Congenital renal malrotation in ovarian cancer surgery: A case report

► We consider a case of laparoscopic aortic lymphadenectomy for an early ovarian cancer including a comprehensive surgical staging. ► The patient was found to have a congenital anatomic abnormality: a right renal malrotation with an accessory renal artery. ► We used a preoperative CT angiography study to diagnose such anatomical variations and to adequate the proper surgical technique.

A multicenter phase II randomized trial of docetaxel/gemcitabine versus docetaxel/capecitabine as first-line treatment for advanced breast cancer: a Gruppo Oncologico Italia Meridionale study

OBJECTIVE

To evaluate two docetaxel-based regimens as first-line treatment in advanced breast cancer patients.

METHODS

Patients were randomly assigned to docetaxel/gemcitabine (arm A: docetaxel 75 mg/m(2) on day 1, gemcitabine 1,000 mg/m(2) on days 1 and 8) or docetaxel/capecitabine (arm B: docetaxel 75 mg/m(2) on day 1, capecitabine 1,250 mg/m(2) twice daily on days 1-14); both chemotherapy regimens were repeated every 21 days. The primary objective of the study was to evaluate the response rate.

RESULTS

Seventy-two patients were enrolled (36 each in arms A and B). Responses according to intention-to-treat analysis were as follows: arm A, 41.7% [95% confidence interval (CI) 25.6-57.8]; arm B, 38.9% (95% CI 23-54.8). Median progression-free survival was 10.9 months (95% CI 8.1-13.7) in arm A and 10 months (95% CI 8.8-11.2) in arm B. Overall survival was 26 months (95% CI 22.0-30.0) in arm A and 28 months (95% CI 23.4-32.6) in arm B. Both treatments were well tolerated; myelosuppression was the dose-limiting toxicity, with grade 3-4 neutropenia in 13.8 and 19.4% of the patients in arms A and B, respectively. No relevant differences in other toxicities were observed in the two arms, except for diarrhea (13.9%) and hand-foot syndrome (11.1%), which occurred only in arm B.

CONCLUSIONS

Both regimens were active and well tolerated in advanced breast cancer.

Laparoscopic staging of early ovarian cancer: results of a multi-institutional cohort study

BACKGROUND

Minimal access surgery to stage early ovarian cancer (EOC) is still regarded as investigational among many gynecologic oncologists. Reporting outcome data from large cohorts is currently the only practical way to further define the appropriateness of minimally invasive surgery for EOC patients. We sought to investigate the safety, adequacy, and outcome of laparoscopic staging of EOC by using a multi-institutional sample.

METHODS

Prospectively collected data in three gynecologic oncology service databases were searched for EOC patients undergoing laparoscopic staging. Surgical, pathologic, and oncologic outcome data were analyzed.

RESULTS

The study cohort consisted of 82 women. The mean operative time was 263 ± 81 minutes. The median estimated blood loss was 100 (range 20-3000) ml. The median number of pelvic and para-aortic lymph nodes collected was 23 (3-39) and 13 (3-43), respectively. The disease was reclassified to a higher stage in 21 women (25.6%). No conversion to laparotomy occurred, and one patient had intraoperative hemorrhage requiring blood transfusion. Thirteen patients (15.8%) experienced postoperative complications. The median follow-up period was 28.5 (range 3-86) months. Overall survival and disease-free survival for the entire cohort were 98.8% and 95.1%, respectively. In the subgroup of patients who had reached or exceeded 3 years' follow-up (n = 34), 3-year overall survival and 3-year disease-free survival were 97% and 91.2%, respectively.

CONCLUSIONS

When performed by appropriately skilled surgeons, laparoscopic comprehensive staging of EOC seems feasible and adequate, with surgicopathologic results that are reproducible in different practice settings.

A multicenter prospective phase II randomized trial of epirubicin/vinorelbine versus pegylated liposomal doxorubicin/vinorelbine as first-line treatment in advanced breast cancer. A GOIM study

BACKGROUND

To evaluate activity and tolerability of two anthracycline-containing regimens as first-line treatment for anthracycline-naïve relapsed breast cancer patients.

METHODS

Patients with relapsed breast cancer not previously treated with adjuvant anthracyclines were randomly assigned to epirubicin/vinorelbine (arm A: EPI/VNB, EPI 90 mg/m2 on day 1, VNB 25 mg/m2 on days 1,5 plus G-CSF subcutaneously on days 7-12, with cycles repeated every 21 days), or to pegylated liposomal doxorubicin/VNB (arm B: PLD/VNB, PLD 40 mg/m2 on day 1, VNB 30 mg/m2 on days 1, 15, with cycles repeated every 4 weeks). Primary objective was to evaluate the efficacy of the two regimens in terms of response rate, secondarily toxicity, progression free survival and overall survival.

RESULTS

One hundred and four patients have been enrolled (arm A 54, arm B 50): characteristics were well balanced between the 2 arms. Responses were as follows: arm A, 3 (5.6%) CR, 20 (37%) PR, (ORR 42.6%, 95%CI 29.3%-55.9%); arm B, 8 (16%) CR, 18 (36%) PR, (ORR 52%, 95%CI 38.2%-65.8%). Median progression free survival was 10.7 months in arm A (95% CI, 8.7-12.6), and 8.8 months in arm B (95% CI, 7.1-10.5). Median overall survival was 34.6 months in arm A (95%CI, 19.5-49.8) and 24.8 months in arm B (95%CI, 15.7-33.9). As toxicity concerns, both treatment regimens were well tolerated; myelosuppression was the dose-limiting toxicity, with G3-4 neutropenia occurring in 18.5% and 22% of the patients of arm A and B, respectively. No relevant differences in main toxic effects have been observed between the two arms, except for alopecia, more common in arm A, and cutaneous toxicity, observed only in arm B. No clinical congestive heart failures have been observed, one case of tachyarrhythmia was reported after the last EPI/VNB cycle, and two reversible ≥ 20% LVEF decreases have been observed in arm A.

CONCLUSIONS

Both anthracycline- containing regimens evaluated in the present study seem to be active and with a satisfactory tolerability in anthracycline-naïve relapsed breast cancer patients.

[Specificity of action of anticancer agents]

Since the first cancer chemotherapy use, efforts have been made in identifying drugs with an antitumor specific action, but cancer is a very complex situation to be cured with a single agent, and to increase drugs selective cytotoxicity new agent combinations, or innovative cellular cycle related schedule, or the use of pro-drugs have been developed. Notwithstanding some relevant improvements in results, chemotherapy remains often a palliative approach. The improved knowledge of the biology of cancer, and of molecular mechanisms and specific targets, has recently modified the approach to various tumors. In particular, the identification of a single and specific genetic alteration in some tumors such as myeloid chronic leukaemia or gastrointestinal stromal tumors (GIST) led to the development of imatinib, a "target" drug with a multikinase inhibitor activity towards the specific genetic alteration; this unique opportunity is not applicable to other tumors, because usually tumors have multiple genetic alterations with very complex molecular pathways. The development of drugs with a multitarget action is probably the best approach to the majority of human cancers, but other possibility are the combination of multiple agents, each with known selective activity towards a specific molecular target, or the choice of a chemotherapic drug in combination with one or more molecularly targeted drugs. The knowledge of the multiple and extremely complex molecular pathways of the neoplastic cells will hopefully drive oncologic science towards a more "exact" science, with the use of "personalized" treatment in each cancer patient.

Biological progression of breast cancer and clinical implications

The classic view of tumor progression is that genetic mutation introduced in differentiated or progenitor cells causes tumors, through the acquisition of advantages for survival, and leading to phenotypic heterogeneity. Another theory (stem cell hypothesis) considers that tumor progression derives from cells within the tumor with stem cell characteristics of self-renewal and multiple differentiation potential. It is still unknown the timing of expression of various biological characteristics of breast cancer during the progression cascade, and the existence of clonal heterogeneity within primary tumor and synchronous or asynchronous distant metastases contributes to treatments failures.

Persistence of HPV after radio-chemotherapy in locally advanced cervical cancer

A causal association of high risk HPV persistent infections with cervical cancer is firmly established by epidemiological and experimental evidence. Since HPV is considered a necessary factor for cervix carcinoma development and disease severity, the HPV DNA persistence may represent an indicator of both therapy effectiveness and risk of recurrence. The presence of HPV in locally advanced cervical carcinoma was analysed at the beginning of therapy, shortly after treatment and during follow-up, in 18 patients with cervix carcinoma treated by radio/chemotherapy. Persistence of HPV DNA sequences was revealed in 62.5% (10/16) of HPV positive patients, in which the HPV type and its physical status were exactly the same as at the onset of therapy, even many years after surgery. Interestingly, in two patients the HPV18 sequence analysis detected the same point mutations in the samples before and after the chemotherapy, and during the follow-up. HPV DNA clearance was associated with a better patient outcome because the majority of the HPV cleared women showed a complete response (6/6), no disease recurrence (4/6), and are still alive. Nevertheless, statistically significant association was seen only with complete responses versus partial or no responses. In conclusion, we demonstrated that HPV DNA positive tumour cells might persist for years in the genital epithelia, even after the surgical removal of the cervix and that HPV DNA detection after therapy is a valid and significant (p=0.03) tool to assess the efficacy of the treatment.

Human papillomavirus prevalence and type-specific relative contribution in invasive cervical cancer specimens from Italy

BACKGROUND

Cervical cancer represents an important global public health problem. It is the 2nd most common cancer among women worldwide. Human papillomavirus (HPV) infection is now well-established as a necessary cause of invasive cervical cancer (ICC) development. Only a few studies on HPV prevalence and type-specific distribution in ICC have been conducted in Italy.

AIM

To describe the prevalence of HPV and the HPV type-specific distribution in ICC cases identified in Rome, Italy.

METHODS

140 paraffin embedded tissue blocks of primary ICC diagnosed between 2001 and 2006 were identified at the Regina Elena Cancer Institute in Rome (Italy). HPV was detected through amplification of HPV DNA using SPF-10 HPV broad-spectrum primers followed by DEIA and then genotyping by LiPA25 (version 1).

RESULTS

134 cases were considered suitable for HPV DNA detection after histological evaluation; and overall, 90.3% (121/134) HPV prevalence was detected. 111 cases had a single HPV type, 4 cases had an uncharacterized type (HPVX) and 6 cases had multiple HPV infections. The five most common single HPV types among positive cases were: HPV16 (71/121; 58.7%), HPV18 (12/121; 9.9%), HPV31, HPV45 and HPV58 (5/121; 4.1% each). 2 (1.5%) of the single infections and 2 (1.5%) of the multiple infections contained low risk types. Statistically significant differences in the relative contribution of HPV18 were found when comparing squamous cell carcinomas with adenocarcinomas.

CONCLUSIONS

HPV16 and HPV18 accounted for almost 70% of all the HPV positive ICC cases. The study provides baseline information for further evaluation on the impact of recently introduced HPV vaccines in Italy.

Recent advances in the adjuvant treatment of early breast cancer

The majority of breast cancers are actually diagnosed at an early stage. Selection of the best treatment in the adjuvant setting represents a paramount step to reduce the risk of recurrence and cancer-specific mortality. At the present time decision making is based on individualized risk assessment, that takes into account patient and tumor clinical-pathological characteristics. New available tools, such as gene expression profiling, offer the potential to provide accurate prognostic and predictive information, but they require further validation. The present article provides an overview of current strategies in adjuvant breast cancer setting, and addresses a number of unresolved questions related to the role of taxanes, trastuzumab and hormonal treatment.

Progression of conservatively treated endometrial complex atypical hyperplasia in a young woman: a case report

OBJECTIVE

To describe a case of progression of endometrial complex atypical hyperplasia (CAH) to extrauterine endometrioid adenocarcinoma in a patient who had requested fertility-sparing management.

DESIGN

Case report.

SETTING

Division of Gynecologic Oncology, National Cancer Institute "Regina Elena," Rome, Italy.

PATIENT(S)

A nulliparous 36-year-old woman with endometrial CAH who decided on a conservative approach.

INTERVENTION(S)

Conservative hysteroscopic resection of the lesion, the surrounding endometrium, and underlying myometrium plus hormone therapy regimen of megestrol acetate (160 mg) daily for 6 months.

MAIN OUTCOME MEASURE(S)

Failure of the conservative therapy and progression of disease.

RESULT(S)

Eighteen months after fertility-sparing management, a laparoscopic operation revealed grade 2 endometrium adenocarcinoma with superficial myometrial invasion and a microscopic metastasis of the left ovary and Douglas peritoneum. The patient underwent adjuvant chemotherapy followed by external beam radiation of the pelvis and brachytherapy. Twenty-five months after, she was free of disease.

CONCLUSION(S)

Conservative therapy is feasible in carefully selected young women with endometrial CAH. However, close follow-up is required because of possible progression to endometrial cancer.

Endometrial biopsy by means of the hysteroscopic resectoscope for the evaluation of tumor differentiation in endometrial cancer: A pilot study

AIMS

To assess the diagnostic accuracy of endometrial biopsy by means of the hysteroscopic resectoscope (EBHR) in evaluating tumor differentiation in patients with endometrial cancer.

METHODS

Between January and December 2005, all the women with a diagnosis of endometrioid adenocarcinoma of the uterus, when admitted to hospital, were enrolled for this study. Patients eligible for surgical treatment underwent a preoperative work-up consisting in pelvic magnetic resonance imaging (MRI) and EBHR. In all patients submitted to a hysterectomy, a comparison between pre- and postoperative tumor grade was carried out.

RESULTS

42 women were enrolled in the study. Hysteroscopic biopsy was carried out in 39 patients (mean age 62.5 years, range 33-79; FIGO stage I: 34, stage II-IV: 5). No complication related to hysteroscopy was observed. The preoperative tumor grade by hysteroscopy correlated with the final grade in 97.1% of cases. No patient had positive peritoneal washing and after a median follow-up of ten months no intraperitoneal tumor relapse was observed.

CONCLUSION

EBHR is a very accurate diagnostic procedure for assessing the preoperative tumor grade in patients with endometrial cancer.

Conservative treatment of reproductive and sexual function in young woman with squamous carcinoma of the vagina

OBJECTIVE

Primary squamous carcinoma of the vagina in young woman is extremely rare. Conservative management of both sexual and reproductive function poses challenging problems to gynecologic oncologists.

METHODS

Between January 2001 and December 2004, four women under 40, nulliparous, with squamous cell carcinoma of the upper third of the vagina, at FIGO Stage I were submitted to conservative surgery of the reproductive/sexual function at our Institution. After written informed consent was obtained, conservative surgical treatment consisting of radical tumorectomy with pelvic lymphadenectomy, in three patients, and partial hemi-vaginectomy plus homolateral paracolpectomy/parametrectomy with pelvic lymphadenectomy, in the forth patient, was carried out.

RESULTS

Mean operative time of conservative surgical treatment was 161 min. No intraoperative or postoperative complications were observed. In one patient, definitive pathologic examination revealed microscopic involvement of the paracolpium. Thus, after carrying out laparoscopic ovarian transposition, adjuvant radiotherapy (RT), consisting of pulsed-dose rate brachytherapy and external RT, was delivered in this woman. After a follow-up time of 51, 45, 21 and 9 months, respectively, all patients are regularly menstruating, sexually active and clinically free of disease.

CONCLUSION

To our knowledge, this is the first report showing the feasibility and the efficacy of conservative surgery of reproductive and sexual function in young woman with vaginal carcinoma. A larger number of patients and a longer follow-up are needed to validate the safety of this approach.

Voluminous mucinous cystadenoma of the ovary in a 13-year-old girl

BACKGROUND

Mucinous cystadenoma of the ovary constitutes about 15% of ovarian tumors. It is more common in women between 20 and 40, but is rare in teenagers and exceptional in pre-menstrual girls. Malignant transformation is possible in 5-10% of cases. Spontaneous or iatrogenic breaks are more common. It makes the different diagnosis of pseudomixoma peritonei more difficult.

CASE REPORT

A 13-year-old girl came to the National Cancer Institute "Regina Elena" of Rome, with increasing abdominal distension over 2 months. The abdominal mass was removed and a left salpingo-oophorectomy was performed. Histological examination of the mass revealed a 40-cm diameter mucinous cystadenoma of the ovary.

CONCLUSION

The rapid enlargement of the ovarian mass, the young age and the difficulty of certain pre-operative diagnosis, make this case interesting. Management of this pathology and fertility-conserving treatment need careful follow-up because of the possibility of recurrence in the remaining ovary.

3-D Ultrastructural Distribution of Collagen in Human Placental Villi at Term in Relation to Vascular Tree

In order to understand the 3-D distribution of collagen in relation to vascularization, chorionic villi of human placentae, belonging to normal pregnancies at term, were studied by scanning electron microscopy (SEM) after alkali maceration techniques, and by transmission electron microscopy (TEM). The villous tree appeared made of an uninterrupted structure of collagen fibres. The collagen fibres connected the chorionic villi axis with their basal plates and organised differently according to the various levels of villous branching. The collagen of stem villi showed copious fibres. The external fibres (facing the villous surface) were arranged mainly longitudinally. The central core of the villi (inner fibres) were arranged concentrically around the wall of the fetal vessels. Both external and internal fibres formed stratified lamellae or small parallel bundles. The inner core of stem villi showed small holes housing capillary spaces. Mature intermediate and terminal villi showed a scarce amount of collagen arranged in thin concentric layer within the villous core, surrounding numerous dilated capillary and sinusoid spaces.These observations demonstrated that the extracellular matrix of human chorionic villi is highly compartmentalised and shows a variable structural 3-D distribution depending on the branching level of the villous tree, such a distribution ensures the most favourable microenvironment for feto-maternal exchanges and it is likely able to provide a modulated support to the developing chorionic fetal vessels and trophoblastic layer as well.

Analysis of chromosomes 3, 7, X and the EGFR gene in uterine cervical cancer progression

The aim of this study was to investigate the possible role of genetic alterations in the genesis and progression of cervical carcinomas. We analysed the 3, 7, X aneusomy of chromosomes and the status of the epidermal growth factor receptor (EGFR) gene by fluorescence in situ hybridisation (FISH) analysis. Polysomy of chromosomes 3 and X defined the transition from high-grade squamous intraepithelium lesions (HSIL) to cervical carcinoma. Chromosome 7 monosomy and polysomy did not show any statistical significant differences between the groups examined. When we compared the chromosomal aneusomies in all of the specimens using the Kruskal-Wallis test, significant differences (P = 0.0001, P = 0.0001 for chromosomes 3 and X, respectively) were observed. Using a ratio of the EGFR gene signals and chromosome 7 centromeric signals, no samples showed gene amplification. Our results demonstrate the importance of chromosomal 3 and X aneusomies in the development and progression from HSIL to cervical carcinoma, highlighting their usefulness as genetic markers for identifying SILs at high-risk of progression.

Role of pelvic lymphadenectomy in the management of stage I endometrial cancer: our experience

OBJECTIVES

To estimate the prognostic value of pelvic-node removal on survival of patients affected by endometrial carcinoma at presurgical FIGO Stage I.

METHODS

A retrospective analysis was performed on a total of 111 patients recruited from 1990 to 1996 at the S. Carlo di Nancy Hospital. Thirty-nine (35%) of them underwent a total hysterectomy and bilateral salpingo-oophorectomy with removal of the vaginal cuff (group 1), while 72 (65%) underwent a total hysterectomy combined with pelvic lymphadenectomy (group 2). Prognostic features including tumor grade, depth of myometrial invasion and histologic subtype. Survival rates were calculated with Cox and Kaplan analyses.

RESULTS

Overall survival rate at five years was 91.2%. The survival rate of group 1 and group 2 was 89% and 92.8%, respectively which is not statistically significant. Stage, grade, histotype, age at diagnosis, and presence of positive lymph nodes did not show any significant prognostic value on survival probability.

CONCLUSIONS

The survival rate for patients submitted to lymphadenectomy (group 2) was the same of patients who did not undergo this treatment (group 1). Nevertheless, pelvic lymphadenectomy in endometrial carcinoma at presurgical FIGO stage I was worthwhile as it allowed correct staging to be performed. The prediction of nodal disease based only on preoperative investigations (such as TC, NMR) is often inaccurate.

Changes of ovarian microvasculature in hCG stimulated rabbits. A scanning electron microscopic study of corrosion casts

The microvasculature of the ovarian cortex was studied by means of scanning electron microscopy of vascular corrosion casts in estrous and hCG stimulated rabbits in order to establish a better understanding of the structural as well as functional vascular changes which accompany the evolution of the luteofollicular complex. According to the various shape and size seven different morphological types of vascular plexuses corresponding respectively to antral follicles (Types 1-2), atretic follicles (Types 3-4), periovulatory follicles (Type 5), growing pseudopregnant corpora lutea (Type 6) and regressing pseudopregnant corpora lutea (Type 7) were identified. Growing to mature cycling type follicles (Types 1-2) showed a gradual enlargement and proliferation of the theca capillaries. These changes, associated with capillary hyper-permeabilization were observed in ovulatory and post-ovulatory follicles (Types 5), after hCG stimulation. The corpus luteum formation (Types 6) was accompanied by additional capillary dilatation, diffuse angiogenetic sprouts and organization of a more conspicuous venous drainage. The regression of the corpus luteum (Type 7) was characterized by the appearance of avascular areas within the glandular tissue and by regression of vascular dilatation. The atretic follicle (Types 3-4) wall showed large interruptions (avascular areas) and focal invasion of the central cavity by newly formed capillaries randomly arranged. The hCG stimulation did not affect consistently the atretic follicle microvasculature. The present observation shows that both thecal capillary vasodilatation and angiogenetic processes support the gradual increase of ovarian blood flow during follicle growth and corpora lutea formation and that microvascular changes of atretic follicles are possibly related to a type of inflammatory reaction since they seem to be a consequence rather than a primary cause of atresia.

The collagen fibrils arrangement in the Wharton's jelly of full-term human umbilical cord

In the present study, a cell maceration/scanning electron microscopy method is employed in order to reveal the three-dimensional organization of the collagen fibrils in the Wharton's jelly of the human umbilical cord at term. By this method the jelly appears as a three-dimensional network of collagen fibrils that runs continuously from the amniotic membrane to the umbilical vessels. A diverse architecture of the collagen fibrillar network in the inner and outer region of the cord is observed suggesting an anatomical as well as a functional compartmentalization. In fact, the network is soft in the inner part and it is characterized by canalicular structures whereas in the outer region the collagen is dense and the network is characteristically composed by a sponge-like system of cavernous spaces. It is suggested that these cavities might store the ground substance and allow its diffusion during twisting or compression of the cord. Furthermore they may facilitate the flow of metabolites throughout the jelly from and to the umbilical vessels and the amniotic cavity.