Mismatch repair gene expression defects contribute to microsatellite instability in ovarian carcinoma

BACKGROUND

hMLH1, the human MutL homologue, has been linked to microsatellite instability (MSI) in gastrointestinal tumors. However, to the authors' knowledge, the role of hMLH1, the other mismatch repair genes (MMR), and MSI in ovarian carcinoma has not been well defined. The purpose of the current study was to determine the relation between MSI of ovarian carcinoma and MMR gene expression, hMLH1 and hMSH2 hypermethylation, and hMLH1 and hMSH2 null mutations.

METHODS

hMLH1 mRNA was detected by reverse transcriptase-polymerase chain reaction (RT-PCR) and amplification of cDNA using a housekeeping gene (glycerol 3-phosphate dehydrogenase) as a control for mRNA quality and quantity. Methylation-specific PCR (MS-PCR) was used to correlate methylation of the hMLH1 and hMSH2 CpG islands with mRNA expression status. Similar techniques were used to evaluate the concomitant expression of five other MMR: hMSH2, hMSH3, hMSH6, PMS1, and PMS2. Microsatellite instability was studied using the National Cancer Institute consensus markers (D2S123, D5S346, D17S250, BAT25, and BAT26) and NM23 as described previously.

RESULTS

One hundred twenty-five primary tumors were analyzed. High-frequency MSI (MSI-H) was found in 21 tumors (16.8%). hMLH1 mRNA was absent in 10 of these 21 tumors (47.6%). In each case, coordinated hypermethylation of both regions A and C of the promoter was identified. Microsatellite stable and low-frequency MSI tumors all were found to express not only hMLH1 but the other MMR genes as well (P < 0.001). Absence of expression of hMSH2 and the four other MMRs occurred in tumors with absent hMLH1 mRNA expression because of CpG island hypermethylation. No absence of expression of hMSH2, hMSH3, hMSH6, PMS1, or PMS2 was found to occur in tumors expressing hMLH1. None of the 11 MSI-H tumors without promoter hypermethylation demonstrated a null mutation in hMLH1 or hMSH2.

CONCLUSIONS

A molecular mechanism to explain > 50% of the MSI-H phenotype in ovarian carcinoma cases was demonstrated. MSI-H may occur because of MMR defects, especially hMLH1 promoter hypermethylation. Additional mechanisms are required to explain the balance between the cases of MSI-H as well as the phenomenon of MSI-L tumors.

Malignant mixed mullerian tumor of the ovary and bilateral breast cancer: an argument for BRCA3, or a coincidental cluster of unconnected cancers?

OBJECTIVES

Malignant mixed mullerian tumors (MMMTs) of the ovary are a rare, aggressive subtype of ovarian cancer without a clear relationship to familial breast-ovarian cancer syndromes.

CASE

We present the case of a woman with bilateral breast cancers who subsequently developed a stage IIIc MMMT of the ovary. The patient had a first-degree female relative with breast and ovarian cancer (not MMMT), as well as second- and third-degree female relatives each with bilateral breast cancers. BRCA1 and BRCA2 sequencing of germline DNA revealed no evidence of a heritable mutation.

CONCLUSIONS

Ovarian MMMTs may be a hallmark of breast/ovarian cancer secondary to genetic risk independent of classic BRCA1/2 pathways.

Methylation: a second hit in the two-hit hypothesis

This case illustrates that methylation of one BRCA1 allele may serve as the second hit in a patient with a diploid locus and missense mutation on the other allele.

Outcome of reproductive age women with stage IA or IC invasive epithelial ovarian cancer treated with fertility-sparing therapy

OBJECTIVES

The purpose of this study was to determine the recurrence rate, survival, and pregnancy outcome in patients with Stage IA and Stage IC invasive epithelial ovarian cancer treated with unilateral adnexectomy.

METHODS

A multi-institutional retrospective investigation was undertaken to identify patients with Stage IA and IC epithelial ovarian cancer who were treated with fertility-sparing surgery. All patients with ovarian tumors of borderline malignancy were excluded. Long-term follow-up was obtained through tumor registries and telephone interviews. The time and sites of tumor recurrence, patient survival, and pregnancy outcomes were recorded for every patient.

RESULTS

Fifty two patients with Stage I epithelial ovarian cancer treated from 1965 to 2000 at 8 participating institutions were identified. Forty-two patients had Stage IA disease, and 10 had Stage IC cancers. Cell type was distributed as follows: mucinous, 25; serous, 10; endometrioid, 10; clear cell, 5; and mixed, 2. Histologic differentiation was as follows: grade 1, 38; grade 2, 9; and grade 3, 5. Twenty patients received adjuvant chemotherapy (mean 6 courses, range 3-12 courses). Patients received the following chemotherapeutic agents: cisplatin/taxol or carboplatin/taxol, 11; melphalan, 5; cisplatin and cyclophosphamide, 3; and single-agent cisplatin, 1. Eight patients had second-look laparotomies and all were negative. Duration of follow-up ranged from 6 to 426 months (median 68 months). Five patients developed tumor recurrence 8-78 months after initial surgery. Sites of recurrence were as follows: contralateral ovary, 3; peritoneum, 1; and lung, 1. Nine patients underwent subsequent hysterectomy and contralateral oophorectomy for benign disease. At present, 50 patients are alive without evidence of disease and 2 have died of disease 13 and 97 months after initial treatment. The estimated survival was 98% at 5 years and 93% at 10 years.Twenty-four patients attempted pregnancy and 17 (71%) conceived. These 17 patients had 26 term deliveries (no congenital anomalies noted) and 5 spontaneous abortions.

CONCLUSION

The long-term survival of patients with Stage IA and IC epithelial ovarian cancer treated with unilateral adnexectomy is excellent. Fertility-sparing surgery should be considered as a treatment option in women with Stage I epithelial ovarian cancer who desire further childbearing.

Inactivation of BRCA1 and BRCA2 in ovarian cancer

BACKGROUND

Although BRCA1 and BRCA2 play important roles in hereditary ovarian cancers, the extent of their role in sporadic ovarian cancers and their mechanisms of inactivation are not yet well understood. Our goal was to characterize BRCA2 mutations and mRNA expression in a group of ovarian tumors previously evaluated for BRCA1 mutations and mRNA expression.

METHODS

The tumors of 92 unrelated women with "ovarian" cancer (i.e., ovarian, peritoneal, or fallopian tube cancer) were screened for BRCA2 null mutations using a protein truncation test. Methylation-specific polymerase chain reaction (PCR) was used to examine the BRCA2 promoter for hypermethylation in tumors that did not express BRCA2 mRNA. All statistical tests were two-sided.

RESULTS

Nine tumors had a germline (n = 5) or somatic (n = 4) BRCA2 mutation; each was associated with loss of heterozygosity. All of the somatic (1445delC, E880X, 4286del8, and 5783delT) and one of the germline (5984ins4) mutations were unique to this study. One tumor had somatic mutations in both BRCA1 and BRCA2. Two tumors are, to our knowledge, the first cases of germline BRCA2-associated peritoneal cancer. Twelve additional tumors lacked detectable BRCA2 mRNA, but the BRCA2 promoter was hypermethylated in only one of them, suggesting that other mechanisms effect transcriptional silencing of BRCA2. Tumors lacking BRCA1 mRNA were more likely to lack BRCA2 mRNA than tumors expressing BRCA1 mRNA (P<.001). Overall, 82% (95% confidence interval [CI] = 74% to 90%) of the tumors contained alterations in BRCA1, BRCA2, or both genes. Of 41 informative tumors with some alteration in BRCA2, 36 also had an alteration in BRCA1. The frequency, but not the mechanism, of BRCA1 or BRCA2 dysfunction in ovarian cancer was independent of family history.

CONCLUSIONS

Multiple mechanisms cause nearly universal dysfunction of BRCA1 and/or BRCA2 in hereditary and sporadic ovarian carcinoma. Ovarian cancers with BRCA2 dysfunction often have simultaneous BRCA1 dysfunction.

Failure of BRCA1 dysfunction to alter ovarian cancer survival

PURPOSE

Many factors modify ovarian cancer survival. There are conflicting reports regarding survival of individuals with hereditary BRCA1-related ovarian cancer. None have controlled for other mechanisms of BRCA1 silencing in the control cohort.

EXPERIMENTAL DESIGN

Fifty-nine cancers with presumed BRCA1 dysfunction because of mutation (24 germ-line and 16 somatic) or absent BRCA1 mRNA because of promoter hypermethylation (n = 19) were identified among 250 consecutively screened ovarian cancers. Controls were matched from the same population based on p53 mutation type, age at diagnosis, Fédération Internationale des Gynaecologistes et Obstetristes surgical stage and histological grade, residual disease, preoperative CA125, disease site, and the presence of BRCA1 mRNA translatable in an in vitro protein expression assay. BRCA1 promoter hypermethylation was determined by the methylation-specific PCR technique. The significance of promoter hypermethylation was confirmed by the absence of detectable BRCA1 mRNA.

RESULTS

The median survival for individuals with ovarian cancer BRCA1 dysfunction was 4.1 years versus 3.5 years in the case matched controls (P = 0.98). Grouped on the basis of the mechanism of BRCA1 dysfunction, median survival was 4.5, 2.8, and 2.3 years for germ-line, somatic, and BRCA1 promoter-silenced ovarian cancers. However, for the corresponding matched controls with wild-type BRCA1 sequence, the median survival was virtually identical: 4.6, 2.8, and 3.3 years, respectively. In a Cox proportional hazards analysis, only residual disease (P = 0.0001), age (P = 0.01), and Fédération Internationale des Gynaecologistes et Obstetristes stage (P = 0.011) entered the survival model.

CONCLUSIONS

In contrast with other published reports, we are unable to detect large survival differences between matched case-control cohorts of ovarian cancers with BRCA1 inactivation by any of three independent mechanisms.

Frequency of BRCA1 dysfunction in ovarian cancer

BACKGROUND

Ovarian cancer is one of the most common hereditary cancers in women. Mutations in the BRCA1 gene increase a woman's risk of ovarian cancer. Testing for BRCA1 mutations is cumbersome and impractical for large populations. Therefore, we developed an efficient strategy to detect various types of BRCA1 dysfunction and also determined the relative frequency of BRCA1 dysfunction in ovarian cancer.

METHODS

Tumors from 221 patients with epithelial ovarian cancer were screened for loss of heterozygosity (LOH) at the BRCA1 locus. BRCA1 complementary DNA (cDNA) and genomic DNA from all cancers with BRCA1 LOH (106 tumors) or noninformative status (15 tumors) were polymerase chain reaction (PCR) amplified and analyzed for protein truncation in a coupled transcription/translation test. When truncated BRCA1 protein was detected, the BRCA1 gene from both the tumor and a paired blood sample was sequenced. When BRCA1 expression in tumor cDNA was not detected with a protein truncation test, a methylation-specific PCR was used to determine whether the promoter region of BRCA1 was methylated and thus inactivated. All statistical tests were two-sided.

RESULTS

Fifty-one (23.1%) of 221 tumors had BRCA1 dysfunction, including 18 with germline mutations, 15 with somatic mutations, and 18 with monoallelic or biallelic hypermethylated promoters. By the consideration of only tumors with LOH or that were noninformative, the efficiency for detecting BRCA1 dysfunction improved to 45 (37.2%) of 121 tumors. Therefore, LOH/noninformative was a strong predictor of mutation status (Fisher's exact test, P<.001). However, this subset of tumors did not include those with BRCA1 missense mutations (estimated at six [2.7%] of 221 not detected by our method) or biallelic promoter methylation (estimated at six [2.7%] of 221).

CONCLUSIONS

BRCA1 dysfunction in ovarian cancer is common and occurs via multiple mechanisms. The use of LOH, rather than a family history of ovarian cancer, as a first step in a screening strategy, followed by protein truncation testing, appears to increase the chance of identifying tumors with BRCA1 dysfunction.

Papillary serous carcinoma of the uterus: increased risk of subsequent or concurrent development of breast carcinoma

OBJECTIVE

Some women with endometrial cancer may be at increased risk for developing breast cancer. The histologic type of endometrial cancer associated with synchronous or subsequent breast cancer has not been clearly established. Our purpose was to determine if a certain histologic type of endometrial cancer was associated with an increased risk of synchronous or subsequent breast cancer.

METHODS

The University of Iowa Hospitals and Clinics tumor registry was queried to ascertain all patients with the diagnosis of uterine cancer from January 1, 1983, to December 31, 1994. Statistics were performed utilizing SPSS for Windows version 9.0 (SPSS Inc., Chicago, IL), including Student's t tests and chi(2) tests.

RESULTS

Five hundred ninety-two patients had endometrial adenocarcinoma during the study period. Five hundred thirty-six women had endometrioid adenocarcinoma, 23 women had papillary serous carcinoma (UPSC), 21 women had adenosquamous carcinoma, 10 women had clear-cell carcinoma, and 1 woman each had mucinous or squamous carcinoma. Twelve patients had previously been diagnosed with breast carcinomas. Twenty-five patients were diagnosed with breast cancer either concurrently or subsequent to their diagnosis of endometrial cancer. Synchronous or subsequent breast cancers developed in 3.2% of patients with endometrioid carcinoma and in 25% of patients with UPSC (P < 0.001).

CONCLUSION

Patients with UPSC have an increased risk of development of breast cancer as compared to patients with endometrioid adenocarcinoma of the uterus.

Ovarian cancer BRCA1 mutation detection: Protein truncation test (PTT) outperforms single strand conformation polymorphism analysis (SSCP)

Recent studies have shown that the BRCA1 tumor suppressor gene plays a role in the development of both hereditary and sporadic ovarian cancer. Since several different mechanisms may give rise to tumor gene defects, a better understanding of these mechanisms may identify BRCA1 as an attractive therapeutic target in ovarian cancer. Sequencing this large gene is not practical on a population-wide basis. The optimal screening strategy is yet to be determined. The purpose of our study is to compare two common screening techniques: the protein truncation test (PTT) and single strand conformational polymorphism analysis (SSCP). Ninety-four patients with epithelial ovarian cancer and available snap-frozen tissue were screened for BRCA1 mutations by both PTT (five individual PCR reactions with complete translation of the product in the TNT System (Promega, Madison, WI)) and SSCP (41 individual PCR reactions covering the entire coding sequence). All abnormal results were confirmed by sequencing. A paired peripheral blood DNA sample was utilized to determine if the sequence abnormality was a germline mutation. Twenty-three mutations in BRCA1 were found in 22 patients (14 germline, eight somatic, one unknown) including four novel mutations: E489X, 3558delT, 3871delGTCT, del exon 7-10. Although the predictive value of a negative test was close for the two methods (PTT 99.1%, SSCP 99.8%), the comparison of positive predictive value overwhelmingly favored PTT (100.0%, vs. 26.4%, respectively). The specificity for PTT was 100.0% while the sensitivity was 82.6%. While for SSCP, the specificity was 99.0% and the sensitivity was only 60.9%. The concordance rate for the two screening tests was 88.9%. Only SSCP can detect missense mutations. PTT is a superior screening test for truncating BRCA1 mutations that are expected to be of clinical significance.

p21 and p53 in ovarian carcinoma: their combined staining is more valuable than either alone

BACKGROUND

Mutations in p53 are the most common genetic alterations in human malignancies. Expression of its protein product has been linked to decreased survival rate in ovarian carcinoma. Less is known about the importance of p21 expression. The purpose of this study was to determine the value of the combination of p21 and p53 expression in patients with epithelial ovarian malignancies.

METHODS

One hundred three consecutive patients with epithelial ovarian carcinoma were studied using snap-frozen tissue specimens. Immunohistochemical staining utilizing the pAb1801 monoclonal antibody to p53 and NCL-WAF-1 monoclonal antibody to p21 was performed. Image analysis was used to determine whether nuclear staining for either antibody was present. In addition to p21 and p53, International Federation of Gynecology and Obstetrics stage, grade, histology, level of cytoreduction, and DNA index were analyzed as prognostic factors. Univariate and multivariate analyses was performed.

RESULTS

One hundred three patients were observed for more than 5 years. Immunohistochemical staining for p21 and p53 were significantly inversely related (P = 0.041). Among the patients whose tumors showed p21 staining but no p53 staining, there were no recurrences and all patients were alive at 5-year follow-up. The 5-year survival rate for these patients was significantly better than for the patients with other combinations of p21/p53 staining (P < 0.0001). The DNA index between these 2 groups was not significantly different (P = 0.057). Multivariate analysis shows the combination of p21 and p53 (P = 0.013) staining to be more valuable as a prognostic indicator than either p53 (P = 0.015) or p21 (P = 0.5) alone.

CONCLUSIONS

This study confirms the importance of the combination of p21 and p53 nuclear staining in patients with ovarian carcinoma. Cox regression analysis revealed combination of p21 positive and p53 negative to be a better independent indicator of prognosis and survival in patients with ovarian carcinoma than either p21 or p53 alone.

Does gender discrimination exist in a gynecology training program in a private hospital?

PURPOSE

Does gender discrimination by attending physicians exists in a residency in regard to residents' opportunities to perform complete/operative management of hysterectomies versus just being surgical assistants?

MATERIALS AND METHODS

The program studied is a 4-year program in obstetrics and gynecology residency with 3 residents per year. All cases involving a resident were recorded in a computer program designed by one of the authors (C.S.M.) to collect data for Residency Review Committee reports. Data were able to be sorted in a variety of methods including level of management, date of procedure, Physicians' Current Procedural Terminology codes, and attending physician name or resident name. Only intrafascial and extrafascial hysterectomies for benign disease were included in the study. Data were collected from July 1, 1996 to March 31, 1997.

RESULTS

Five hundred and forty-nine hysterectomies with residents participating as primary surgeon (complete/operative management) or surgical assistant were performed during the study period. Complete/operative management was performed by the resident in 82.5% of cases while the resident was surgical assistant in 17.5%. Male residents were responsible for complete/operative management in 81.6% of cases and female residents in 83.2% of cases (P = 0.33). Male attending physicians were more likely to allow residents (male or female) to participate as the primary surgeon in abdominal hysterectomies (95.3%) and vaginal hysterectomies (68.5%) than female attending physicians (abdominal, 87.0% and vaginal, 57.3%) (P < 0.001 and P = 0.006, respectively).

CONCLUSIONS

Although male attending physicians were more likely than female attending physicians to allow residents to perform complete/operative management, there was no discrimination as to whether the resident in question was male or female.

PRECIS

When determining the level of management private gynecologists will allow residents to perform they do not practice gender discrimination.

Clear cell carcinoma of the ovary: poor prognosis compared to serous carcinoma

BACKGROUND

A review of literature comparing the survival of patients with clear cell carcinoma of the ovary to patients with serous carcinoma reveals divided opinions. No studies of statistical significance have demonstrated worse survival in a cohort of patients with clear cell carcinoma matched stage for stage with patients with serous carcinoma of the ovary. The purpose of this study was to compare survival in a cohort of clear cell carcinoma patients to a cohort of serous carcinoma patients matched for stage, age, treatment, and cytoreduction.

METHODS

All cases of clear cell carcinoma and serous carcinoma of the ovary operated on by the gynecology oncology service from January 1, 1981 to December 31, 1989 were evaluated for patient age, length of survival and level of primary cytoreduction, as well as FIGO stage and histology.

RESULTS

Twenty-two patients with clear cell carcinoma found in the years noted were compared to a cohort of 22 patients with serous carcinoma matched for stage (I, 18.2%; II, 9.1%; III, 63.6%; IV, 9.1%), age (clear cell carcinoma 58 years, serous carcinoma 60 years (p = 0.330)), and level of primary cytoreduction (optimal in 63.6% of both clear cell carcinoma and serous carcinoma cohorts and non-optimal in 36.4% of both groups). Survival in the clear cell carcinoma cohort (16 months) was worse than in the serous carcinoma cohort (36 months) (p = 0.045).

CONCLUSION

Patients with clear cell carcinoma have a significantly worse prognosis than patients with serous carcinoma when matched for age, stage, and level of primary cytoreduction.

Successful laparoscopic treatment of an abdominal pregnancy in the posterior cul-de-sac

PURPOSE

To describe the laparoscopic treatment of a first trimester abdominal pregnancy found in the cul-de-sac between the right uterosacral ligament and the rectum.

CASE REPORT

A 32-year-old female presented to the emergency department with abdominal pain beginning a few hours prior to presentation. The serum betahCG level was 543 mIU/ml. An ultrasound examination revealed an empty uterus, bilateral normal fallopian tubes, and a large quantity of fluid in the pelvis. Secondary to patient symptoms, laparoscopy was performed. After the pelvis was irrigated to remove blood and clot, bilaterally normal fallopian tubes and ovaries were found. Further laparoscopic examination revealed an abdominal pregnancy implanted on the peritoneum between the right uterosacral ligament and the rectum. Hydrodissection was used to help elevate the peritoneum away from adjacent structures, and the products of conception were removed laparoscopically.

CONCLUSION

In select first trimester patients with abdominal pregnancies, laparoscopic management can be performed.

Immunohistochemical staining of the mismatch repair gene, hMSH2, and survival in patients with ovarian carcinoma

OBJECTIVE

hMSH2 is a mismatch repair gene. The protein of this gene can be demonstrated by immunohistochemical methods. The authors wanted to analyze whether the percent of positive nuclear area staining of the hMSH2 protein correlated with survival in patients with ovarian carcinoma.

METHODS

One hundred and two patients with epithelial ovarian carcinoma were studied. Slides were prepared from snap frozen tissue. Quantification of staining and DNA index were performed using image analysis. In addition to hMSH2, FIGO stage, grade, histology, and level of cytoreduction were analyzed as prognostic factors.

RESULTS

Mean follow-up was 64 months and median was 59 months. Nineteen patients had stage I cancers, 4 stage II, 59 stage III, and 20 stage IV. Optimal cytoreduction was accomplished in 71% of patients. hMSH2 staining was significantly higher in better differentiated tumors (p=0.006), but there was no difference in staining among the FIGO stages (p=0.43). Cox regression analysis revealed FIGO stage (p=0.0005), level of cytoreduction (p=0.006) and hMSH2 staining (p=0.016) to be independent predictors of survival in patients with ovarian carcinoma.

CONCLUSION

The hMSH2 protein can be demonstrated by immunohistochemical methods and quantified by image analysis. hMSH2 staining was shown to be an independent prognostic indicator of survival in patients with ovarian carcinoma.

Radical hysterectomy in the elderly female: a comparison to patients age 50 or younger

BACKGROUND

Longevity in the United States is increasing, therefore the knowledge of whether radical surgery can be performed on patients over age 65 with acceptable morbidity and mortality is increasingly important. A retrospective study of elderly patients undergoing radical hysterectomy was performed with a comparison to a younger cohort.

METHODS

A retrospective case study of all patients over 65 years of age having undergone a radical hysterectomy for cervical cancer in one practice of gynecologic oncology was performed. Each patient was matched with two patients age 50 or younger having undergone a similar operation during the same year. No patients between July 1, 1965, and March 31, 1998, were knowingly excluded. All patients were analyzed for preexisting medical conditions, length of postoperative stay, morbidity, and postoperative mortality.

RESULTS

Sixty-two patients over age 65 having undergone a radical hysterectomy and pelvic lymphadenectomy were found. These patients were matched with 124 patients age 50 or younger having undergone a radical hysterectomy during the same calendar year. No differences in operative morbidity (minor, P > 0.57; major, P > 0.93) or mortality (no deaths in either group) were found. Patients age 65 or older had more comorbidities prior to surgery than the younger cohort (minor, P < 0.001; major, P < 0.001). The mean postoperative hospital stay was significantly longer in the older cohort (P = 0.005).

CONCLUSIONS

Radical hysterectomy is a safe surgical procedure in a select population of patients 65 and over. No differences in operative mortality or morbidity were found when compared to a cohort of patients age 50 or younger. However, hospital stay was longer in the older cohort.

Tumor markers and molecular biological markers in gynecologic malignancies

Gynecologic oncology is a rapidly growing field due to constant advances in immunohistochemistry and molecular biology. This review serves as an overview of new studies promoting the use of tumor markers and molecular biological prognostic factors in malignancies affecting women. The majority of studies focus on either endometrial or ovarian carcinoma. Other gynecologic malignancies (cervical, vulvar, and vaginal carcinoma) have a much smaller representation in the world literature. Multiple new markers were examined over the last year. We conclude that although some markers show promise as potential new consensus prognostic indicators, more work is needed to confirm results and clarify any existing discrepancies.

The great imitator: miliary peritoneal tuberculosis mimicking stage III ovarian carcinoma

PURPOSE

To report a case of peritoneal tuberculosis initially mistaken at the time of surgery for metastatic ovarian carcinoma.

CASE REPORT

A 31-year-old Filipino female was found to have increasing abdominal pain, ascites, early satiety, increasing abdominal girth and bilateral complex masses. Diagnostic laparoscopy revealed the presence of > 4 liters of ascites, a frozen pelvis secondary to what appeared to be bilateral ovarian carcinomas, along with miliary seeding of the entire anterior abdominal wall, omentum, small bowel and small bowel mesentery, right and left diaphragmatic surfaces, and hepatic surface. Frozen section, at the time of laparotomy, revealed necrotizing granulomas most consistent with disseminated tuberculosis that was confirmed at the time of final pathologic review and culture.

CONCLUSION

Peritoneal tuberculosis can be mistaken for widely metastatic ovarian carcinoma at time of surgery.

Docetaxel extravasation causing significant delayed tissue injury

PURPOSE

Docetaxel is a relatively new taxane that has not been associated with significant tissue injury after extravasation. We present a case of a patient who had grade 4 tissue toxicity after extravasation of docetaxel infused through a peripheral intravenous site.

CASE REPORT

A 71-year-old female was being treated for recurrent ovarian cancer with docetaxel and carboplatin. Shortly after the docetaxel infusion began, she experienced docetaxel extravasation into the dorsum of her left hand. The infusion was halted, and then the administration was continued in a peripheral intravenous site in the other upper extremity. Erythema was noted by the patient on the dorsum of her left hand 6 days after infiltration. The following day, the patient noted severe pain, decreased function, and blistering along with increased erythema. The patient presented to the gynecology oncology clinic 11 days after the extravasation injury occurred. Conservative management was undertaken, and over the next 4 weeks the patient had resolution of the skin changes and full return of function.

CONCLUSION

Docetaxel can cause significant delayed tissue injury if extravasation occurs.

p53 and bcl-2 in epithelial ovarian carcinoma: their value as prognostic indicators at a median follow-up of 60 months

OBJECTIVE

p53 is the most common tumor suppressor gene involved with human malignancies. Mutations in p53 are present in approximately 50% of human malignancies. bcl-2 is a protooncogene. Expression of its protein product is related to better prognosis in several malignancies.

METHODS

One hundred and three patients with epithelial ovarian carcinoma were studied. Immunohistochemical staining using the pAb1801 monoclonal antibody to p53 and the anti-bcl-2 124 monoclonal antibody to bcl-2 was performed. Image analysis was used to measure percentage positive nuclear area staining of mutant p53. In addition to bcl-2 and p53, FIGO stage, grade, histology, and level of cytoreduction were analyzed as prognostic factors. Univariate as well as Cox regression analysis was performed.

RESULTS

One hundred and three patients were followed for a mean of 60 months. Twenty patients had FIGO stage I disease, 4 stage II, 59 stage III, and 20 stage IV. Immunohistochemical staining for mutant p53 was not significantly related to DNA index (P = 0.99) but was related to increasing FIGO stage (P < 0.001) and increasing histologic grade (P = 0.039). Using Cox regression analysis, increased mutant p53 staining was an independent predictor of survival in these patients (P = 0.0032), along with stage (P < 0. 0001) and level of cytoreduction (P < 0.0001). Although by itself bcl-2 was not an independent prognostic indicator (P = 0.18), the combination of p53 and bcl-2 was independently predictive of survival (P = 0.038).

CONCLUSION

This study confirms the authors' earlier report on the importance of p53 as a prognostic indicator of survival in ovarian carcinoma. Cox regression analysis reveals mutant p53 staining to be a better independent indicator of prognosis and survival in patients with ovarian carcinoma than the combination of bcl-2 and p53.

Trisomy 21 fetus co-existent with a partial molar pregnancy: case report

BACKGROUND

Approximately 1 in 1,000 pregnancies in the United States are complicated by the presence of a hydatidiform mole. A Medline search revealed no reported cases of a trisomic fetus co-existent from 1966-1998. We present the case of a patient, initially found to have hypertension, edema, and proteinuria in the first trimester, and later found to have a partial molar gestation co-existent with a trisomy 21 infant.

CASE REPORT

A 31-year-old female presented to her family practitioner in the first trimester and was found to have hypertension and proteinuria. A thorough work-up by a nephrologist revealed no cause. The patient was transferred to the Maternal-Fetal Medicine Service at 26 weeks' and 1 day estimated gestational age. An amniocentesis revealed the presence of a fetus with trisomy 21. At 27 weeks' and 3 days estimated gestational age, the patient underwent a cesarean delivery for a non-reassuring fetal heart rate. Pathologic examination of the placenta revealed the presence of a partial hydatidiform molar pregnancy.

CONCLUSION

The present account represents the first reported case of a fetus with trisomy 21 co-existent with a partial hydatidiform mole.

MIB-1 in endometrial carcinoma: prognostic significance with 5-year follow-up

OBJECTIVE

MIB-1, a monoclonal antibody to the Ki-67 antigen, has presumptively been shown to be predictive of recurrent disease in patients with endometrial cancer. In order to more conclusively establish whether MIB-1 staining can be used as a prognostic indicator of recurrent disease or survival, a larger group of patients with a minimum follow-up of 5 years was analyzed.

METHODS

The tumors from 147 consecutive patients receiving primary surgical therapy for endometrial carcinoma were evaluated with the MIB-1 monoclonal antibody. Proliferation index was quantified by image analysis. Patients were followed for a minimum of 60 months. In addition to MIB-1 staining, histologic type, stage, grade, depth of invasion, lymphovascular space invasion, and peritoneal cytology were evaluated as prognostic indicators.

RESULTS

Twenty-five of 147 patients died during the study period. MIB-1 staining was not significantly elevated in advanced (stage II, III, and IV) as opposed to early (stage I) carcinomas (P = 0.38). In patients whose tumor MIB-1 staining was less than 33.0%, no deaths occurred. By multivariate analysis, only MIB-1 staining (P < 0.001), FIGO stage (P = 0.005), and LVI (P = 0.005) were shown to be independent prognostic indicators predictive of survival.

CONCLUSION

In this series of 147 consecutive patients with endometrial carcinoma, the monoclonal antibody MIB-1 was shown to be an independent prognostic indicator of 5-year survival. This follow-up further validates the previous work regarding the significance and potential usefulness of MIB-1 as a prognostic indicator.

What staging surgery should be performed on patients with uterine papillary serous carcinoma?

OBJECTIVE

While uterine papillary serous carcinoma (UPSC) is an aggressive histologic subtype, it fortunately is not as common as some other histologic subtypes. Overall, patients with UPSC have a poor survival rate. Since the optimal surgical procedure to perform on patients with this tumor is unknown, the authors wanted to determine what the optimal surgical management of patients with UPSC should be.

METHODS

All patients with the preoperative or frozen section intraoperative diagnosis of UPSC were treated with a staging or cytoreductive procedure analogous to patients with serous carcinoma of the ovary. Patients analyzed underwent surgery from March 1983 to September 1995.

RESULTS

Sixty-five patients with UPSC were found. Twenty patients had FIGO stage I tumors, 6 stage II tumors, 8 stage III tumors, and 31 stage IV tumors. Twenty-nine patients had upper abdominal disease (17 gross disease and 12 microscopic disease only). Forty-eight patients underwent pelvic and paraaortic lymphadenectomy, with 6 of 48 having positive lymph nodes. All 14 patients with lymphovascular space invasion had stage IV disease. Thirty-one of sixty-five patients had positive cytology at the time of surgery.

CONCLUSION

Based on the clinical experience of these investigators, patients with UPSC should undergo a staging laparotomy similar to the procedure undertaken for patients with ovarian carcinoma. The surgery should include at least partial omentectomy, total abdominal hysterectomy and bilateral salpingo-oophorectomy, peritoneal washings, peritoneal biopsies, and pelvic and paraaortic lymphadenectomy similar to an ovarian cancer staging procedure if no gross disease > or =2 cm is found at time of surgery. If disease > or =2 cm is found, cytoreduction should be undertaken when feasible.

p53 expression as a prognostic indicator of 5-year survival in endometrial cancer

BACKGROUND

One of the most common genetic alterations to occur in human cancers is an alteration of the p53 tumor suppressor gene. The purpose of this article was to build upon the authors' previous work with p53 and determine whether p53 was a prognostic indicator of 5-year survival.

METHODS

One hundred thirty-seven consecutively surgically treated patients with endometrial cancer had their p53 expression studied by immunoperoxidase staining and quantified by image analysis. All patients were evaluable for 5-year survival.

RESULTS

One hundred three patients had endometrioid adenocarcinoma; 6, adenosquamous carcinoma; 14, papillary serous carcinoma; 10, clear cell carcinoma; and 4, undifferentiated carcinoma. p53 expression ranged from 0.0 to 58.2% positive nuclear area with a mean of 11.5% (median 2.6%) for the cohort. For the patients with endometrioid carcinoma, the mean p53 expression was 7.1% while for the nonendometrioid tumors it was 24.6% (P<0.001). Fifty-nine of the 103 endometrioid tumors (57.3%) stained positive for p53 while 32 of the 34 nonendometrioid (94.1%) tumors stained positive (P<0.001). Increasing histologic grade correlated with an increasing p53 expression (P = 0.003). The percentage of tumors expressing p53 was found to be higher in FIGO stage II, III, and IV than in FIGO stage I cancer (P = 0.003). However, mean p53 expression did not differ between early (stage I) and advanced (stage II, III, and IV) cancers (P = 0.088). Utilizing 5-year survival as the endpoint for multivariate analysis, FIGO stage (P = 0.0028) and p53 expression (P<0.001) were the only independent prognostic indicators found.

CONCLUSION

p53 expression is more commonly found in nonendometrioid than in endometrioid adenocarcinoma of the endometrium. It, along with FIGO stage, is an independent prognostic indicator of 5-year survival.