Effect of spinal anaesthesia on the lower urinary tract in continent women

OBJECTIVE

To evaluate the effect of spinal anaesthesia on the bladder neck position and the urethral closure function in the resting state and during clinical stress test in healthy, continent women.

DESIGN

Controlled clinical trial.

SETTING

Department of Gynaecology and Obstetrics, Vienna University Medical School.

PARTICIPANTS

Fourteen continent women, of which seven were nulliparous and seven parous, underwent minor gynaecological procedures under spinal anaesthesia. Urodynamics and ultrasound investigations were performed before and during spinal anaesthesia.

MAIN OUTCOME MEASURES

Changes in the bladder neck position and the urethral closure function before and during spinal anaesthesia.

RESULTS

Bladder neck position was found to be lower and more posterior during spinal anaesthesia as compared with pre-operative assessment. The posterior urethrovesical angle increased significantly both at rest and during maximum straining. We observed a significant increase in bladder compliance, and all parameters of the urethral pressure profile decreased significantly. While none of the nulliparous women had a positive clinical stress test during spinal anaesthesia, 4/7 parous women demonstrated leakage (Fisher's exact test, P = 0.003).

CONCLUSIONS

Blockage of nerve supply to the pelvic floor muscles in continent women is associated with a significant loss of support of the bladder neck region confirming the theory of an active mechanism of muscular elements providing continence.

Prostate specific antigen (PSA) in breast and ovarian cancer

Prostatic specific antigen (PSA) is commonly used for the diagnosis and monitoring of prostatic adenocarcinoma, and has recently been detected in breast cancer and it is also thought to be produced by ovarian cancer. To examine the prognostic value of PSA tumor expression, we investigated the tumor cytosols of 26 patients with breast cancer and of 16 women with ovarian cancer. We used a chemiluminescence immunoassay for the quantitative determination of PSA (detection limit 0.003 ng/ml). The median PSA level in breast cancer patients was 0.31 ng/mg (minimum 0.003, maximum 4.4). PSA expression was significantly lower in poorly differentiated breast cancers compared to moderately and highly differentiated tumors. Advanced lymph node metastases were also correlated with lower PSA expression. We found no correlation with relapse free or overall survival. Median PSA level in our ovarian cancer patient collective was 0.014 ng/mg (minimum 0.003, maximum 0.046). We found a significant correlation between PSA expression and the estrogen receptor content of the tumor. PSA expression showed no correlation with histological grading, tumor size or other tumor characteristics in ovarian cancer. There was no correlation with relapse free or overall survival in ovarian cancer patients. Our study demonstrates that PSA is expressed in ovarian malignancies but at a lower level compared to breast cancer tissue. PSA was not able to identify a subset of patients with good prognosis in breast and in ovarian cancer patients.

Serum evaluation of interleukin 6 in ovarian cancer patients

BACKGROUND

Cytokines are intercellular hormones, believed to play a functional role in the natural history of various malignant diseases. In vitro and in vivo studies have indicated that interleukin 6 (IL-6) may provide autocrine and paracrine growth stimulation in ovarian cancer cells.

METHODS

In the present study we measured IL-6 in the serum of 73 patients with FIGO stage I to IV ovarian cancer. Enzyme-linked immunosorbent assay (ELISA) was used to determine IL-6 serum levels. Results were correlated to clinical data. Serum levels of IL-6 were additionally evaluated in a panel of 50 normal controls.

RESULTS

Median serum levels of IL-6 in patients with ovarian cancer and normal controls were 55.6 (minimum 0, maximum 2869.0) pg/ml and 0.5 (minimum 0, maximum 2.14) pg/ml, respectively (Mann-Whitney U test, P = 0.0001). When serum levels of IL-6, taken prior to therapy, were grouped by FIGO stage, lymph node involvement, and grading of tumor cells, we found a statistically significant correlation with FIGO stage (Mann-Whitney U test, P = 0.04). Lymph node involvement and grading of tumor cells were not correlated with IL-6 levels. Elevated IL-6 serum levels prior to therapy were significantly correlated with poorer disease-free (log-rank test, P = 0.003) and overall survival (log-rank test, P = 0.01).

CONCLUSION

Elevated IL-6 serum levels prior to therapy are correlated with a poor relapse-free and overall survival in ovarian cancer patients.

Serum M3/M21 in cervical cancer patients

Cytokeratins are polypeptides which constitute a subclass of intermediate filaments in epithelial cells. The serum tumour marker M3/M21 is based on monoclonal antibodies against the epitopes M3 and M21 of cytokeratin 18. In the present study, we measured M3/M21 serum levels in 50 patients with FIGO stage IB-IIB cervical cancer and in 50 control subjects using a two-site radiometric immunoassay directed against soluble fragments of cytokeratin 18. Median serum levels of M3/M21 in patients with cervical cancer and in normal controls were 70.6 U/ml (range 0-397.7) and 6.5 U/ml (range 0-205.2), respectively (Mann-Whitney U-test, P = 0.0001). Median serum levels of M3/M21 prior to therapy and 4 weeks after therapy were 104.2 U/ml (range 24.6-397.7) and 39.3 U/ml (range 0-234.7), respectively (Mann-Whitney U-test, P = 0.004). We found a significant correlation between elevated M3/M21 serum levels and metastatic disease in pelvic lymph nodes (Mann-Whitney U-test, P = 0.002). 24 patients relapsed after complete remission. In these patients, elevated M3/M21 serum levels before the detection of relapse by computed tomography was observed in 13 cases. Considering these preliminary results, further studies with an increased number of patients are justified to clarify the prognostic value and the monitoring abilities of M3/M21 in cervical cancer patients.

CD44 is an independent prognostic factor in early-stage cervical cancer

The expression of specific cell-adhesion molecule CD44 isoforms (splice variants) is associated with metastatic spread and poor prognosis in human malignancies. The aim of this study was to evaluate whether CD44 isoform expression is a prognostic factor in early-stage cervical cancer. We used 4 different variant exon sequence-specific murine monoclonal antibodies to the CD44 isoforms CD44v3, CD44v5, CD44v6 and CD44v7-8 to study the prognostic value of CD44 splice variants in 200 cases of International Federation of Gynecology and Obstetrics (FIGO) stage-IB cervical cancer by immunohistochemistry. In the univariate analysis, the expression of CD44v3 (log-rank test, p = 0.03) and CD44v6 (log-rank test, p = 0.03) was correlated with poor overall survival. In the subgroup of patients without metastatic disease in the pelvic lymph nodes, expression of CD44v6 was correlated with poor disease-free and overall survival (log-rank test, p = 0.04 and p = 0.01, respectively). Multivariate analysis, correcting for the confounding variables pelvic lymph-node involvement, depth of invasion and histologic grading, revealed CD44v6 to be an independent prognostic factor for overall survival of patients with early-stage cervical cancer. The results of this study indicate that CD44v6 is an additional prognostic marker in surgically treated cervical cancer. The assessment of CD44 isoform expression could be of clinical value in deciding upon adjuvant therapy, resulting in a more individualized management of therapy.

Fallopian tissue sampling with a cytobrush during hysteroscopy: a new approach for detecting tubal infection

OBJECTIVE

To evaluate whether the transcervical approach for fallopian tissue sampling is a practicable and safe method to establish an etiologic diagnosis of salpingitis.

DESIGN

Controlled clinical study.

SETTING

Academic research environment.

PATIENT(S)

Twenty women with primary or secondary sterility undergoing hysteroscopy and laparoscopy.

INTERVENTION(S)

During hysteroscopy, fallopian tissue samples were obtained from the proximal parts of both tubes with a cytobrush inserted through the working channel of the hysteroscope. Diagnostic laparoscopy with assessment of tubal patency was performed in the same session. The specimens were split and used for chlamydial testing by both cell culture and polymerase chain reaction. Serum samples were evaluated for the presence of antichlamydial antibodies.

MAIN OUTCOME MEASURE(S)

Practicability and safety of the method.

RESULT(S)

The sampling procedure was performed in all patients without complications. Adequate samples were obtained from both tubes in all 20 patients. The fallopian specimens showed evidence of chlamydial infection in one patient.

CONCLUSION(S)

Those data indicate that transcervical fallopian tissue sampling with a cytobrush is a reliable and safe technique.

Serum M3/M21 in ovarian cancer patients

Cytokeratins are polypeptides that constitute a subclass of intermediate filaments in epithelial cells. The aim of the present study was to evaluate the clinical usefulness of the serum evaluation of M3/M21 in patients with ovarian cancer. This retrospective study comprises 75 patients suffering from ovarian cancer FIGO stages Ia-III. M3/M21 reached a sensitivity of 78%, a specificity of 85%, a PPV of 89% and a NPV of 83% using a cut-off level of 45 U 1(-1). Forty-four women developed recurrent disease after complete remission during the observation period. M3/M21 showed lead time effects in 19 patients, ranging from 2 to 8 months (median 3.2 months). Elevated M3/M21 serum levels before therapy were associated with a poor overall survival (log-rank test, P = 0.02). Considering these preliminary results, the value of M3/M21 as a serum tumour marker, i.e. to evaluate the tumour burden, seems promising.

Detection of p53 point mutations in primary human vulvar cancer by PCR and temperature gradient gel electrophoresis

Clinical and experimental evidence is consistent with a key role of point mutations of the p53 tumor suppressor gene in the etiology of squamous cell carcinoma. To determine the relation of tumor behavior and patient survival in vulvar cancer in regard to p53 status, we retrospectively analyzed 38 paraffin-embedded specimens of primary vulvar cancer for genetic alterations of exons 5-8 of the p53 gene. For detection of p53 point mutations we used in vitro amplification by polymerase chain reaction (PCR) and temperature gradient gel electrophoresis (TGGE) and, as a detection method, direct sequencing for mutation verification. p53 point mutations were detected in 12/38 tumor specimens. Patients bearing p53 point mutations showed a significantly shorter relapse-free (log-rank test, P = 0.002) and overall survival time (log-rank test, P = 0.0006). We conclude that PCR-TGGE is an appropriate method for detection of p53 point mutations in paraffin-embedded material. We show that loss of wild-type p53 is an adverse prognostic factor in patients suffering from vulvar cancer.

Menstrual phase and breast cancer surgery: influence on clinical outcome or pitfall of statistical analysis?

The influence of menstrual status at the time of surgery on the prognosis of women suffering from breast cancer is still discussed controversially. In our patient collective, including 149 patients, we obtained statistically significant results for six different time intervals, indicating that patients who underwent surgery between 11 and 22 days after the last menstrual period (LMP) have a poorer outcome. Focusing on the effect of statistical data evaluation strategy we designed a simulation study to evaluate the amount of type I error (error of a false positive test result) in a multiple testing situation involving a cyclical covariate. Accordingly, we corrected the minimum P-values for the occurring type I error rates. After that correction all six previously significant P-values failed to achieve statistical significance. The impact of different statistical data evaluation strategies in a multiple testing situation is discussed.

Influence of microvessel density and vascular permeability factor/vascular endothelial growth factor expression on prognosis in vulvar cancer

Microvessel density (MVD) and expression of vascular permeability factor/vascular endothelial growth factor (VPF/VEGF), acting as a highly specific inducer of angiogenesis, were evaluated in tissue specimens of 25 patients with squamous cell cancer of the vulva. MVD was quantified by immunostaining for factor VIII-related antigen at one field of 0.25 mm2. VPF/VEGF expression was evaluated immunohistochemically using a monoclonal anti-VEGF antibody. FIGO stages I, II, and III were diagnosed in 12, 7, and 6 patients, respectively. MVD >20/field was found in 10 of 25 tumors and moderate or strong expression of VPF/VEGF in 10 of 25 tumors. High MVD was significantly more frequent in tumors with moderate or strong VPF/VEGF expression compared to tumors with no or weak VPF/VEGF expression (P = 0.01). Overall survival rates of patients with tumors of high MVD (P = 0.01) and strong VPF/VEGF expression (P < 0.01) were significantly poorer compared to those patients with low MVD or poor VPF/VEGF expression. Strong VPF/VEGF expression and high MVD are considered important parameters of tumor angiogenesis and therefore are related to poor survival probability in vulvar cancer patients.

Prognostic value of immunohistochemically detected CD44 isoforms CD44v5, CD44v6 and CD44v7-8 in human breast cancer

We investigated the expression of CD44 isoforms containing variant exons v5, v6 and v7-8 in 115 human breast cancer specimens by means of immunohistochemistry. CD44 isoforms CD44v5, CD44v6 and CD44v7-8 were detected in 56% (n = 64), 24% (n = 28) and 15% (n = 17), respectively. In 36 specimens of axillary lymph node metastasis, expression of CD44v5, CD44v6 and CD44v7-8 was found in 94% (n = 34), 92% (n = 33) and 89% (n = 32), respectively. Five year survival rates with or without CD44v5 and CD44v6 expression were 71% versus 86% (log-rank test, P = 0.02) and 62% versus 81% (log-rank test, P = 0.001), respectively. For disease-free survival, expression of CD44v5, CD44v6 and CD44v7-8 showed a prognostic impact (log-rank test, P = 0.004, P = 0.0001 and P = 0.0001, respectively). However, multivariate analysis revealed that all investigated CD44 isoforms failed to be independent predictors of the patient's outcome.

Quantification of uPA receptor expression in human breast cancer cell lines by cRT-PCR

The conversion of plasminogen to active plasmin is thought to be a crucial step in the process of extracellular matrix degradation associated with metastatic spread. Activation of plasminogen is initiated by urokinase plasminogen activator (uPA). The binding of uPA to the uPA cell surface receptor (uPA-R) accelerates plasmin generation from plasminogen and localizes uPA activity to the cell surface. We investigated the mRNA-expression of uPA-R in 19 different human breast cancer cell lines. In a competitive reverse transcription polymerase chain reaction (cRT-PCR) we simultaneously co-amplified two different RNA templates bearing the same primer recognition sequences, the cell line RNA and a known amount of an in vitro synthesized uPA-R-RNA internal standard. We analyzed the two PCR products differing 50 bp in size by agarose gel electrophoresis and calculated the initial uPA-R-RNA template concentration from the relative intensities of the bands quantified by video densitometry. We grouped the investigated cell lines according to their in vitro invasiveness according to literature. Cell lines with a high potential of invasiveness showed a higher expression of uPA-R compared to those with a low potential of invasiveness (Student's t-test, p 0.04). In addition to that we compared the uPA-R mRNA levels with uPA-R, uPA, and PAI-1 protein levels in culture supernatants and cell lysates. The obtained results in breast cancer cell lines with different invasiveness and in benign epithelial cell lines revealed the complex cooperation of the urokinase type proteolytic pathway. uPA, uPA-R, and PAI-1 are to be considered as a diagnostic tool rather than assaying a particular molecule alone. Our findings support the hypothesis that the urokinase proteolytic pathway plays a central role in the acquisition of an invasive phenotype and favors its potential use as a prognostic marker in patients with breast cancer.

The serum tumor marker M3/M21 in the follow-up of breast cancer patients

The aim of this study was to evaluate the new serum tumor marker M3/M21 in comparison to CA 15-3, CEA and MCA in the follow-up of breast cancer patients. We investigated 267 serum samples from 35 patients suffering from invasive breast cancer, International Union Against Cancer (UICC) stage pT1 to pT4. Cut-off values for M3/M21, CA 15-3, CEA, and MCA were 25 U/I, 30 U/I, 5 ng/ml and 11 U/I, respectively. Serum tumor marker results were correlated with the results of the clinical and radiological examinations. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of serum CA 15-3, CEA and MCA were 47/85/61/76%, 24/90/55/70% and 39/84/55/73%, respectively. Serum M3/M21 showed a sensitivity of 45%, specificity of 81%, PPV of 73% and NPV of 69%. The combination of CA 15-3 and M3/M21 increased the sensitivity to 55%, with a specificity, PPV and NPV of 83%, 79% and 86%, respectively. CA 15-3 measurements showed a lead time effect in 5 patients, ranging from 3 to 7 (median 4.1) months. The combination of CA 15-3 and M3/M21 provided lead time effects in 7 cases, ranging from 2 to 8 (median 5.7) months. We conclude that the detection of breast cancer recurrence with CA 15-3 is improved by combination with M3/M21.

p53 protein overexpression in early stage endometrial cancer

Overexpression of p53 protein has been reported to correlate with a poor prognosis in endometrial cancer. Most endometrial adenocarcinomas are clinical stage I at the time of diagnosis and the majority of women to die of this neoplasm had stage I disease at initial presentation. The aim of our study was to evaluate the prognostic significance of p53 overexpression in early stage endometrial carcinoma. Ninety-two patients with surgically treated endometrial adenocarcinoma FIGO stage I were examined for overexpression of immunohistochemically detected mutant p53 protein. Follow-up time ranged from 0.4 to 137.8 months (mean, 34.8). Thirteen women died of their tumor. A nuclear staining reaction for p53 was observed in eight cases. Women with p53 protein overexpression showed a significant poorer overall survival in univariate analysis (relative risk, 4.78; 95% confidence interval, 1.56-14.61; P = 0.006, Wald test) and also in multiple analysis adjusted for grading (relative risk, 4.39; 95% confidence interval, 1.39-13.90; P = 0.01, Wald test). Histological grading and histologic stage did not correlate with p53 protein overexpression (P = 0.26, P = 1.0, respectively, exact chi 2 test). Immunohistochemically detected p53 protein overexpression in early stage endometrial adenocarcinoma could aid in predicting prognosis and subsequently have some impact on adjuvant therapy.

Prognostic value of immunohistochemically detected CD44 expression in patients with carcinoma of the vulva

BACKGROUND

Overexpression of alternatively spliced CD44 isoforms has been reported to correlate with poor prognosis in several human malignancies. To the authors' knowledge, there are no studies concerning the prognostic value of CD44 isoform overexpression in patients with squamous cell carcinoma of the vulva.

METHODS

Thirty cases of squamous cell carcinoma of the vulva with International Federation of Gynecology and Obstetrics Stage I to III were examined immunohistochemically for overexpression of CD44 isoforms. We used 3 different variant exon sequence-specific murine monoclonal antibodies to CD44 isoforms containing variant exons v5, v6, and v7 to -8, respectively. The correlation of CD44 overexpression with clinical stage, histologic grade, and disease free and overall survival was investigated.

RESULTS

CD44 isoforms CD44v5, CD44v6, and CD44v7-8 were detected in 83% (25/30), 63% (19/30), and 27% (8/30) of the tumor samples, respectively. Patients with tumors overexpressing CD44v6 showed a significantly shorter relapse free (log rank test, P = 0.002) and overall survival (log rank test, P = 0.003) compared with patients with tumors lacking CD44v6 overexpression. Expression of CD44v5 and CD44v7 to 8 had no impact on patients' survival. Clinical stage and histologic grade did not correlate with CD44 overexpression.

CONCLUSIONS

Immunohistochemically detected overexpression of CD44 isoforms containing variant exon v6 is correlated with a poor relapse free and overall survival in patients with carcinoma of the vulva.

Expression of the adhesion molecule CD44v3 is a prognostic factor in vulvar carcinoma

Our aim was to evaluate the prognostic value of CD44v3 overexpression in vulvar cancer patients. Twenty-five cases of squamous cell carcinoma of the vulva with International Federation of Gynecology and Obstetrics (FIGO) stages I to III were examined for overexpression of the CD44 isoform CD44v3. The correlation of CD44v3 overexpression with clinical stage, histologic grade and overall survival was investigated. Follow-up ranged from 36 to 120 months. Clinical stage and histologic grade did not correlate with CD44v3 overexpression. CD44v3 overexpression was associated with poorer overall survival (log rank: P < 0.03). Immunohistochemically detected CD44v3 overexpression is significantly correlated with a reduced overall survival rate for patients with vulvar carcinoma.

Drug resistance against gemcitabine and topotecan mediated by constitutive hsp70 overexpression in vitro: implication of quercetin as sensitiser in chemotherapy

Heat shock proteins have been reported to confer resistance to certain antineoplastic drugs. We investigated the impact of hsp70 overexpression on the efficacy of two new anti-cancer drugs, topotecan and gemcitabine. We used the fibrosarcoma WEHI-S cells stably transfected to overexpress the hsp70 cDNA from the constitutive SV40 promoter and appropriate control cells. After topotecan and gemcitabine treatment hsp70-overexpressing cells showed a marked elevation in cell survival, suggesting that hsp70 overexpression was sufficient to confer resistance to the drugs. In addition, hsp70-overexpressing cells were capable of starting cell proliferation after treatment with drug dosages that were lethal to control cells. Our results demonstrate that hsp70 overexpression represents a possible cause of drug resistance. In order to transfer these data to tumour cells constitutively expressing stress hsp70 due to the constitutive activity of the original hsp70 promoter we sought to supress the heat shock response pathway by the natural flavonoid quercetin, known to inactivate the heat shock transcription factor (HSF). Using a suitable cell line, we demonstrated the sensitising activity of quercetin. We found that antineoplastic drug concentrations exerting cytotoxic activity were markedly lower when cells were pretreated with quercetin. Concomitantly, hsp70 expression was strongly down-regulated under quercetin treatment. Our data indicate that quercetin may be useful as a sensitiser in chemotherapeutically treated patients suffering from hsp70-overexpressing tumours.

Immunohistochemical detection of adhesion molecule CD44 splice variants in lymph node metastases of cervical cancer

Expression of specific cell adhesion molecule CD44 isoforms (splice variants) has been shown to be associated with poor prognosis in human cervical cancer. We used 3 different variant exon sequence-specific murine monoclonal antibodies (MAbs) to epitopes encoded by exons v5, v6 and v7-v8 of human variant CD44 to study the expression of CD44 splice variants in 35 primary squamous-cell carcinomas of the cervix and pelvic lymph node metastases by means of immunohistochemistry. Primary tumors showed expression of CD44 splice variants CD44v5, CD44v6 and CD44v7-8 in 93%, 73% and 33% of cases, respectively. Lymph node metastases expressed CD44v5, CD44v6 and CD44v7-8 in 83%, 53% and 21% of cases, respectively. Tumors with expression of CD44v6 in pelvic lymph node metastases showed metastatic spread to 2 or more pelvic lymph nodes significantly more often compared to patients without expression of splice variant CD44v6. Patients suffering from tumors with lymph node metastases expressing splice variant CD44v6 had a poorer recurrence-free survival compared to patients without CD44v6 expression in lymph node metastases, but this trend was not statistically significant. Expression of CD44 splice variants containing epitopes encoded by exon v6 in primary tumors and pelvic lymph node metastases of cervical cancer patients is consistent with a prominent role of CD44 in the process of metastasis formation.

Radiosurgery in the management of cervical intraepithelial neoplasia

OBJECTIVE

To evaluate the loop electrosurgical excision procedure (LEEP) and large loop excision of the transformation zone-conization (LLETZ-conization) in the management of cervical intraepithelial dysplasia using high-frequency, filtered waveform energy (radiosurgery).

STUDY DESIGN

Two hundred thirteen women attending the outpatient cervical colposcopy clinic with smears consistent with an epithelial abnormality, but macroscopically or colposcopically not consistent with invasive carcinoma, were included in the study. LEEP and LLETZ-conization were performed in 72 and 141 women, respectively. A matched pair group of patients undergoing cold knife conization was used for the comparison with LLETZ-conization. Using LEEP, in 83% a clear resection margin of the biopsy specimen was achieved. In this subset, diagnosis and therapy were achieved in a single visit. No complications, such as hemorrhage, occurred during the operation or postoperative period.

RESULTS

Comparison of LLETZ-conization with the matched-pair group undergoing cold knife conization showed a significantly shorter duration of surgery for LLETZ-conization (mean, 10.8 vs. 16.5 minutes, P < .001). We found no differences concerning posttreatment bleeding complications (2.8% vs. 3.3%) or clear resection margins (92% vs. 86%). Patients undergoing LLETZ-conization needed significantly less analgesic (P < .01).

CONCLUSION

Radiosurgical loop excision is a safe and cost-effective method in the diagnosis and treatment of cervical intraepithelial neoplasia.

[Behçet's disease of the uterine cervix--a case report]

Behçet's disease is a chronic disorder of unclear pathogenesis defined by multiple genital and oral ulcers, as well as ophthalmic changes. The patient described in this case report presented clinically with recurrent genital discharge, recurrent mild genital pain and a cervical ulcer. The diagnosis of Bechet's disease was established by the presence of cervical ulceration, two minor aphthous lesions in the vestibulum oris and a positive pathergy test. Although rare, Behcet's disease should be considered in the differential diagnosis of genital ulceration of unknown etiology.

Immunohistochemical and serological evaluation of CD44 splice variants in human ovarian cancer

The surface glycoprotein CD44 is widely distributed in different tissues. In contrast to healthy tissue, tumour samples show a more complex pattern of CD44 expression, indicating a loss of splice control. Beside cell-surface expression, the measurement of soluble CD44 in serum of cancer patients could be useful in early diagnosis and assessment of disease status. We evaluated the surface expression of CD44 isoforms in 22 ovarian cancer patients by means of immunohistochemistry. Additionally, we investigated 134 serological samples of these patients for the occurrence of CD44 isoform expression. For CD44 standard, CD44v5 and CF44v6 mean serum levels in patients with clinically detectable or non-detectable ovarian cancer were 422.4 +/- 143.8 ng ml-1 and 547.4 +/- 148.2 ng ml-1, 12.3 +/- 7.9 ng ml-1 and 21.9 +/- 12.2 ng ml-1 and 105.5 +/- 37.9 ng ml-1 and 144.9 +/- 50.9 ng ml-1 respectively (P-values not significant). CD44 surface proteins containing epitopes encoded by splice variants CD44v5, CD44v6 and CD44v7-8 were immunohistochemically detected in 9% (n = 2), 13% (n = 3) and 4% (n = 1) of the 22 tumour samples respectively. In the present study we showed that in ovarian cancer CD44 isoforms CD44v5 and CD44v6 are expressed in very low amounts by the tumours. In accordance with this, we found that the presence of tumour is not associated with higher serum levels of CD44standard, CD44v5 and CD44v6 in preoperative serum samples in ovarian cancer patients.

Serum evaluation of basic FGF in breast cancer patients

Basic fibroblast growth factor (bFGF) is a potent endothelial cell mitogen found in a variety of normal and tumour tissues and is of prognostic relevance in human malignancies such as renal cell carcinoma and leukaemia. This study presents the data of 104 serum samples of 20 patients suffering from breast cancer. Mean serum levels of bFGF in these patients were 13.9 +/- 17. 1 (min 0, max 56.4) pg/ml and 2.4 +/- 5.9 (min 0, max 24.7) pg/ml, respectively (p = 0.01). Basic FGF reached a sensitivity of 61% at a specificity of 87% when applying a cut-off level of 5 pg/ml. A continuous increase of bFGF serum levels before the clinical detection of relapse (lead time) was seen in 3 out of 8 cases with a mean lead time of 4 months. Preoperative serum levels were not of prognostic value and showed no correlation with axillary lymph node metastasis. These preliminary results indicate that, in breast cancer patients, soluble bFGF may be useful in early detection of primary tumours, recurrences and monitoring of therapy.

Prognostic value of CD44 splice variants in human stage III cervical cancer

The expression of specific cell adhesion molecule CD44 isoforms (splice variants) has been shown to be associated with poor prognosis in human malignancies, such as breast cancer. We used three different variant exon sequence-specific murine monoclonal antibodies to epitopes encoded by exons v5, v6 or v7-v8 of human variant CD44, to study the expression of CD44 splice variants by immunohistochemistry in human stage III cervical cancer. We investigated 40 pretreatment punch biopsies of cervical cancer FIGO stage III. CD44 splice variants CD44v5, CD44v6 and CD44v7-8 were detected by means of immunohistochemistry in 90%, 55% and 25%, respectively. CD44 epitopes encoded by exon v5 were not correlated with prognosis. Expression of CD44 splice variants containing epitopes encoded by exon v6 were correlated with significantly poorer prognosis (Mantel test, P = 0.008). Five-year survival rates with or without CD44v6 expression were 20% versus 71%, respectively. Expression of CD44v7-8 was also correlated with significantly poorer overall survival (Mantel test, P = 0.02). Expression of CD44 splice variants containing epitopes encoded by exons v7-v8 and especially exon v6 is associated with significantly poorer prognosis in stage III cervical cancer patients.

Influence of glutamine on the phenotype and function of human monocytes

Reduced concentrations of glutamine (GLN) in plasma and skeletal muscle, defective host defense systems, and a diminished expression of the HLA-DR antigen on monocytes are important diagnostic parameters for late post-injury sepsis. In this in vitro study, we investigated whether blood monocyte-derived macrophage antigen expression and function from healthy donors is influenced by GLN. Lowering the GLN concentration in culture medium from 2 mmol/L to 200 mumol/L reduced the expression of HLA-DR by 40% (P < .001) on monocyte-derived macrophages, and decreased tetanus toxoid-induced antigen presentation. In addition, low GLN levels downregulated the expression of intercellular adhesion molecule-1 (ICAM-1/CD54), Fc receptor for IgG (Fc gamma RI/CD64), and complement receptors type 3 (CR3; CD11b/CD18) and type 4 (CR4; CD11c/CD18). A correlation was found between the phagocytosis of IgG-sensitized ox erythrocytes or opsonized Escherichia coli and the decreased expression of Fc gamma RI and CR3. Monocyte expression of CD14, CD71, and Fc gamma RIII/CD16 and capacity to phagocytose latex beads were not affected by altering the level of GLN. Depletion of GLN was associated with a significant reduction in cellular adenosine triphosphate (ATP), which may have influenced cell surface marker expression and phagocytosis. It remains to be seen whether these in vitro findings are of clinical significance in the treatment of sepsis.

Serum evaluation of basic fibroblast growth factor in cervical cancer patients

We present the data of 105 serum samples from 20 patients suffering from cervical cancer. Mean serum levels of basic fibroblast growth factor (bFGF) in patients with or without tumor present were 31.3 +/- 32.1 (minimum 0, maximum 156.7) pg/ml and 4.8 +/- 6.8 (minimum 0, maximum 29.6) pg/ml, respectively (P = 0.0001). bFGF reached a sensitivity of 65.7% at a specificity of 91.5% when applying a cut-off level of 15 pg/ml. Four patients relapsed after complete remission. A continuous increase of bFGF serum levels before the clinical detection of relapse (lead time) was seen in two cases with a mean lead time of 4 months. Preoperative serum levels were not of prognostic value and showed no correlation with pelvic lymph node metastasis. These preliminary results indicate that in cervical cancer patients soluble bFGF may be useful in early detection of primary tumors, recurrences and monitoring of therapy.

[The Bethesda system--an improvement in classification of cervix cytology?]

Cervical cytology screening programmes have significantly reduced cervical cancer mortality. In 1988 the National Cancer Institute developed a new classification for reporting cervical cytology--"The Bethesda System". The aim of our study was to compare the clinical usefulness of this new classification with the classification used in German-speaking countries (which discriminates cytologically between moderate and severe dysplasia) including a verbal classification predicting the histological grade of cervical intraepithelial neoplasia (CIN I, II, III). 671 patients with abnormal cervical cytology results and subsequent conisation or hysterectomy were included. We correlated cytological and histological diagnosis (gold standard). In cases of cytologically suggested moderate dysplasia we found histologically CIN I, CIN II and CIN III in 11%, 41% and 42%, respectively. Our results show that discrimination of CIN II and CIN III by means of cytology is limited. Using our therapy schedules we found that adequate therapy is possible by each of the cytological classification systems. The cervical smear is used as a screening test to determine which women require further examination using colposcopy. Under these circumstances an adequate therapy is possible with both classifications. The results underline the importance of colposcopy in the management of cervical dysplasia. As long as conisation is commonly used in German-speaking countries as the only diagnostic tool after an abnormal cervical smear the Bethesda System increases the risk of overtreatment.

Modulation of IgA, IgE, and IgG Fc receptor expression on human mononuclear phagocytes by 1 alpha,25-dihydroxyvitamin D3 and cytokines

The effects of 1 alpha,25-dihydroxyvitamin D3/calcitriol on the expression of Fc receptors (FcR) for IgA (Fc alpha R), IgE (Fc epsilon RII), and IgG (Fc gamma R) on human peripheral blood monocytes and the cell lines U937, THP-1, and Mono Mac-6, in combination with various cytokines, was examined by flow cytometry. On both monocyte-derived macrophages and the myelomonocytic cell lines, Fc alpha R/CD89 expression was induced by calcitriol alone and additively in combination with tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), and granulocyte-macrophage colony-stimulating factor. Constitutive and interleukin-4 (IL-4)-driven Fc epsilon RII/CD23 expression was markedly diminished on calcitriol-treated U937 cells and monocytes. Fc epsilon RII was also triggered by IFN-gamma, TNF-alpha, and IL-6 on all the cell lines, an effect blocked by calcitriol. On monocytes, the basal level and IFN-gamma-induced Fc gamma RI/CD64 expression was down-regulated by calcitriol and IL-4. The expression of Fc gamma RII/CD32 on monocytes was strongly suppressed by calcitriol. Transforming growth factor-beta induced Fc gamma RIII/CD16 on monocytes, an effect opposed by calcitriol. The ability of calcitriol-treated monocytes to phagocytose IgG-sensitized ox erythrocytes was diminished. Our results demonstrate that calcitriol, alone or in combination with cytokines, modulates Fc alpha R, Fc epsilon RII, Fc gamma RI, and Fc gamma RII expression on human mononuclear phagocytes, as well as Fc gamma R-mediated phagocytosis.

Prognostic value of tumour microvessel density in cancer of the uterine cervix stage IB to IIB

High intensity of tumour angiogenesis has been correlated with an increased potential of metastasis and poor prognosis in human malignancies. We investigated 43 patients with cervical cancer stages IB (n = 13), IIA (n = 8) and IIB (n = 22). All patients were treated by radical hysterectomy and lymphadenectomy. In the tumour specimen blood vessels were highlighted by staining endothelial cells for factor VIII. Microvessels were counted on a 200x field (0.74 mm2) in the most active areas of neovascularisation. The mean microvessel counts per field for stage IB, IIA and IIB tumours were 59.6 +/- 28.1, 56.3 +/- 24.3 and 55.7 +/- 55.6, respectively (p-value = n.s.). We found no significant correlation of microvessel density and established prognostic factors like pelvic lymph node involvement, vascular space invasion and stromal reaction. Patients with tumours showing low microvessel density (< 40 microvessels per field) had a significantly poorer recurrence-free interval (log-rank test: p-value = 0.01).

IL-10 augments CD23 expression on U937 cells and down-regulates IL-4-driven CD23 expression on cultured human blood monocytes: effects of IL-10 and other cytokines on cell phenotype and phagocytosis

The effects of human recombinant interleukin-10 (IL-14) on the expression of several markers on U937 and human peripheral blood monocytes was studied by immunofluorescence and fluorescence-activated cell sorter (FACS) analysis. IL-10 augmented Fc IgE receptor (Fc epsilon RII/CD23) further enhanced by cotreatment with IL-4 or interferon-gamma (IFN-gamma). In contrast, the basal level of Fc epsilon RII expression on blood monocytes appeared to fall in response to IL-10, and this effect became more evident on IL-4-treated cells. Furthermore, the constitutive and IFN-gamma-triggered Fc gamma RI/CD64 expression was augmented on both monocytes and U937 cells. Thus the expression of Fc gamma RII/CD32, Fc gamma/RIII/CD16, Fc alpha R/CD89, the receptor for complement components (CR1/CD35, CD3/CD11b, CR4/CD11c) and the receptor for transferrin/CD71 was not significantly influenced on IL-10-treated cells. IL-10 modestly triggered CD14 antigen expression on monocytes but not U937. The expression of intercellular adhesion molecule-1 (ICAM-1)/CD54 on monocytes was significantly inhibited by IL-10. As expected, a marked reduction of the constitutive as well as of the IFN-gamma or IL-4-driven expression on HLA-DR, HLA-DP and HLA-DQ was observed on IL-10-cultured monocytes. On the other hand, the expression of major histocompatibility complex (MHC) class I molecules was slightly and dose-dependently induced on IL-10-treated monocytes. The ability of blood monocytes to phagocytose IgG-sensitized ox erythrocytes, and to bind and ingest opsonized Escherichia coli or latex particles, was amplified by IL-10. Our data demonstrate that IL-10 modulates the expression of a wide variety of structures on human mononuclear phagocytes, and augments their phagocytic capacity.

Splice variants of CD44 in human cervical cancer stage IB to IIB

Aberrant expression of the cell adhesion molecule CD44 has been detected in human tumors and the expression of specific CD44 isoforms (splice variants) has been shown to be associated with metastasis and poor prognosis in human malignancies. We used three different variant exon sequence-specific murine monoclonal antibodies to epitopes encoded by exon v5, exon v6, or exon v7-v8 of human variant CD44 to study the expression of CD44 splice variants by immunohistochemistry in human cervical cancer. One-hundred five patients with surgically treated squamous cell carcinomas of the cervix stages IB to IIB were included in the study. CD44 splice variants CD44v5, CD44v6, and CD44v7-8 were detected in 70, 67, and 26%, respectively. Tumors expressing exon v6 had significantly more often metastasized to the pelvic nodes (58 vs 79%, P = 0.04). Expression of exon v6 was significantly correlated with a greater probability of vascular space invasion (73 vs 50%, P = 0.04) and a significantly lower rate of inflammatory stromal reaction (48 vs 78%, P = 0.004). Patients suffering from tumors expressing splice variant CD44v6 showed poorer overall survival (P = 0.03). In cases with negative pelvic lymph nodes we found a poorer prognosis when tumors expressed CD44v6 (P = 0.01) or CD44v7-8 (P = 0.02). Among the investigated CD44 splice variants expression of exon v6 is the most promising prognostic marker in surgically treated cervical cancer.

Tissue polypeptide specific antigen and cancer associated serum antigen in the follow-up of ovarian cancer

420 clinical and serological examinations prior to surgery and during follow-up were performed in 30 patients suffering from ovarian cancer. The population consisted of three FIGO stage Ia, nine stage Ic, four stage II and fourteen stage III cases. Serous carcinoma of the ovary, mucinous carcinoma and other kinds of ovarian cancer were found in 16, 9 and 5 cases, respectively. The serum levels of the tumor markers tissue polypeptide specific antigen (TPS), cancer associated serum antigen (CASA) and carbohydrate antigen 125 (CA 125) were determined. Cut-off values of 97 U/l, 4 U/ml and 35mU/ml for TPS, CASA and CA 125, respectively, were selected according to the 95% of serum concentrations measured in healthy controls. Sensitivity, specificity, PPV and NPV of CA 125 were 75%/96%/69%/92%, respectively. Sensitivity, specificity, PPV and NPV of TPS were 67%/84%/59%/90%, respectively. CASA showed a sensitivity of 58%, specificity of 96% and a PPV and NPV of 73%/94%, respectively. The combination of TPS and CA125 increased the sensitivity to 81%, reaching a specificity of 82% and a PPV and NPV of 58/96%, respectively. The combination of CASA and CA125 showed a sensitivity, specificity, PPV and NPV of 88/85/65/96%, respectively. Twelve patients developed recurrence of disease after response to primary treatment. TPS, CASA and CA 125 detected recurrent disease in six, two and four cases, respectively. For TPS mean lead time was 4.6 months (range 2-18 months), for CASA 1.7 months (range 1-6 months), and for CA 125 3.5 months (range 1-24 months. As a matter of fact TPS never showed lead time effects in patients without elevated pretherapeutic levels. A combination of all makers showed a mean lead time of 6.72 months. Detection of recurrent disease by CA 125 is improved when CA 125 is used in combination with TPS, especially in those patients with pretherapeutically elevated TPS serum levels.

Serum CD44 splice variants in cervical cancer patients

Aberrant expression of the cell adhesion molecule CD44 has been detected in human tumours and has been shown to be associated with metastasis and poor prognosis in human malignancies. We evaluated serum levels of different soluble CD44 molecules (CD44 standard form and CD44 splice variants v5 and v6) in cervical cancer patients stage IB to IIIB. Two-hundred three serum samples were analysed. Serum levels of CD44st and CD44v5 showed no significant correlation with the presence or absence of cervical cancer. The splice variant CD44v6 showed a mean concentration of 227.3 +/- 90.9 (minimum 71.4, maximum 543.9) ng/ml when tumour was present and a mean concentration of 198.7 +/- 135.4 (minimum 67.2, maximum 696.3) ng/ml in cases of complete remission (P-value = 0.0001). However, in this preliminary study the sensitivity/specificity characteristic of CD44v6 was poor.

Influence of age and human papillomavirus-infection on reliability of cervical cytopathology

The aim of the present study was to evaluate the effect of age and human papillomavirus (HPV) infection associated cellular changes on the predictive value of cervical cytology. In a group of 671 women with Papanicolaou smears suggesting low grade squamous intraepithelial lesion (LSIL), a high grade squamous intraepithelial lesion (HSIL) or invasive cervical cancer, cervical cytology was correlated with the histological finding. Predictive values were calculated and related to severity of the lesion, age and HPV associated changes. The predictive values of Papanicolaou (cervical) smears suggesting LSIL, HSIL and invasive carcinoma were 40%, 86%, and 78%, respectively. A poor predictive value of smears suggesting LSIL was found among older women. HPV associated changes were diagnosed in 80% of women < or = 25 years of age, 66% in the age group 26 to 35 years, 51% in the age group 36 to 45 years and 38% in women aged > or = 46 years (P = 0.03). The presence of HPV associated cellular changes led to a significantly higher number of overdiagnoses (9% with HPV infection compared to 4% without HPV infection) and HPV negative cases were more frequently associated with underdiagnosis (15% without HPV infection compared to 8% with HPV infection, P = 0.0011). This result remained significant after adjustment for age (P = 0.004). Cellular changes associated with HPV infection most frequently occurred in young women. HPV infection should therefore be acknowledged as source of overdiagnosis in the cytological evaluation of SIL especially in young women.

[CD44 splice variants as prognostic factors in invasive cervix carcinoma]

OBJECTIVE

Aberrant expression of specific isoforms of the cell adhesion molecule CD44 has been detected in various malignant human tumors. We wanted to verify whether the expression of these splice variants was associated with a higher incidence of metastasis and poor prognosis.

METHODS

We studied the expression of CD44 splice variants v5, v6 and v7-8 by immunohistochemistry in human cervical cancer. 105 surgically treated patients with cervical cancer of stages IB-IIB were included in the study.

RESULTS

Tumors expressing exon v6 had significantly more often metastasized to the pelvic nodes (p = 0.04), and patients suffering from tumors expressing CD44v6 showed poorer overall survival. Even in cases with negative pelvic lymph nodes, we found a significantly poorer prognosis when tumors expressed CD44v6.

CONCLUSIONS

Among the investigated CD44 splice variants, expression of exons v6 and v7-8 is the most promising prognostic marker in cervical cancer. They can possibly identify patients with an increased risk earlier than morphologic prognostic parameters.

Vascular space invasion and inflammatory stromal reaction as prognostic factors in patients with surgically treated cervical cancer stage IB to IIB

We assessed the prognostic value of the local tumor characteristics inflammatory stromal reaction (ISR) and vascular space invasion (VSI) together with established prognostic criteria, in cervical cancer patients. One hundred and forty-two patients with carcinoma of the cervix stage IB to IIB undergoing radical hysterectomy and lymphadenectomy between October 1980 and September 1990 were included in the study. Pelvic lymph node involvement, stage, parametrial involvement, age and histological tumor type were analysed together with VSI and ISR as prognostic factors. The most important prognostic parameters for recurrence-free interval and overall survival in the univariate analysis were pelvic lymph node involvement (P-value < 0.0001/0.0001) and stage (P-value < 0.0001/0.0005). ISR and VSI showed a significant prognostic value for recurrence-free interval (both P-values = 0.0014) and overall survival (ISR: P-value < 0.0001; VSI: P-value = 0.0018). In the multivariate analysis ISR showed an independent prognostic value for overall survival (P-value = 0.03, Relative Risk = 5.4, 95%-confidence interval 1.2-24.5). ISR, reflecting the biological behavior of the tumor, should be considered in the evaluation of prognosis in surgically treated squamous cell carcinoma of the cervix.