four patients, dynamic T₂*-weighted MRI was performed in the transaxial plane using a multi-shot echo planar imaging sequence whilst patients breathed room air followed by oxygen (15 dm³/min). Later, a multi-echo gradient echo examination was added to provide quantitative R₂* measurements. The baseline T₂*-weighted signal intensity was quite stable, but increased to various extents in tumors on initiation of oxygen breathing. The signal in normal uterus increased significantly, whereas that in the iliacus muscle did not change. R₂* responded significantly in healthy uterus, cervix and eight cervical tumors. This preliminary study demonstrates that BOLD MRI of cervical cancer at 3T is feasible. However, more patients must be evaluated and followed clinically before any prognostic value can be determined.

Lymph node metastasis in endometrioid adenocarcinomas of the uterine corpus with occult cervical involvement

OBJECTIVE

Surgical-pathologic studies have defined the risk of lymphatic metastasis in clinical stage I endometrial cancers. However, data on the risk of lymph node metastasis in endometrial cancers involving the uterine cervix are less robust. The aim of this study was to determine the risk of lymphatic metastasis in patients with endometrial cancers with occult tumor extension to the uterine cervix.

METHODS

Our institutional tumor registry identified all patients with endometrioid endometrial cancers who underwent comprehensive surgical staging. Patients with gross involvement of the cervix and patients with extra-uterine disease were excluded. The risk of lymphatic metastasis associated with cervical involvement was analyzed in the context of known uterine risk factors for lymphatic metastasis such as age, depth of invasion, grade, and lymphovascular space invasion (LVSI).

RESULTS

We identified 169 patients who met inclusion and exclusion criteria. Univariate analyses revealed that LVSI (p<0.01), tumor grade (p<0.01), depth of myometrial invasion (p<0.01), tumor free distance (p<0.01), tumor size (p=0.02), and cervical involvement (p<0.01) were associated with lymphatic metastasis while age at diagnosis (p=0.85) was not. Multivariate analyses revealed that only LVSI (p<0.01), tumor grade (p=0.02), and depth of myometrial invasion (p=0.03) were independently associated with lymphatic metastasis.

CONCLUSION

Cervical involvement is not an independent predictor of lymphatic metastasis in endometrial cancer. In an unstaged patient, decisions regarding adjuvant treatment or additional diagnostic procedures such as lymphadenectomy should be based on uterine factors.

In vitro chemosensitivity assay for patients with gynecologic sarcoma

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Background: This study describes the in vitro drug response of gynecologic sarcomas and clinical implications of in vitro testing. Methods: Ovarian or uterine sarcomas were analyzed for response to any of 7 drugs (carboplatin [Carb], cisplatin [Cis], paclitaxel [Ptx], docetaxel [Dtx], doxorubicin [Dox], gemcitabine [Gem], Ifosfamide [Ifo]) with a chemosensitivity assay (ChemoFx, Precision Therapeutics, Inc, Pittsburgh PA). In combination therapy, tumors were considered sensitive if responsive to at least 1 drug. Results: 68 tumors were analyzed (21 ovarian and 47 uterine; 54 primary and 14 recurrent; carcinosarcoma [n=53], leiomyosarcoma [n=13], other [n=2]). 24% of tumors were responsive to Carb, 30% to Cis, 33% to Ptx, 9% to Dtx, 18% to Dox, 26% to Gem, 27% to Ifo, 40% to Carb+Ptx, 39% to Cis+Ifo, 48% to Ptx+Ifo, 24% to Gem+Dtx, and 27% to Gem+Dox (Table). Ovarian sarcomas were more responsive than uterine sarcomas and primary more than recurrent tumors. Carcinosarcomas were more responsive than leiomyosarcomas to Ifo (P=0.02). Conclusions: In vitro tumor response testing may enable physicians to individualize chemotherapy regimens for their patients. [Table: see text]

Recurrence patterns in patients with stage IIIC1 versus IIIC2 endometrial adenocarcinoma

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Background: To identify differences in recurrence patterns between stage IIIC1 and IIIC2 endometrial adenocarcinomas. Methods: A retrospective review was performed with IRB approval of all patients treated for stage IIIC1 and IIIC2 endometrial adenocarcinoma at our institution from 1989-2011. Patients were required to have comprehensive surgical staging including total abdominal hysterectomy, bilateral salpingo-ophorectomy, pelvic and paraaortic lymph node dissection. Descriptive statistics were performed using Microsoft Excel 2011 and Fischer’s exact test, Kaplan-Meier analyses were used to compare disease free (DFS) and overall survival (OS). Results: Eighty-seven patients with stage IIIC endometrial adenocarcinoma were identified, of which 69 were evaluable. The mean age was 59 years and the mean follow up was 32 months. There were 31 patients with stage IIIC1 and 38 patients with stage IIIC2 disease. There was no statistical difference in histology between the two groups: 47 endometrioid, 11 papillary serous, and 11 with other types of adenocarcinoma. Patients with stage IIIC1 disease were more likely to receive pelvic radiation (p=0.0004) and patients with IIIC2 disease were more likely to receive chemotherapy (p=0.014). Median DFS was 28.9 months (range 0-112) and 15.0 months (range 0-166) (p=0.017) and median OS was 31.9 months (range 0-134) and 18.0 months (range 0-166) (p=0.061) for the IIIC1 and IIIC2 groups respectively. Seven of 31 (23%) patients with stage IIIC1 disease recurred: 1 (14%) at the vaginal cuff and 6 (86%) distant. The patient who recurred locally was initially treated with chemotherapy alone. Of the 6 patients with distant recurrences only 1 received chemotherapy. Twelve of the 38 (32%) patients with stage IIIC2 experienced a recurrence: 6 (50%) vaginal/pelvic and 6 (50%) distant. There was a difference between the rates of local versus distant recurrence in patients with IIIC1 and IIIC2 endometrial cancer. Conclusions: IIIC1 patients were less likely to receive systemic chemotherapy and more likely to recur distantly. Our findings suggest a role for adjuvant chemotherapy and radiation in the frontline treatment of both IIIC1 and IIIC2 endometrial cancer.