The molecular genetic basis of ovarian cancer and its roadmap towards a better treatment

OBJECTIVES

Ovarian cancer remains a major health problem for women. Although there is considerable clinico-pathological heterogeneity, the molecular genetic basis of ovarian cancer remains poorly understood. Recently, high-resolution genomic maps generated by genome-wide SNP analyses and novel sequencing technologies, have started to dissect the genetic basis of ovarian cancer.

METHODS

Here, we will describe our first insights on how somatic mutations may contribute to the diagnostic re-classification of ovarian cancer. We will discuss how copy number alterations and epigenetic changes represent promising biomarkers to predict resistance to treatment in ovarian cancer, and will also highlight how some of the recently-discovered microRNAs might represent interesting therapeutic targets for ovarian cancer.

RESULTS AND CONCLUSIONS

Future studies, such as the Cancer Genome Atlas Project, involving a large number of ovarian tumors and combining various high-throughput genetic technologies with sophisticated integrative bioinformatic analyses, will be required and are expected to fine-map the full genetic spectrum of ovarian cancer. It is hoped, however, that once the molecular genetic basis of ovarian cancer is understood, this will lead to better and personalized treatments for ovarian cancer.

Prognostic Significance of Nodal and PgR Status on Early Relapse in Operable HER-2 Positive Breast Cancer from the Pre-Trastuzumab Era

Background: Over the last decade, trastuzumab has become a standard adjuvant treatment option in HER-2 positive breast cancers. However, with a mainly 'on-treatment' effect only, the economic burden and adverse effects incurred from its routine use for 1 year following completion of chemotherapy, there emerges a need to identify a group of HER-2 positive breast cancers at low-risk for relapse. We, therefore, investigated potential prognostic factors in a cohort of HER-2 positive breast cancers in the era before trastuzumab, especially focusing on hormonal status.Methods: We retrospectively reviewed the data of 240 trastuzumab-naïve patients with a HER-2 FISH-positive breast cancer who had primary surgery at University Hospitals Leuven between January 2000 and December 2005. We collected data including age at diagnosis, menopausal status, histologic type, tumor size, grade, lymph node involvement, estrogen receptor (ER) /progesterone receptor (PgR) status, and disease-free survival (DFS) outcome. A multivariate Cox hazard model was used to identify prognostic factors and the cumulative DFS rate was determined using the Kaplan-Meier method.Results: After a median follow-up of 57.5 months there were 50 breast cancer related events meaning that 5-year DFS rate was 78.4% for the entire cohort. Median time to first event was 20 months and ranged from 4 to 96 months. Cox model revealed that only PgR status and lymph node involvement were independent prognostic factors for disease relapse. (p = 0.03 and p < 0.01 respectively). In Kaplan-Meier analysis, patients with PgR+ showed better DFS rate than those with PgR- (figure 1; 83.8% vs. 73.1%, p = 0.02) while ER status didn't reach statistical significance (p = 0.154).Nodal involvement ≥4 was strongly associated with poor DFS rate compared with node negativity. (p = 0.00). Of note, a subgroup of patients with PgR+ and LN-. presented no relapse within the first two years after surgery (figure 2).Conclusions: In this series of HER-2 positive breast cancers, PgR and nodal status were strong prognostic factors for early breast cancer relapse. Patients with a PgR+/LN- phenotype were unlikely to relapse within the first two years of surgery. We propose to evaluate the added benefit of adjuvant trastuzumab to chemotherapy in women with this phenotype as such data are yet not available from the major adjuvant trastuzumab trials.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 6046.

Gynaecological Assessment of Postmenopausal Women with an Asymptomatic Thickened Endometrium While on Tamoxifen: Results from a Double Blind Randomized Controlled Trial Comparing Continuation of Tamoxifen and Anastrozole

Background: The switch to adjuvant anastrozole/exemestane after 2-3 years of tamoxifen improves breast cancer outcome. Prior to this knowledge, we designed a multicentre randomised placebo-controlled study, to evaluate uterine and quality of life (QoL) issues comparing those switching to anastrozole and those continuing on tamoxifen in patients with a thickened endometrium after 2-3 years of tamoxifen treatment. The study was prematurely closed when anastrozole/exemestane became reimbursed by our health authorities following publication of a survival benefit from the adjuvant switch strategy in this setting. We here report on all randomized patients.Patients and Methods: Patients were postmenopausal, asymptomatic with a double endometrial thickness (DET) on transvaginal ultrasound (TVUS) of more than 7 mm. They were randomized between 20mg tamoxifen and 1mg anastrozole during the rest of 5 years of endocrine treatment; tablets were unrecognizable for drug assignment. The study aimed at investigating the TVUS changes with a measurement at baseline, at year 1 and when completing the endocrine therapy unless there were QoL issues, progression or vaginal bleeding. The primary study-endpoint was the change in DET and uterine volume (UV). Secondary endpoints were differences in the occurrence of menopausal symptoms between groups. Longitudinal fixed-effects regression analysis methods were used to evaluate uterine changes and QoL scores over time. Age and BMI were used as covariates.Results: The study randomized 72 subjects (37 anastrozole and 35 tamoxifen) from 5 institutions. Mean age (range) was 60 years (43 – 77 years); demographics were comparable but patients randomized to anastrozole were more likely lymph node positive. Subjects on anastrozole had a significant decrease in mean change in DET and UV already after 1 year. Both primary endpoints did not change over time when continuing tamoxifen but between-group differences were significant (p-values < 0.001). The covariates did not influence the effect of medication. Eleven patients withdrew from the study (7 on anastrozole; 4 on tamoxifen, ns); 2 had disease progression (both on anastrozole), 1 (on tamoxifen) developed a hematologic cancer, 7 stopped because of side effects (5 on anastrozole and 2 on tamoxifen) and arthralgia being most frequently reported for early stopping (4 anastrozole and 1 tamoxifen). AEs/SAEs were observed in 54% and 11% of patients on anastrozole and in 51% and 17% of patients on tamoxifen (ns). Regarding QoL, vaginal dryness increased for patients on anastrozole but not for patients on tamoxifen (p=0.008). No different evolution of arthralgia between both groups is suggested, even though more anatrozole patients withdrew due to arthralgia problems. Vaginal bleeding was reported in 5 (3 on tamoxifen and 2 on anastrozole).Conclusion: Although the study was prematurely stopped, we were able to show a strong decrease in DET and UV in asymptomatic postmenopausal tamoxifen users with a thickened endometrium after 2-3 years of tamoxifen who change to anastrozole.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 4093.

Prevalent breast cancer patients with a homozygous mutant status for CYP2D6*4: response and biomarkers in tamoxifen users

Retrospective studies suggest that single nucleotide polymorphisms in the cytochrome P450 2D6 (CYP2D6) gene predict reduced tamoxifen metabolism, better tolerance and worse treatment outcome. We hypothesized that women with this genotype lack tamoxifen-induced endometrial and biochemical changes in follicle-stimulating hormone (FSH) and sex hormone-binding globulin (SHBG). We identified 56 breast cancer patients attending the follow-up clinic with a homozygous mutant (HM) status for the CYP2D6*4 null variant. Here, we report a detailed assessment of tamoxifen activity in 19 CYP2D6 HM women, while they were using tamoxifen either for metastatic (n = 5) or for early disease (n = 14). We assessed response to tamoxifen in metastatic disease. Endometrial appearances and serum levels of FSH and SHBG were assessed from retrospective and prospective testing. Our findings do suggest that the presence of two CYP2D6*4 alleles does not exclude a durable response of tamoxifen in metastatic breast cancer. The transvaginal ultrasonographic appearance of the endometrium in CYP2D6*4/*4 patients on tamoxifen is similar as seen in the normal population of tamoxifen users. The endometrium is increased in thickness with subepithelial cysts and endometrial polyps. Serum levels of FSH and SHBG in CYP2D6*4 HM tamoxifen users were in the range of what would be expected during tamoxifen treatment in the general population. Our findings do show CYP2D6*4/*4 carriers to have activity of tamoxifen on breast cancer, endometrium and serum levels of FSH and SHBG. They support clinical trials prospectively testing the effect of CYP2D6 genetic variability in response to tamoxifen before denying this drug to breast cancer patients only based on their CYP2D6*4 status.

Neoadjuvant chemotherapy followed by interval debulking surgery in patients with serous endometrial cancer with transperitoneal spread (stage IV): a new preferred treatment?

Background:

To investigate the value of neoadjuvant chemotherapy (NACT), followed by interval debulking surgery (IDS), in endometrial cancer with transperitoneal spread (stage IV).

Methods:

Patients with endometrial cancer with transperitoneal spread, as determined by laparoscopy (±pleural effusion), were treated with NACT. Efficacy was determined according to the Response Evaluation Criteria in Solid Tumors, residual tumour at IDS and histopathological assessment of tumour regression.

Results:

A total of 30 patients (median age: 65 years; range:44–81 years) received 3–4 cycles of NACT (83% paclitaxel/carboplatin). Histopathological subtypes were as follows: serous (90%), clear cell (3%) and endometrioid (6%) carcinoma. Response according to RECIST was as follows: 2 (7%) complete remission, 20 (67%) partial remission, 6 (20%) stable disease and 2 (7%) progressive disease (PD). Patients with PD were not operated upon. A total of 24 patients (80%) had optimal cytoreduction (R ⩽1 cm), of whom 22 (92%) were without residual tumour. Four patients were considered inoperable and were excluded from further analysis. The median progression-free survival and overall survival times were 13 and 23 months, respectively.

Histopathological features of chemoresponse in both uterus and omentum were related to a better PFS (P=0.017, hazard ratio (HR) =0.785) and overall survival (P=0.014, HR=0.707). In particular, the absence of tumour infiltration and necrosis were associated with prognosis.

Conclusion:

The use of NACT resulted in a high rate (80%) of optimal IDS for the treatment of endometrial cancer with transperitoneal spread.

Biology and prognosis by age of primary operable breast cancer

Abstract #2082

Introduction Breast cancer (BC) biology and prognosis are age dependent. We studied the effect of age on BC biology, treatment and prognosis.
 Methods Data from 2059 consecutive patients, primary operated for invasive BC in UZ Leuven (01/01/00–01/06/05), were used. Patients with ≥ 3.5 yrs follow-up were included (n=1064) to study relapse in relation to age (logistic regression).
 Results Early relapse in BC is age-related, decreasing 3.2% each yr for patients < 60 yrs at diagnosis (p=0.0132, 95% CI OR: 0.943-0.993). This relation is reversed >60 yrs: early relapse increases 5.5% each yr (p=0.0007, 95% CI OR: 1.021-1.082). The positive lymph node status is decreasing 3.5% each yr <65 yrs (p<0.0001, 95% CI OR: 0.950-0.980) and increasing 3.8% each yr ≥65 yrs (p=0.0259, 95% CI OR: 1.004-1.072) (Fig 1). The chance on a positive estrogen receptor (ER) increases with increasing age until 60 yrs (p=0.0071, 95% CI OR=1.009-1.059) with no significant effect >60 years. For the progesterone receptor (PR), this depends quadratically on the age at diagnosis (p=0.0108, 95% CI OR=0.999-1.000), decreasing <50 years and increasing above. With increasing age, the chance on HER-2 positivity decreased (p=0.0414, 95% CI OR: 0.970-0.999). Grade 3 tumors dropped significantly until 50 yrs (p<0.0001 CI OR=0.900 (0.869-0.933) whereafter we observed a non significant upward trend (Fig 2). The chance to receive any adjuvant therapy decreased with age (p=0.0023, 95% CI OR: 0.958-0.991). Above 70 yrs, systemic adjuvant therapy was absent in 12.95% of non-relapsing -, but in 28.95% of relapsing patients. Radiotherapy was not taken into account.
 Conclusion Early relapse was higher with increasing/decreasing age, starting from age 60. This goes in parallel with the U-shape curve of lymph node involvement (Fig1). Increased relapse and lymph node positivity in elderly might partially be a reflection of the fact that BC is diagnosed in a later stage in elderly patients but might also be related to different biological behavior or to decreased use of adjuvant systemic treatment. HER-2 overexpression decreases with age and age related differences in ER and PR expression as well as tumor grading are observed (Fig 2).
 
 
 


Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 2082.

Ineffective attempt to preserve fertility with a levonorgestrel-releasing intrauterine device in a young woman with endometrioid endometrial carcinoma: a case report and review of the literature

BACKGROUND

The treatment of endometrial cancer in young women who want to preserve their fertility is challenging.

CASE

A 25-year-old woman (A0P0G0) was diagnosed with grade 1 endometrioid endometrial carcinoma (EEC). Imaging studies including transvaginal ultrasound (TVS), computed tomography and magnetic resonance imaging (MRI) could not detect myometrial invasion or metastatic disease. The immunohistochemical expression of the estrogen and progesterone receptor in the tumor was strongly positive, whereas p53 staining was negative. After extensive counseling, we decided to use a levonorgestrel-releasing intrauterine device to preserve her fertility. Follow-up was organized every three months and consisted of serum CA125 levels, TVS, endometrial biopsy and MRI. The tumor regressed after ten months and the intrauterine device was removed. However, nine months later, recurrent EEC was diagnosed and a hysterectomy performed. Pathological examination confirmed Stage Ia EEC.

CONCLUSION

Despite the presence of favorable prognostic factors of EEC as determined by grade and immunohistochemistry, the levonorgestrel-releasing intrauterine device was unable to preserve fertility.

Breast cancer in pregnancy: a literature review

Breast cancer is the most common cancer diagnosed during pregnancy. The incidence of breast cancer in pregnancy (BCP) is expected to increase since women tend to postpone childbearing until later in life and since the incidence of breast cancer increases with age. The management of this co-incidence is a clinical and ethical multidisciplinary challenge for all involved medical care workers since two lives are at risk. Breast cancer treatment is possible during pregnancy. Still, little prospective research data are available on this condition. In this review, we present an overview of the current knowledge about the safety of diagnostic imaging, staging methods and treatment options of BCP. We also discuss the prognosis, neonatal outcome and recommendations concerning prenatal care.

Sexual and psychological functioning in women after pelvic surgery for gynaecological cancer

Pelvic surgery for gynecological cancer can affect sexuality through a number of anatomical, physiological and psychological mechanisms. We aimed to examine the prevalence of sexual dysfunction and psychological functioning in women who underwent pelvic surgery for gynecological cancer. Fifty women who underwent pelvic surgery for vulvar, cervical or endometrial cancer in a gynecological oncology unit completed questionnaires evaluating marital satisfaction (DAS), depression (BDI-II) and sexual functioning (SSFS and an in-house Specific Sexual Problems Questionnaire). Medical records were used to obtain disease-specific data. The control group consisted of 39 healthy age-matched control women attending an outpatient screening clinic. Significantly more women with gynaecological cancer than controls reported sexual problems (83 vs 20%), including decreased desire (76 vs 14%) and impaired vaginal lubrication (42 vs 9%). Pelvic surgery was specifically related to changed intensity of orgasm (43%), reduced vaginal sensitivity (38%), vaginal elasticity (30%), superficial dyspareunia (27%), vaginal narrowing (26%) and shortening (22%). Although no significant differences were found between either group for depression (17% vs 13%) or total quality of the partner relationship, women with a history of gynecological cancer reported significant lower marital cohesion. These results indicate that although the psychological adjustment of women who underwent pelvic surgery seems to be satisfactory, they seem to be at risk for sexual dysfunctions.

Limited clinical benefit from trastuzumab in recurrent endometrial cancer: two case reports

BACKGROUND

It is hypothesized that the HER-2/neu receptor could be used for targeted therapy in recurrent endometrial cancer.

CASES

A patient with type II endometrial cancer (serous), showing strong HER-2/neu overexpression and gene amplification in both primary and recurrent tumor, received single-agent trastuzumab (3x weekly, 8 mg/kg loading, 6 mg/kg maintenance dose). Because of progression after 4 cycles, weekly paclitaxel-trastuzumab (80 mg/m(2) paclitaxel; trastuzumab 4 mg/kg loading, 2 mg/kg maintenance dose) was initiated. However, progressive disease was also noted after 11 weeks of combined treatment. A second patient, with recurrent type II endometrial cancer (grade III endometrioid), had HER-2/neu gene amplification in the primary tumor. However, biopsy from a lung metastasis 3 years later appeared to be HER-2/neu-negative.

CONCLUSION

Based on lack of response and changes in tumor biology, trastuzumab was of little clinical value in 2 cases of recurrent type II endometrial cancer. This report underscores the importance of reassessment of a recurrent tumor before initiating targeted treatment.

Laparoscopic para-aortic lymphadenectomy and positron emission tomography scan as staging procedures in patients with cervical carcinoma stage IB2IIIB

The objective of this study was to determine the role of laparoscopic lower para-aortic lymphadenectomy and positron emission tomography (PET) scan in the staging of cervical carcinoma. Ninety consecutive patients with FIGO stage IB2-IIIB were scheduled for laparoscopic para-aortic lymphadenectomy.

EXCLUSION CRITERIA

obvious metastatic para-aortic nodes on computed tomography (CT)/PET or PET-CT. The procedure was stopped when a node was positive on frozen section. In ten patients, no para-aortic lymphadenectomy was performed as scheduled. Forty-seven patients were operated retroperitoneally, 22 transperitoneally, and 21 cases were converted from retroperitoneally to transperitoneally. Median number of removed nodes was 6 (1-24). In 10 of 80 patients, para-aortic metastases were diagnosed. Despite a nonsuspect PET result, 5 of 44 patients had positive para-aortic nodes. Two-year survival was 76% and 16% without and with para-aortic metastases, respectively (P = 0.0001). Laparoscopic para-aortic lymphadenectomy showed metastases in 13% of the patients. In the subgroup with negative PET scan, 11% had metastases. The procedure had a low morbidity and identified a group with an extremely poor prognosis.

Timing of debulking surgery in advanced ovarian cancer

It is clear that primary debulking remains the standard of care within the treatment of advanced ovarian cancer (FIGO stage III and IV). This debulking surgery should be performed by a gynecological oncologist without any residual tumor load, or so-called "optimal debulking." Over the last decades, interest in the use of neoadjuvant chemotherapy together with an interval debulking has increased. Neoadjuvant therapy can be used for patients who are primarily suboptimally debulked due to an extensive tumor load. In this situation, based on the randomized European Organization for Research and Treatment of Cancer-Gynaecological Cancer Group trial, interval debulking by an experienced surgeon improves survival in some patients who did not undergo optimal primary debulking surgery. Based on the GOG 152 data, interval debulking surgery does not seem to be indicated in patients who underwent primarily a maximal surgical effort by a gynecological oncologist. Neoadjuvant chemotherapy can also be used as an alternative to primary debulking. In retrospective analyses, neoadjuvant chemotherapy followed by interval debulking surgery does not seem to worsen prognosis compared to primary debulking surgery followed by chemotherapy. However, we will have to wait for the results of future randomized trials to know whether neoadjuvant chemotherapy followed by interval debulking surgery is a good alternative to primary debulking surgery in stage IIIc and IV patients. Open laparoscopy is probably the most valuable tool for evaluating the operability primarily or at the time of interval debulking surgery.

Role of diaphragmatic surgery in 69 patients with ovarian carcinoma

Diaphragmatic stripping or coagulation is a technique aiming to optimally cytoreduce ovarian cancer. We investigated the complications, the overall survival, and the relapse rate following this procedure. Records of 69 patients with diaphragmatic involvement who underwent debulking surgery between September 1993 and December 2001 were reviewed. A total of 69 patients underwent diaphragmatic surgery as part of cytoreductive surgery for epithelial ovarian cancer. In 17 cases, the diaphragmatic tumors were stripped from the muscle, in 22 cases coagulated, and in 30 cases stripped and coagulated. Postoperative complications were pleural effusion (41 cases, 3 needed a chest drain, 7 needed a pleural puncture, 1 needed both) and pneumothorax (4 cases, 1 needed a chest drain). In one case of bilateral pleural effusion, the patient developed pneumonia. In one case of pleural effusion on the right side, the patient needed a pleural puncture and developed a partial atelectasis of the middle lobe of the right lung. The median overall survival was 66 months in the stripping group compared with 49 months in the coagulation group. In 56 cases (81%), the patient developed a relapse, and the first site of relapse was the diaphragm in 11 cases (20%). We conclude that diaphragmatic resection is an important part of optimal debulking surgery with an acceptable morbidity.

Classification of radical hysterectomy adopted by the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer

The Piver classification of radical hysterectomy for the treatment of cervical cancer is outdated and misused. The Surgery Committee of the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer (EORTC) produced, approved, and adopted a revised classification. It is hoped that at least within the EORTC participating centers, a standardization of procedures is achieved. The clinical indications of the new classification are discussed.

Clinical study investigating the role of lymphadenectomy, surgical castration and adjuvant hormonal treatment in endometrial stromal sarcoma

The objective of this study is to assess the therapeutic importance of surgical castration, adjuvant hormonal treatment and lymphadenectomy in endometrial stromal sarcoma (ESS). A retrospective and multicentric search was performed. Clinicopathologic data were retrieved from cases that were confirmed to be ESS after central pathology review. The protocol was approved by the Ethical Committee. ESS was confirmed histopathologically in 34 women, but follow-up data were available in only 31 women. Surgical treatment (n=31) included hysterectomy with or without bilateral salpingo-oophorectomy (BSO) in 23 out of 31 (74%) and 8 out of 31 (26%) cases, respectively. Debulking surgery was performed in 6 out of 31 cases (19%). Stage distribution was as follows: 22 stage I, 4 stage III and 5 stage IV. Women with stage I disease recurred in 4 out of 22 (18%) cases. Among stage I women undergoing hormonal treatment with or without BSO, 3 out of 15 (20%) and 1 out of 7 (14%) relapsed, respectively. Among stages III–IV women receiving adjuvant hormonal treatment or not, 1 out of 5 (20%) and 3 out of 4 (75%) relapsed, respectively (differences=55.0%, 95% CI=−6.8–81.2%). Kaplan–Meier curves show comparable recurrence rates for stage I disease without adjuvant hormonal treatment when compared to stages III–IV disease treated with surgery and adjuvant hormonal treatment. Furthermore, women taking hormones at diagnosis have a better outcome when compared to women not taking hormonal treatment. Three out of 31 (9%) patients had a systematic lymphadenectomy whereas 3 out of 31 (9%) had a lymph node sampling. In one case, obvious nodal disease was encountered at presentation. Isolated retroperitoneal recurrence occurred in 1 out of 31 (3%) of all cases and in 1 out of 8 (13%) recurrences. This single woman later also developed lung and abdominal metastases. Leaving lymph nodes in situ does not appear to alter the clinical outcome of ESS. Although numbers are low, the retrospective data suggest that the need for surgical castration (BSO) in premenopausal women with early-stage disease should be discussed with the patient on an individual basis. The data support the current practice in some centres to administer adjuvant hormonal treatment.