[Gynecologic cancer]

Surgery and radiation therapy have been the main types of treatment for gynecologic cancer. However, chemotherapy in gynecologic oncology has recently made dramatic progress and presently is becoming the most widespread treatment. After the discovery of cisplatin in the field of chemotherapy for epithelial ovarian cancer, it has now become the leading treatment modality. According to the result of several important phase III randomized control trials (RCTs), the platinum-taxane combined therapy has now become the standard treatment regimen. Regarding endometrial cancer, Cisplatin-Adriamycin-Cyclophosphamide (CAP) therapy has been used as an effective adjuvant chemotherapy in Japan. The adjuvant chemotherapy (Adriamycin-Cisplatin therapy) for the endometrial cancer has now been recognized worldwide as the standard therapy based on the findings of a phase III RCT. Concurrent chemoradiotherapy for cervical cancer has also been recommended as the standard therapy in Japan since 1999 based on the successful results of numerous RCTs which proved its efficacy. The chemotherapy for gynecologic cancers has been investigated and standardized based on the results of numerous clinical trials. These trials have been conducted by many clinical trial groups, such as the Gynecologic Oncology Group (GOG), Southwest Oncology Group (SWOG), and the European Organization for Research and Treatment of Cancer (EORTC) throughout the world, in addition to the Japan Clinical Oncology Group (JCOG) and the Japanese Gynecologic Oncology Group (JGOG) in Japan. The valuable contributions of these clinical trials are helping in the development of new drug therapies, thus leading to such treatment regimens playing increasingly important and wider roles in the field of gynecologic oncology treatment in the future.

Development and verification of a prediction model using serum tumor markers to predict the response to chemotherapy of patients with metastatic or recurrent breast cancer

PURPOSE

The aim of this study was to develop a prediction model using serum tumor markers to predict the response to chemotherapy of patients with metastatic or recurrent breast cancer.

METHODS

We retrospectively analyzed a training set of 105 patients with metastatic or recurrent breast cancer. Their chemotherapeutic response had been evaluated according to the World Health Organization (WHO)'s response criteria. Our model for predicting response using carcinoembryonic antigen (CEA), carbohydrate antigen (CA) 15-3, and NCC-ST-439 was determined using the area under the receiver operating characteristic curve (ROC-AUC) and the overall misclassification rate (OMR) in a random cross-validation. The prediction model was then verified in a consecutive set of 64 patients. Their response had been evaluated using the response evaluation criteria in solid tumors (RECIST) criteria.

RESULTS

The best prediction model consisted of the serum CEA, CA15-3, and NCC-ST-439 levels, but the prediction formula varied according to the baseline CA15-3 level (elevated or normal). The overall ROC-AUC and OMR in the training set were 0.83 and 0.19, respectively. The overall ROC-AUC and OMR in the verification set were 0.72 and 0.28, respectively. When the verification set was stratified according to either the objective response or the predicted response, the time-to-progression, but not the overall survival, was significantly different.

CONCLUSION

Our model for predicting the response to first-line chemotherapy of patients with metastatic or recurrent breast cancer may be valid because it predicted the outcome of more than 70% of the patients in an independent verification set.

Novel missense mutation in the P-box of androgen receptor in a patient with androgen insensitivity syndrome

Mutations in the X-linked AR gene cause androgen insensitivity syndrome (AIS) by impairing androgen-dependent male sex differentiation to various degree. Here we describe a partial AIS patient with confliction with the assigned female sex. Although the patient was noticed to have ambiguous genitalia at birth, the patient was reared as a female with no medical intervention. At the age of 31 years, the patient visited us because the patient was dissatisfied with the assigned female sex. The patient was treated with systemic testosterone and topical dihydrotestosterone, but the external genitalia responded only minimally to the treatment. The genetic analysis revealed a novel missense K580R mutation in the P-box of the DNA-binding domain of androgen receptor, which was the first missense mutation shared by AIS and prostate cancer. Although the best predictor of the adult gender identity is documented to be the initial gender assignment in patients with partial AIS as well as those with complete AIS, deciding gender assignment for infants with partial AIS is still challenging.

Analysis of the clinicopathological prognosis of stage IVb cervical carcinoma

The aim of this study was to evaluate the clinicopathological prognostic factors in patients with stage IVb cervical carcinoma (CC). All patients with stage IVb CC included in the study were diagnosed from 1997 to 2006 at the National Cancer Center Hospital. We retrospectively examined clinicopathological parameters in these patients, including the efficacy of chemotherapy. Survival was evaluated using Kaplan-Meier curve analysis and log-rank test. The independent prognostic factors found to be predictive of survival in univariate and multivariate analysis were evaluated using a Cox's proportional hazard model. Thirty-six patients (median age 54 years) were diagnosed with stage IVb CC. The median progression-free survival and overall survival were 3.8 and 11.1 months, respectively. As initial treatment, 4 patients underwent hysterectomy, 13 received chemotherapy, 17 received radiotherapy, and the remaining 2 patients refused treatment. A total of 21 patients received chemotherapy, of which 13 were initial cases, 7 were persistent/recurrence cases, and 1 was a postoperative adjuvant case; 15 patients were never treated with chemotherapy. On univariate analysis, poor performance status (PS) and non-chemotherapy groups were considered poor prognostic factors, respectively. On multivariate analysis, poor PS (p=0.007; hazard ratio, 2.64) and non-chemotherapy (p=0.016; hazard ratio, 6.03) were independent prognostic factors of survival, respectively. Poor PS and non-chemotherapy groups were found to have poor prognosis in patients with stage IVb CC. Chemotherapy may improve the survival for stage IVb CC.

Nonclassic steroid 21-hydroxylase deficiency due to a homozygous V281L mutation in CYP21A2 detected by the neonatal mass-screening program in Japan

Since 1989, neonatal mass screening for congenital adrenal hyperplasia (CAH) has been carried out in Japan. The mass screening has detected not only the patients with the classic form of steroid 21-hydroxylase deficiency (21-OHD), but also those with the nonclassic (NC) form of 21-OHD, and the molecular basis in these patients has been elucidated. However, the homozygous V281L mutation in CYP21A2, the common mutation in the NC form in Caucasians, has not been described in Japanese patients, implying at least two possibilities; 1) the V281L mutation itself might be very rare in Japanese, and 2) nonclassic 21-OHD patients bearing the V281L mutation might be barely detectable by the mass-screening program, hence overlooked in Japan. In the present study, we describe a Brazilian girl with the NC form of 21-OHD, who was pointed out to have mildly elevated 17 alpha-hydroxyprogesterone in blood by the mass screening in Japan. Genetic analysis revealed that the patient was homozygous for the V281L mutation, and that the parents were heterozygous for the V281L mutation. Thus, the NC patients due to the homozygous V281L mutation can be detectable by the mass-screening program for CAH in Japan, and further accumulation and analysis of the NC patients should elucidate the frequency of the V281L allele in Japan.

Weekly Paclitaxel and Carboplatin against Advanced Transitional Cell Cancer after Failure of a Platinum-Based Regimen

OBJECTIVE

Weekly administration of paclitaxel plus carboplatin is hypothesized to be an effective second-line treatment for advanced transitional cell cancer after failure of platinum-based regimen. In this phase 2 trial, we tested this hypothesis.

PATIENTS AND METHODS

Patients with advanced transitional cell cancer who showed evidence of progressive or recurrent disease after methotrexate, vinblastine, doxorubicin, and cisplatin (MVAC) therapy were eligible for this study. Weekly paclitaxel (80mg/m(2)) and carboplatin (AUC 2) were administered on days 1, 8, 15, 22, 29, and 36; the cycle was repeated every 7 wk until disease progression or intolerable toxicity (maximum 18 doses).

RESULTS

Thirty-five patients entered this study. Among the 31 patients who were assessable, 10 had an objective response (overall response rate: 32.3%, 95% confidence interval, 15.8-48.7%). The median progression-free survival (PFS) and median survival times were 3.7 and 7.9 mo, respectively. Among the 22 patients who received prior MVAC therapy for metastatic disease, 36% had an objective response; their median PFS and median survival times were 4.3 and 7.9 mo, respectively; neither survival time significantly differed from the survival time of those who received prior MVAC as adjuvant setting. Toxicities were mild except one toxic death due to neutropenic sepsis.

CONCLUSIONS

Weekly paclitaxel plus carboplatin was a manageable, active second-line treatment for advanced transitional cell cancer after failure of platinum-based therapy.

U7 snRNA-mediated correction of aberrant splicing caused by activation of cryptic splice sites

A considerable fraction of mutations associated with hereditary disorders and cancers affect splicing. Some of them cause exon skipping or the inclusion of an additional exon, whereas others lead to the inclusion of intronic sequences or deletion of exonic sequences through the activation of cryptic splice sites. We focused on the latter cases and have designed a series of vectors that express modified U7 small nuclear RNAs (snRNAs) containing a sequence antisense to the cryptic splice site. Three cases of such mutation were investigated in this study. In two of them, which occurred in the PTCH1 and BRCA1 genes, canonical splice donor sites had been partially impaired by mutations that activated nearby intronic cryptic splice donor sites. Another mutation found in exonic region in CYP11A created a novel splice donor site. Transient expression of the engineered U7 snRNAs in HeLa cells restored correct splicing in a sequence-specific and dose-dependent manner in the former two cases. In contrast, the third case, in which the cryptic splice donor site in the exonic sequence was activated, the expression of modified U7 snRNA resulted in exon skipping. The correction of aberrant splicing by suppressing intronic cryptic splice sites with modified U7 is expected be a promising alternative to gene replacement therapy.

[Ovarian cancer from the standpoint of medical oncology]

Ovarian cancer is chemosensitive. Staging surgery followed by the first line chemotherapy is recommended no matter the stage. For recurrent disease, it is difficult to prolong the survival by chemotherapy. The goal is palliation. When primary debulking surgery can not be achieved because of patients' status, neoadjuvant chemotherapy followed by interval debulking surgery should be considered, although it is still in clinical-trials.

Evaluation of clinicopathological features from core needle biopsy and CT imaging as predictors of response to primary systemic therapy for operable breast cancer

11086

Background: Primary systemic therapy (PST) is standard therapy for patients with locally advanced breast cancer and increasingly used for early-stage operable disease. Clinical and pathologic responses are important prognostic parameters and clinicopathological markers to predict response to PST are needed to individualize treatment. Methods: From 1998 to 2005, 403 primary breast cancer patients were underwent curative surgical treatment after PST (Anthlacycline and/or Taxane) at NCCH. We retrospectively evaluated the clinicopathological features (age, histological type, histological grade, ER, PgR and HER-2) and classification of tumors using CT (localized tumor type and diffused tumor type) at before PST and analyzed the correlation with clinical response and pathological complete response (pCR). The log-rank statistic was used for univariate comparisons and multivariate analysis performed using Cox hazard model. Results: Overall response and pCR rate were 87% and 18%. Breast conserving surgery was performed 37% patients. Histological grade 3 (p<0.0001), ER negative (p<0.0001), PgR negative (p<0.0001), solid-tubular type (p=0.0006), age (>50) (p=0.008) and localized tumor type (p=0.02) correlated with pCR. In multivariate analysis, Histological grade 3 (p=0.01) and localized tumor type (p=0.036) were independent predictors for pCR. ER positive, histological grade 2 or 1, invasive lobular carcinoma and diffuse tumor type associated with low chemosensitivity and low breast conserving surgery rate. Conclusions: Clinical and pathological response significantly associated with ER status and histological grade. Furthermore the classification of tumor type using CT was effective to predict of response to PST.

No significant financial relationships to disclose.

Current Trends and Controversies over Pre-operative Chemotherapy for Women with Operable Breast Cancer

The multi-disciplinary approach, including surgery, chemotherapy, endocrine therapy and radiation therapy, has become the standard treatment for primary breast cancer patients. The indication of pre-operative chemotherapy has been extended to women with potentially operable breast cancer based on the results of large randomized studies and has become an attractive option that extends the chance of breast conservation. The clinical and pathological responses to pre-operative chemotherapy correlates with long-term outcome. The anthracycline-containing regimen is now considered the standard. Sequential administration of non-cross-resistant drugs, namely taxanes, improves local tumor response but its long-term benefit has been controversial. Prediction of response to pre-operative chemotherapy still remains a challenge. Identification of useful predictive markers and development of molecular-targeted drugs is the key to individualized therapy in the future.