Decrease in tumor volume and histologic response to intraarterial neoadjuvant chemotherapy in patients with cervical and endometrial adenocarcinoma

Endometrial Carcinomas with Intestinal-Type Metaplasia/Differentiation: Does Mismatch Repair System Defects Matter? Case Report and Systematic Review of the Literature

BACKGROUND

Intestinal metaplasia/differentiation in primary endometrial carcinomas is an uncommon phenomenon, with only few cases described.

MATERIAL AND METHODS

We performed a systematic review of endometrial carcinomas with intestinal metaplasia/differentiation interrogating the electronic databases Pubmed, Web of Science, and Scopus, and we reported an additional case arising in a 49-year-old woman.

RESULTS

We identified only eight patients diagnosed with endometrial carcinomas exhibiting intestinal metaplasia/differentiation, and additionally our case. Endometrial carcinomas with intestinal-type features can present in pure or mixed forms in association with usual-type endometrioid carcinomas; in mixed forms, the two neoplastic components may derive from a common neoplastic progenitor, as evidenced by the concomitant loss of MSH2 and MSH6 protein expression in our case. Disease recurrences occur in a significant fraction of the cases, including patients diagnosed in low-stage disease.

CONCLUSIONS

Endometrial carcinomas with intestinal metaplasia/differentiation are rare and they may represent a more aggressive tumor variant, thus requiring a proper treatment despite the low-tumor stage. The ProMise classification should be performed also in these unusual tumors, since they can be associated with mismatch repair system defects.

A 73-gene proliferative transcriptomic signature predicts uterine serous carcinoma patient survival and response to primary therapy

OBJECTIVES

To develop a transcriptomic signature capable of predicting overall survival (OS) for uterine serous carcinoma (USC).

METHODS

RNAseq data for 58 USC patients were obtained from TCGA. Expression of 73 candidate genes was measured for 67 Augusta University (AU) samples using NanoString technology.

RESULTS

Analysis of the TCGA RNAseq data identified 73 genes that individually predict prognosis for USC patients and an elastic net model with all 73 genes (USC73) distinguishes a good OS group with low USC73 score from a poor OS group with high USC73 score (5-year OS = 83.3% and 13.3% respectively, HR = 40.1; p = 3 × 10^-8). This finding was validated in the independent AU cohort (HR = 4.3; p = 0.0004). The poor prognosis group with high USC73 score consists of 37.9% and 32.8% of patients in the TCGA and AU cohort respectively. USC73 score and pathologic stage independently contribute to OS and together provide the best prognostic value. Early stage, low USC73 patients have the best prognosis (5-year OS = 85.1% in the combined dataset), while advanced stage, high USC73 patients have the worst prognosis (5-year OS = 6.4%, HR = 30.5, p = 1.2 × 10^-12). Consistent with the observed poor survival, primary cell cultures from high USC73 patients had higher proliferation rate and cell cycle progression; and high USC73 patients had lower rates of complete response to standard therapy.

CONCLUSIONS

The USC73 transcriptomic signature and stage independently predict OS of USC patients and the best prediction is achieved using USC73 and stage. USC73 may also serve as a therapeutic biomarker to guide patient care.

Management of Surgical Stage III and IV Endometrioid Endometrial Carcinoma: An Overview

This paper covers an overview of the literature on the management of advanced endometrial cancer, concentrating on patients with histopathologic endometrioid type of tumors. The different treatment modalities are described and management recommendations are proposed.

The standard surgical procedure includes an extrafacial total hysterectomy with bilateral salpingo-oophorectomy, collection of peritoneal washings for cytology, and exploration of the intraabdominal contents. In cases of extensive disease in the abdomen, an optimal surgical cytoreduction is associated with improved survival. Further treatment with radiotherapy may be indicated based on the pathological staging information to improve loco-regional control. Primary radiotherapy is indicated in cases where surgery is contraindicated. Systemic treatment can either be hormone therapy or chemotherapy. Progesterons are the cornerstone of hormone therapy. Prognostic factors for response are the presence of high levels of progesterone and estrogen receptors and low grade histology. Paclitaxel is the most active single agent drug. The combination therapy with paclitaxel and carboplatin is adopted as first choice in patients with endometrial cancer because of the efficacy and low toxicity, although not proven in a randomized trial.

The literature on the management of patients with advanced endometrial cancer is discussed in detail. Each stage of advanced disease is presented separately, and management recommendations are proposed, and alternative approaches are given.

Ongoing clinical trials are described, and the focuses of ongoing research are mentioned.

Neoadjuvant chemotherapy with cisplatin, aclacinomycin A, and mitomycin C for cervical adenocarcinoma - a preliminary study

Between 1989 and 2002, 28 patients with locally advanced cervical adenocarcinoma (bulky IB-IIIB) were recruited for a pilot study aimed at evaluation of the effectiveness of neoadjuvant chemotherapy with cisplatin, aclacinomycin-A, and mitomycin-C (PAM), followed by radical surgery. This regimen was administrated intra-arterially or intravenously. In addition to patients treated with PAM, we retrospectively analyzed the prognoses of 26 patients in stage I and II, who had been treated between 1975 and 1981 with radical surgery with/without radiation therapy. Twenty-eight patients received PAM therapy as neoadjuvant chemotherapy, and 75.0% of the 16 intra-arterially infused patients showed a response, as did 66.7% of the 12 intravenously infused patients. There was a significant difference in the 5-year prognosis of stage II (PAM group, 72.9%; without-PAM group, 36.4%). The results suggest that, as the free space in the parametrium is widened by neoadjuvant chemotherapy with PAM, it is possible that the tumor could be completely resected by radical hysterectomy. Thus, neoadjuvant chemotherapy with PAM is expected to improve the survival rate of patients with advanced cervical adenocarcinoma by the preliminary study. However, the survival rates of stage II with lymph node metastasis in the without-PAM group seem low, and we must also consider that the various technologies to evaluate and treat the cervical adenocarcinomas, e.g. computed tomography, magnetic resonance imaging, and surgical equipments, had improved during 1989-2002 than was the scenario during 1975-1981, and these improvements contributed to better prognosis. A prospective-randomized study is needed to assess the value of this approach compared with standard management.

Current approaches of neoadjuvant chemotherapy in cervical cancer

Despite remarkable improvement in clinical management, the survival of cervical cancer patients has shown only minor progress in the last decade, particularly in patients with advanced and high-risk disease. Multimodal treatment option has been investigated, such as the concurrent use of chemotherapy and radiation, neoadjuvant chemotherapy and radical hysterectomy, or neoadjuvant chemotherapy followed by radiotherapy. Recently, a flow of randomized clinical trials have demonstrated a benefit from the concurrent chemoradiation for the treatment of the cancer of the cervix. This review will summarize the role and benefit of neoadjuvant chemotherapy in combination with sequential or concurrent radiotherapy and radical surgery for treatment of cervical cancer.

Neoadjuvant Chemotherapy Using Low-Dose Consecutive Intraarterial Infusions of Cisplatin Combined with 5-Fluorouracil for Locally Advanced Cervical Adenocarcinoma

OBJECTIVE

The goal of this work was to evaluate response rate, toxicity, and survival in treatment with intraarterial 5-fluorouracil (5-FU) and cisplatin in a neoadjuvant setting; this combination was administered to patients with locally advanced cervical adenocarcinoma.

METHODS

Eleven patients were treated with preoperative neoadjuvant chemotherapy. Those eligible included patients with previously untreated stage IB, II, or III adenocarcinoma with good performance status. Treatment consisted of bilateral internal iliac artery infusion of cisplatin (a total of 10 mg/day) for 30 min, followed by 5-FU (a total of 250 mg/day) given by 24-hour continuous infusion for 10 days. Treatment was repeated every 3 weeks for a total of two or three cycles. All except one patient with progressive disease underwent radical hysterectomy following neoadjuvant chemotherapy. Postoperative radiotherapy was given to the whole pelvis to 6 patients; 3 of the 6 patients with involved common iliac nodes received radiotherapy to a paraaortic field in addition to the whole pelvis.

RESULTS

Among 11 eligible patients, 7 had a partial response (64%). Stable disease was observed in 3 cases (27%) and progressive disease in 1 (9%). Histopathological changes related to chemotherapy, however, revealed only mild effects. Of the 24 treatment cycles administered, no Grade 3 or 4 toxicity was observed and there were no therapy-related deaths. The median follow-up period was 30 months (range, 1-65 months). The mean survival period was 34.7 months and the 5-year survival rate was 21.2%.

CONCLUSIONS

Intraarterial neoadjuvant chemotherapy effectively reduced tumor size in patients with locally advanced cervical adenocarcinoma; however, a survival advantage was not clear.

DNA image cytometry in the differential diagnosis of endocervical adenocarcinoma

BACKGROUND

The value of DNA image cytometry in the differential diagnosis of endocervical adenocarcinoma was tested on a series of 65 cases of normal endocervical cells (n = 25), inflammatory changes (n = 18), and endocervical adenocarcinoma (n = 22).

METHODS

The investigation was performed on gynecologic routine smears by using a television image analysis system MIAMED-DNA (Leica, Wetzlar, Germany), combined with an automated Leica Medilux microscope. First, the Papanicolaou stained specimens were rescreened, and the x/y coordinates of at least 150 endocervical nuclei were stored per case by using a scanning program. After restaining according to Feulgen, the epithelial cells were relocalized and the DNA content, and the nuclear area were determined. The DNA content of 25-30 squamous epithelial cells of intermediate type served as an internal standard for the normal diploid value in each case. Various DNA cytometric parameters and the mean nuclear area were calculated. For statistical analysis, the cases of adenocarcinoma (n = 22) were defined as positive, and the cases with normal endocervical epithelium or inflammatory changes (n = 43) were defined as negative.

RESULTS

The presence of nuclei with a DNA content greater than 9c was observed exclusively in adenocarcinoma (sensitivity, 95.9%; specificity, 100%), indicating that this parameter is suited best for the differentiation between malignant and nonmalignant endocervical epithelium. High sensitivity rates at a specificity level of 100% also were calculated for the 2.5cER (95.5%), the mean ploidy (90.9%), 5cER (90.9%), and the diploid deviation quotient (90.9%). For the 2cDI (86.4%), the entropy (81.8%) and the ploidy imbalance (77.3%) lower values were obtained.

CONCLUSIONS

DNA single cell cytometry represents a highly relevant tool in the identification of malignant transformation in endocervical lesions that could be used as a complementary diagnostic method in cytologically difficult cases. Investigations on endocervical adenocarcinoma in situ should be performed in the near future.

Reduced immunologic cell performance as a prognostic parameter for advanced cervical cancer

The proliferative response of lymphocytes to mitogens is known to be decreased in cancer patients; this phenomenon is thought to play an important role in disease progression, but it has not been studied as a prognostic factor in cervical cancer patients receiving treatment. Fourteen patients with advanced cervical cancer submitted to chemotherapy with cis-platinum (100 mg/m2/cycle) and bleomycin (30 mg/cycle) over three cycles every 4 weeks were evaluated. Mean follow-up time was 30 months. The following laboratory tests carried out on peripheral blood lymphocytes collected before and at the end of chemotherapy were used as prognostic factors: proliferative response of lymphocytes to phytohemagglutinin (PHA) and stimulated with interleukin 12 (IL-12), capacity of gamma interferon production (IFN-gamma), and variations in memory T cell (CD45-RO) and naive T cell (CD45-RA) subsets. A clear correlation was obtained between response to treatment, survival rates, and PHA-induced proliferative response. A significant difference was observed in the number of CD45-RO lymphocyte at the pre-chemotherapy period and IFN-gamma production at the post-chemotherapy period in the group of good responders to treatment. The use of IL-12 produced a leveling in both groups for lymphocyte proliferation, i.e., a recovery from the deficiency presented by the lymphocyte of the poor responders group. The parameters of immunologic assays, especially proliferative response, appears to be correlated with prognosis and survival rates and therefore are good discriminating factors for the selection of groups of patients that will benefit from this type of treatment. IL-12 seems to play an important role in the regulation of the antitumor immune response and should be considered for therapeutic use.