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.

Human papillomavirus infection in Norwegian women with cervical cancer

The objective of the present study was to determine the prevalence of human papillomavirus (HPV) infections in Norwegian women with cervical cancer. We used the polymerase chain reaction (PCR) and Southern blot techniques to assess the prevalence of HPV in cervical biopsies of 133 women admitted to the Norwegian Radium Hospital for treatment of cervical cancer. At the time of sampling (from February 1988 to April 1989) about 85% of Norwegian women with cervical cancer were treated at the Norwegian Radium Hospital. HPV was found in biopsies of 91 (68%) of women with cancer; 70 (53%) biopsies contained HPV type 16, 19 (14%) HPV type 18, 4 (3%) HPV type 33, 2 (1.5%) HPV type 11, and 3 (2%) HPV DNA of unknown type (HPVX). Five percent of biopsies were doubly infected, chiefly with HPV 16 + 18. We found a significant association between HPV 18 and low age, poorly differentiated tumors and adenocarcinomas. Our results show that there is an association between HPV types 16 and 18 and cervical cancer also in a Norwegian setting. PCR was more sensitive than Southern blotting for detection of HPV. Thirty-six (27.5%) of cancer biopsies were positive by PCR but negative by Southern blotting, as against 49 (73.5%) positive by both methods; we also encountered 4 samples positive by Southern blotting and negative by PCR. In 23/53 cancer biopsies positive by Southern blotting we found evidence for integrated or rearranged HPV genomes.

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).

Are borderline tumors of the ovary overtreated both surgically and systemically? A review of four prospective randomized trials including 253 patients with borderline tumors

The optimal treatment of early-stage ovarian borderline tumors is controversial. Only a few randomized trials evaluating adjuvant treatment for this disease have been published. Between 1970 and 1988 four consecutive randomized trials, including patients with ovarian borderline tumors, were conducted at the Norwegian Radium Hospital. After surgery, 253 stage I-II borderline tumors without residual disease were randomly allocated to these protocols. The adjuvant treatment in the four trials consisted of [1] external irradiation (Ext) combined with intraperitoneal instillation of radioactive gold (198Au) or Ext alone, [2] intraperitoneal radioactive therapy followed by thio-TEPA or no further treatment, [3] thio-TEPA or no adjuvant therapy, and [4] cisplatin or 32P treatment. The patients were equally distributed according to prognostic variables within the eight randomization groups. The overall corrected and crude survival were 99 and 94%, respectively. In 83% of the patients a hysterectomy, bilateral salpingo-oophorectomy, and omentectomy was performed. None of the patients with less extensive surgery relapsed. Adjuvant therapy did not seem to improve the overall corrected survival. On the contrary, toxicity was added with small bowel complications after radiation therapy, neurotoxicity after cisplatin treatment, and bone marrow toxicity after thio-TEPA therapy. It is concluded that stage I borderline tumors should not receive any adjuvant treatment.

Effect of estradiol on tumor growth, cell kinetics and p53 oncoprotein expression in human endometrial adenocarcinoma heterotransplanted into nude mice

To study the importance of estradiol concentrations in which tumors are growing to progression of tumor growth and cell kinetics, we have used a human tumor-nude mice model. In this model a human endometrial adenocarcinoma with estradiol independent but estradiol-responsive growth phenotype (i.e. the tumor was capable of growing in absence of estradiol but its growth could be stimulated by estradiol at the start of preparation phase) was examined. In the preparation phase pieces from this tumor were transplanted into nude mice, randomly divided into two groups, one with and one without estradiol treatment. After 18 months growth in these different hormone conditions the tumors were measured for p53 protein expression and pieces from both these groups were again transplanted into oophorectomized nude mice, each group being randomly allocated to two subgroups, one with and one without estradiol treatment (experimental phase). Tumor growth was measured during the experimental phase, whereas cell kinetic parameters and steroid receptor concentrations were analyzed after the experimental phase. Our findings indicate that progression of the growth phenotype is independent of estradiol conditions in which human endometrial adenocarcinomas are grown. Long-term growth in estradiol-poor conditions results in estradiol resistance of the cell cycle, probably accompanied by overexpression of the p53 protein. Tumor growth in estradiol-rich conditions, however, may protect, at least to some extent, the same tumor, which retains higher sensitivity of cell proliferation to estradiol and normal production of the p53 protein despite progressive changes in growth regulation.

Gestational trophoblastic tumors: cytostatic treatment response evaluated from hCG modelling

Fifty-eight patients representing with gestational trophoblastic tumors were treated at the department of Gynaecologic Oncology of the Norwegian Radium Hospital during the period from 1977 to 1990. Individual serial measurements of hCG were analyzed applying a mathematical dynamic tumor marker model.

Prospective malignancy grading, flow cytometry DNA-measurements and adjuvant chemotherapy for invasive squamous cell carcinoma of the uterine cervix

In a prospective study comprising 310 consecutive patients with carcinoma of the cervix, FIGO stages I-IV, the prognostic significance of clinical and flow cytometric variable was evaluated in a univariate and multivariate analysis. The parameters studied included stage according to FIGO, age, histopathologic grade according to Ackerman and MGS scores, DNA ploidy, S-phase fraction as well as treatment with radiation only, surgery only or a combination thereof as well as adjuvant chemotherapy. Univariate analysis showed that patients in FIGO stages IA-IIA with MGS up to 14 points survived significantly better than other groups. MGS parameter mitosis, vascular invasion and type of invasion predicted survival as did clinical stage. Diploid cases with SPF > 15% survived less than remaining other cases. Multivariate analysis not including treatment indicated that FIGO stage and diploid cases with SPF > 15% predicted survival but not total MGS score and age. When treatment for FIGO stages IA-IIA was included, elderly women had a worse prognosis. Adjuvant chemotherapy, surgical alone or radiation alone did not demonstrate any differences within groups. In Figo stages IIB-IV, cases with radiotherapy only survived significantly better than patients with other treatment schedules. The frequency of low malignancy patients (< MGS 16) in relation to year of initial diagnosis was found to have decreased between years 1967 and 1988, probably as a result of screening activities.

Clinical stage I carcinoma of the cervix. Value of MR imaging in determining invasion into the parametrium

Using MR imaging with a body coil parametrial invasion was determined prospectively in 169 consecutive patients considered on the basis of clinical examination to have carcinoma confined to the cervix. After radical hysterectomy correlation with histologic examination was performed for the left and right parametrium separately. The criterion for parametrial invasion was a high-signal-intensity lesion with disruption of the full thickness of the cervical stroma combined with areas of abnormal signal intensity within the parametrial region on T2-weighted images. Histologic examination showed that 18 parametria in 13 patients were invaded by tumor. MR had an overall accuracy of 93%, a sensitivity of 89%, and a specificity of 93% in demonstrating parametrial involvement. Positive and negative predictive values were 43% and 99%. The main weakness of MR was 21 false-positive tests. This represents a limitation when MR is performed with a body coil.

Combined bleomycin and irradiation in preoperative treatment of advanced squamous cell carcinoma of the vulva

Forty-two patients with advanced squamous cell carcinoma of the vulva were treated with a combination regimen of bleomycin 180 mg and external irradiation 30-45 Gy. Twenty patients had primary lesions, and 22 patients had recurrent disease. Fifteen (75%) of the patients with primary disease showed objective response (five complete and ten partial response). Four underwent surgery. Of these, one is alive after 60 months with no evidence of disease. Two have died of unrelated causes without signs of recurrence. Seventeen relapsed and died of carcinoma of the vulva. Median survival for patients treated for primary disease was 8.0 months. Thirteen (59%) of 22 patients treated for recurrence showed objective response (two complete and eleven partial responses). None underwent surgery. All these patients died of carcinoma of the vulva. Median survival was 6.4 months. Toxicity was acceptable, and there were no treatment-related deaths. Even taking into account that our patients had very advanced disease, the results are disappointing. An increase of the radiation dose beyond the maximum of 45 Gy given, and more aggressive surgery, might have improved the results.

Molecular and biological factors in the pathogenesis of ovarian cancer

BACKGROUND

The classic prognostic parameters are insufficient for predicting the prognosis of the individual patient. Knowledge of molecular and biological factors which are responsible for the development and progression of ovarian cancer may improve the prediction of prognosis.

MATERIALS AND METHODS

Recent data both on factors associated with the development and control of ovarian cancer cells and on DNA ploidy have been reviewed.

RESULTS

Observations suggest that steroid and peptide hormones have a role in disease etiology and progression, and that peptide growth factors and cytokines, oncogenes and tumor suppressor genes, by their impact on mitosis and cell number may influence the rate of mutations, which could confer malignant transformation. DNA ploidy is an objective independent prognostic factor. DNA aneuploidy indicates high risk, diploidy low risk. Only tumours shown to be DNA diploid by flow-cytometry and image cytometry are considered diploid. S-phase fraction is currently not reliable.

CONCLUSION

Understanding the mechanisms involved in ovarian cancer development and growth will allow opportunities for the rational design of effective anti-tumour treatment modalities. More objective and reproducible prognostic variables will improve the predictiveness of prognosis.

Therapeutic efficacy of the alpha-emitter 211At bound on microspheres compared with 90Y and 32P colloids in a murine intraperitoneal tumor model

alpha-Emitting radionuclides such as 211At have a number of physical characteristics which make them attractive for the treatment of micrometastases. 211At was bound to polymer microspheres and its efficacy was compared with the beta-emitting 32P and 90Y colloids for the treatment of intraperitoneally growing K13 hybridoma tumors in mice. Single graded doses of 0.1-2.5 MBq 211At microspheres injected intraperitoneally 24 hr after inoculation of the hybridoma cells improved survival and produced higher cure rates than 32P colloid, 90Y colloid, or no treatment. One of the most striking contrasts between 211At microspheres and 90Y or 32P colloids was the ability of relatively low doses 211At to affect cures. When comparing the groups with the highest survival rate for each radionuclide (0.1-1 MBq 211At, 2.5 MBq 90Y, and 2.5 MBq 32P), 211At treatment resulted in an improved survival over that with 32P therapy, but the difference was not significant between 211At and 90Y. Toxicity studies with 211At microspheres showed that dosages up to 17 MBq per mouse were not lethal. In conclusion, the present study suggests that the high-energy transfer and the short-range cytotoxicity of the alpha-emitter 211At might be of benefit for intracavitary radiotherapy.

Hexamethylmelamine as second-line therapy in platin-resistant ovarian cancer

A total of 61 patients with recurrent or persistent clinically measurable platin-resistant epithelial ovarian carcinoma were treated with 260 mg/m2 oral hexamethylmelamine daily for 14 days, repeated at 4-week intervals. Platin resistance was defined as progression or stable disease during cis- or carboplatin treatment (used alone or in combination with other drugs), or relapse within 6 months after the end of that therapy. Fifty patients were evaluable for response and 57 for toxicity. The objective response rate was 14% (3 complete and 4 partial responses). The response rate was higher in patients with relapse within 6 months than in patients with progression or stable disease on platin-based therapy. This observation underscores the importance of defining response and time to progression after first-line chemotherapy. The median duration of response was 8 months and the median survival in responding patients was 9+ months versus 5 months for patients with progression on hexamethylmelamine. Nausea and vomiting requiring antiemetic treatment occurred in 8 (14%) patients and reversible peripheral neuropathy in 3 patients. Two patients developed agitation, insomnia, and depression during hexamethylmelamine therapy. In conclusion, the 14% objective response rate and the occurrence of complete responses with oral hexamethylmelamine treatment in a group of ovarian cancer patients with true platin resistance are noteworthy.

Distribution of intraperitoneally injected microspheres labeled with the alpha-emitter astatine (211At) compared with phosphorus (32P) and yttrium (90Y) colloids in mice

The alpha-emitter 211At was bound to polymer microspheres with a diameter of 1.8 microns. The distributions in mice of intraperitoneally injected 211At microspheres, 90Y silicate colloid, and 32P chromic phosphate colloid were compared. The microspheres with 211At spread rapidly in the peritoneal cavity and remained mainly on the intraperitoneal surfaces. Intraperitoneal injection of 90Y colloid resulted in high levels in intraperitoneal fat and the diaphragm, but 1 day after injection 8.5% of the injected dose per gram was found in blood and after 6 days 2.5% was observed in bone. The highest accumulation of 32P was found in liver and spleen. The injection of additional nonradioactive chromic phosphate colloid resulted in an even higher accumulation of 32P in spleen and liver. The same phenomenon was not observed with 211At microspheres. It is suggested that it is not only the particle size which is important in the distribution of intraperitoneally injected colloid, but the amount of colloid, the type of colloid, the addition or presence of other substances such as ascites, and the animal species might also influence the distribution. In conclusion, the intraperitoneal distribution of 211At-labeled microspheres in mice was favorable compared with 90Y and 32P colloid. These data must be viewed cautiously since the distribution might be different in other animal species or humans.

Flow cytometric DNA measurements in squamous cell carcinoma of the vulva: an important prognostic method

One hundred and thirty-one squamous cell carcinomas of the vulva were examined by FCM-DNA measurements. Samples were prepared from paraffin-embedded tissue. Of these, 66 were found to be diploid, 52 aneuploid and 13 could not be evaluated. The 5-year crude survival rate was 62% for the diploid and 23% for the aneuploid tumors (P < 0.001). The aneuploid tumors without lymph node (LN) metastases showed a 5-year cancer-related survival rate of 44% as compared to 58% for the diploid tumors with LN metastases. In a multivariate Cox regression analysis the most important independent prognostic parameters were (1) LN involvement (P < 0.0001), (2) tumor ploidy (P = 0.0001) and (3) tumor size (P = 0.0039). By using ploidy and lymph node involvement in this way as prognostic factors we are able to identify high- and low-risk groups of patients. We strongly believe that these results should lead to a different attitude towards therapy in vulva cancer patients.

The influence of low fat, low lactose diet on diarrhoea during pelvic radiotherapy

In a prospective clinical trial 143 women undergoing pelvic radiotherapy for gynaecological malignancies, were randomized to receive either a low-fat, low-lactose diet (intervention group) or a regular diet (control group) in order to evaluate the possible impact of diet therapy on radiation induced diarrhoea, nausea and vomiting. The daily number and consistency of stools, use of antidiarrhoeal agents, nausea and vomiting were recorded before radiotherapy was begun (week 0), in the last week of therapy (week 6) and 6 weeks after the end of therapy (week 12). The intervention group used half the amount of antidiarrhoeal agents in week 6, than used by the control group (mean 0.6 tablets per day versus 1.1, p < 0.01). 14 patients (23%) in the intervention group reported diarrhoea, versus 32 (48%) in the control group (p < 0.01). In week 12 there were no differences in the use of antidiarrhoeal agents and the prevalence of diarrhoea between the groups.

Lymphoid cell distribution as prognostic factor in carcinoma of the uterine cervix

Pretreatment assessment of blood lymphoid cells was performed in 44 patients with carcinoma of the cervix and in 19 healthy controls. White blood cells were determined by routine differential counting, and T-lymphocyte subsets and monocytes were quantitated using monoclonal antibodies. Increase in monocyte numbers, as determined by the 1D5 antibody, was seen in the cancer patients, especially in the group with advanced disease. No change in T-lymphocyte subpopulations could be found. During the 5-year follow-up period, 17 patients had a recurrence or died of cancer. The best prognostic information was obtained from conventional clinical parameters, e.g. stage, tumor size and lymph node status. Increased numbers of granulocytes and monocytes were found in advanced stage disease but had no independent prognostic influence. In pelvic lymph node biopsies taken from patients undergoing Wertheim-Meigs operation the T-helper/T-suppressor ratio was higher and the monocyte number lower than in peripheral blood. No correlation could be detected between node cell distribution and the prognosis. It is concluded that immunological testing, as performed in this study, elicits very little new prognostic information.

CA125 and placental alkaline phosphatase as serum tumor markers in epithelial ovarian carcinoma

Placental alkaline phosphatase (PLAP) was measured by an immunoradiometric assay using the monoclonal antibody C2 (PLAP-C2). Serum samples of 135 patients with epithelial ovarian cancer were analyzed, and the results were compared with CA125 levels. CA125 and PLAP-C2 were elevated in 85 and 43% of the patients, respectively. Only 1 patient with normal CA125 and evidence of disease at the time of sampling had an elevated PLAP-C2. Fifty-three patients with measurable tumor were followed longitudinally during chemotherapy. Correct correlation with disease evolution was observed in 95% of the patients for CA125 and in 59% for PLAP-C2. The PLAP-C2 assay did not add significantly to the predictive value of CA125 in the diagnosis and follow-up of epithelial ovarian cancer.

Cancer of the endometrium: value of MR imaging in determining depth of invasion into the myometrium

The depth of invasion into the myometrium correlates with the frequency of lymph node metastases in patients with cancer of the endometrium. A distinction between superficial invasion (less than 50% of the thickness of the myometrium) and deep invasion (greater than 50%) is particularly important. The ability to distinguish between these two groups on MR was studied in 33 patients with endometrial cancer who had primary hysterectomy. The overall accuracy of MR in showing deep invasion was 82%, with a sensitivity of 91% and a specificity of 64%. The main limitation of MR was four false-positive results with regard to deep invasion. In all of these, the erroneous diagnosis was found at histologic examination to be due to a large polypoid tumor that distended the uterus so that a thin rim of myometrium was stretched over it rather than being deeply infiltrated by it. Our experience shows that MR can be used to distinguish between superficial and deep invasion of the myometrium. However, degree of invasiveness may be overestimated in exophytic polypoid tumors with significant intraluminal extension.

[DNA examinations in gynecological cancer and breast cancer]

During the past years, automated methods for analytical cytology have produced a large quantity of data on DNA-ploidy disturbances in different types of human cancers. Flow cytometry (FCM) provides a quick and precise method for determining DNA-ploidy and distribution of the cell cycle in tumours. This paper surveys DNA-aberrations in human endometrial, cervical, ovarian and breast carcinomas, and shows that prognosis is much better for diploid than for aneuploid tumors, and that the prognostic ability of DNA-patterns is proved to be much better than that of the parameters used before, such as degree of differentiation, myometrial invasion and receptor concentrations.