Screening for ovarian cancer by transvaginal ultrasound and serum CA125 measurement in women with a familial predisposition: A prospective cohort study

Neural network-derived multivariate index assay demonstrates effective clinical performance in longitudinal monitoring of ovarian cancer risk

OBJECTIVE

We recently characterized the clinical performance of a multivariate index assay (MIA3G) to assess ovarian cancer risk for adnexal masses at initial presentation. This study evaluated how MIA3G varies when applied longitudinally to monitor risk during clinical follow-up.

METHOD

The study evaluated women presenting with adnexal masses from eleven centers across the US. Patients received an initial blood draw at enrollment and at the standard-of-care follow-up visits. MIA3G was determined for all visits but physicians did not have access to MIA3G scores to determine clinical management. The primary outcome was the relative change value (RCV) of MIA3G over the period of clinical observation.

RESULTS

A total of 510 patients of 785 enrolled met study criteria. Of these, 30.8% had a second, 25.4% a third and 22.2% a fourth blood draw following initial collection. The median duration from initial draw was 131 d to second draw, 301.5 d to the third draw and 365.5 d to the fourth draw. MIA3G RCV of >50% was observed in 22-26% patients, whereas 70-75% patients had MIA3G RCV >5%. An empirical baseline RCV of 56% - transformed to 1 in logarithmic scale - was calculated from averaging RCVs of all patients who had no malignancy risk after 210 days. RCV > 1 log was associated with higher incidence of surgical intervention (29.6%) compared to RCV < 1 log (16.9%).

CONCLUSIONS

Variation in MI3AG does not change the accuracy of the test for excluding malignancy, while marked changes may be associated with a slightly higher likelihood of surgical intervention. In addition to MIA3G score itself, the MIA3G RCV may be important for clinical management.

Survey on Physicians' Knowledge and Training Needs in Genetic Counseling in Germany

Background

In recent years, germline testing of women with a risk of developing breast and ovarian cancer has increased rapidly. This is due to lower costs for new high-throughput sequencing technologies and the manifold preventive and therapeutic options for germline mutation carriers. The growing demand for genetic counseling meets a shortfall of counselors and illustrates the need to involve the treating clinicians in the genetic testing process. This survey was undertaken to assess their state of knowledge and training needs in the field of genetic counseling and testing.

Methods

A cross-sectional survey within the European Bridges Study (Breast Cancer Risk after Diagnostic Gene Sequencing) was conducted among physician members (n = 111) of the German Cancer Society who were primarily gynecologists. It was designed to examine their experience in genetic counseling and testing.

Results

Overall, the study revealed a need for training in risk communication and clinical recommendations for persons at risk. One-third of respondents communicated only relative disease risks (31.5%) instead of absolute disease risks in manageable time spans. Moreover, almost one-third of the respondents (31.2%) communicated bilateral and contralateral risk-reducing mastectomy as an option for healthy women and unilateral-diseased breast cancer patients without mutations in high-risk genes (e.g. BRCA1 or BRCA2). Most respondents expressed training needs in the field of risk assessment models, the clinical interpretation of genetic test results, and the decision-making process.

Conclusion

The survey demonstrates a gap of genetic and risk literacy in a relevant proportion of physicians and the need for appropriate training concepts.

Ovarian cancer: Current status and strategies for improving therapeutic outcomes

Of all the gynecologic tumors, ovarian cancer (OC) is known to be the deadliest. Advanced‐stages of OC are linked with high morbidity and low survival rates despite the immense amount of research in the field. Shortage of promising screening tools for early‐stage detection is one of the major challenges linked with the poor survival rate for patients with OC. In OC, therapeutic management is used with multidisciplinary approaches that includes debulking surgery, chemotherapy, and (rarely) radiotherapy. Recently, there is an increasing interest in using immunomodulation for treating OC. Relapse rates are high in this malignancy and averages around every 2‐years. Further treatments after the relapse are more intense, increasing the toxicity, resistance to chemotherapy drugs, and financial burden to patients with poor quality‐of‐life. A procedure that has been studied to help reduce the morbidity rate involves pre‐sensitizing cancer cells with standard therapy in order to produce optimal results with minimum dosage. Utilizing such an approach, platinum‐based agents are effective due to their increased response to platinum‐based chemotherapy in relapsed cases. These chemo‐drugs also help address the issue of drug resistance. After conducting an extensive search with available literature and the resources for clinical trials, information is precisely documented on current research, biomarkers, options for treatment and clinical trials. Several schemes for enhancing the therapeutic responses for OC are discussed systematically in this review with an attempt in summarizing the recent developments in this exciting field of translational/clinical research.

Targeted metabolomic profiling of low and high grade serous epithelial ovarian cancer tissues: a pilot study

INTRODUCTION

Epithelial ovarian cancer (EOC) remains the leading cause of death from gynecologic malignancies and has an alarming global fatality rate. Besides the differences in underlying pathogenesis, distinguishing between high grade (HG) and low grade (LG) EOC is imperative for the prediction of disease progression and responsiveness to chemotherapy.

OBJECTIVES

The aim of this study was to investigate, the tissue metabolome associated with HG and LG serous epithelial ovarian cancer.

METHODS

A combination of one dimensional proton nuclear magnetic resonance (1D H NMR) spectroscopy and targeted mass spectrometry (MS) was employed to profile the tissue metabolome of HG, LG serous EOCs, and controls.

RESULTS

Using partial least squares-discriminant analysis, we observed significant separation between all groups (p < 0.05) following cross validation. We identified which metabolites were significantly perturbed in each EOC grade as compared with controls and report the biochemical pathways which were perturbed due to the disease. Among these metabolic pathways, ascorbate and aldarate metabolism was identified, for the first time, as being significantly altered in both LG and HG serous cancers. Further, we have identified potential biomarkers of EOC and generated predictive algorithms with AUC (CI) = 0.940 and 0.929 for HG and LG, respectively.

CONCLUSION

These previously unreported biochemical changes provide a framework for future metabolomic studies for the development of EOC biomarkers. Finally, pharmacologic targeting of the key metabolic pathways identified herein could lead to novel and effective treatments of EOC.

A quantitative performance study of two automatic methods for the diagnosis of ovarian cancer

We present a quantitative study of the performance of two automatic methods for the early detection of ovarian cancer that can exploit longitudinal measurements of multiple biomarkers. The study is carried out for a subset of the data collected in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS). We use statistical analysis techniques, such as the area under the Receiver Operating Characteristic (ROC) curve, for evaluating the performance of two techniques that aim at the classification of subjects as either healthy or suffering from the disease using time-series of multiple biomarkers as inputs. The first method relies on a Bayesian hierarchical model that establishes connections within a set of clinically interpretable parameters. The second technique is a purely discriminative method that employs a recurrent neural network (RNN) for the binary classification of the inputs. For the available dataset, the performance of the two detection schemes is similar (the area under ROC curve is 0.98 for the combination of three biomarkers) and the Bayesian approach has the advantage that its outputs (parameters estimates and their uncertainty) can be further analysed by a clinical expert.

Case of Ovarian Cancer in a Woman with Undiagnosed Graves' Disease: A Case Report and Review of the Literature

Epithelial ovarian cancer (OC) is a leading cause of death among females in the United States, due in part to challenges of diagnosis in the early stages of the disease. While efforts are underway to develop a high-quality screening test, it is equally important to consider whether high-risk populations are appropriate to screen. One such population may be females with hyperthyroidism, as epidemiologic studies have shown an association between this condition and OC. In this report, we present a case of a female with OC and Graves’ disease to highlight the potential significance of this association.

Highly-accurate metabolomic detection of early-stage ovarian cancer

High performance mass spectrometry was employed to interrogate the serum metabolome of early-stage ovarian cancer (OC) patients and age-matched control women. The resulting spectral features were used to establish a linear support vector machine (SVM) model of sixteen diagnostic metabolites that are able to identify early-stage OC with 100% accuracy in our patient cohort. The results provide evidence for the importance of lipid and fatty acid metabolism in OC and serve as the foundation of a clinically significant diagnostic test.

Präventive operative Optionen für Frauen mit einer familiären Brust- und Eierstockkrebsbelastung

Für das familiäre Mamma- und Ovarialkarzinom ist seit der Entdeckung der beiden Hochrisikogene BRCA1 und BRCA2 in den 1990er-Jahren die genetische Testung und die damit einhergehende individuelle Risikobestimmung möglich. In den zurückliegenden 20 Jahren waren im Rahmen der Betreuung von BRCA-Mutationsträgerinnen und ihren Familien die Bestimmung der Inzidenz und des Phänotyps der Karzinome sowie der Nachweis der Effizienz von prophylaktischen Operationen, intensivierter Brustkrebsfrüherkennung und zielgerichteter Therapieverfahren möglich. Dies versetzt uns heute in die Lage, bei Ratsuchenden individuelle Risikokalkulationen durchzuführen und sie im Rahmen nicht direktiver Beratungsgespräche auf dem Weg zu einer informierten und präferenzsensiblen Entscheidung in Bezug auf die Inanspruchnahme risikoadaptierter Präventionsmaßnahmen zu begleiten. Aktuell und zukünftig gilt es die Herausforderungen z. B. im Zusammenhang mit der Zulassung des ersten PARP-Inhibitors sowie mit der Entdeckung neuer Risikogene zu bewältigten. Schwerpunkt dieses Artikels ist der Nachweis, dass v. a. Frauen mit Mutationen in den Hochrisikogenen BRCA1/2 von operativen Maßnahmen profitieren.

[Risk-adapted surveillance: focus on familial breast and ovarian cancer]

Breast cancer surveillance programs for the general population are not adequate for the small number of women with hereditary breast and ovarian cancer syndrome. Breast cancer screening for women in Germany starts at the age of 50 years, but nearly half of all women with familial risk are already diagnosed with breast cancer at that time. Moreover, mammography alone is not suitable for an early diagnosis of breast cancer in young women from high-risk families. Their typical dense breast tissue causes a high rate of false-negative cases. Therefore, national and international prospective clinical trials were initiated to offer a multimodal breast cancer surveillance program including magnetic resonance tomography for the breast and semi-annual screening intervals to women with BRCA1/2 mutations and those from high-risk families who tested negative for BRCA1/2 mutations. This program will currently be evaluated by the 15 centers of the German Consortium for Hereditary Breast and Ovarian Cancer.

Impact of Prophylactic Mastectomy in BRCA1/2 Mutation Carriers

Unlike the general decrease in invasive oncologic care, the trend for prophylactic bilateral mastectomy in healthy women and prophylactic contralateral mastectomy in women with unilateral breast cancer is steadily rising. This is even more surprising when considering that for e.g. prophylactic contralateral mastectomy no clear survival benefit has been demonstrated so far. The decision-making process around risk-reducing surgery may be influenced by several conflicting parameters such as the patient's fears and desire to achieve a survival advantage, the surgeon's financial motivations, or the oncologist's paternalistic approach to the above trend. Physicians should support their patients throughout the decision-making process, guide them through the dense fog of information, and encourage them to reconsider all options and alternatives before embarking on an irreversible surgical intervention. Healthy and diseased women should be comprehensively informed about their absolute individual risks for cancer, the benefits and harms of the surgery, alternative preventive strategies, and last but not least the competing risks of preceding carcinomas and cancer in general. Within the framework of non-directive counseling in the specialized centers of the German Consortium for Hereditary Breast and Ovarian Cancer (GC-HBOC), decision-making aids are being developed with grants from the Federal Ministry of Health and the German Cancer Aid to support women in making conclusive and satisfactory decisions.

Baseline and post prophylactic tubal-ovarian surgery CA125 levels in BRCA1 and BRCA2 mutation carriers

The aim of this study was to determine whether BRCA1 and BRCA2 mutation carriers have different baseline CA125 levels compared with non-carriers, and whether a significant difference in pre- and post-operative CA125 levels exists in BRCA mutation carriers undergoing risk-reducing bilateral salpingo-oophorectomy (RRBSO). The study also considered whether CA125 measurements should continue in unaffected BRCA mutation carriers after RRBSO. 383 Eligible women were identified through retrospective review of the BRCA Carrier Clinic at The Royal Marsden NHS Foundation Trust, London, UK. These women all had CA125 levels measured as they were either a carrier or at risk of a BRCA1 or BRCA2 mutation. Of these, 76 went on to have a negative predictive test for their familial mutation and so are classed as 'non-carriers'. 133 BRCA1 and 87 BRCA2 carriers had RRBSO, with a further 26 BRCA1 carriers, 28 BRCA2 carriers and one non-carrier developing ovarian cancer. The remaining 21 BRCA1 and 28 BRCA2 carriers did not have RRBSO or develop ovarian cancer in the time of study follow-up. CA125 levels were measured as surveillance or as part of pre-RRBSO care. CA125 measurement post-RRBSO was continued in 48 BRCA1 and 40 BRCA2 carriers. In 154 BRCA1 mutation carriers, the median baseline (i.e. before RRBSO and with no clinical signs of ovarian cancer) CA125 level was 9.0 U/ml (range 2-78) and was 10.0 U/ml (range 1-43) in 115 BRCA2 mutation carriers. When compared with the 75 non-carriers (median baseline CA125 10.0 U/ml; range 2-52), there was no significant difference between the BRCA1, BRCA2 and non-carrier groups. There was a significant reduction in CA125 from pre- to post-RRBSO in 48 BRCA1 carriers (p = 0.04) but no significant difference in 40 BRCA2 mutation carriers (p = 0.5). Out of a total of 220 mutation carriers who underwent RRBSO, two had an incidental ovarian cancer found on histopathology and another developed primary peritoneal cancer during the follow-up period. Our study is the first to compare initial serum CA125 levels in BRCA1 and BRCA2 mutation carriers with those of non-carriers. Our study found no significant difference between the three groups. A drop in CA125 levels after RRBSO in BRCA1 carriers supports the finding of earlier studies, but differed in that the fall was not seen in BRCA2 carriers. The finding of only one case of post-operative peritoneal cancer in 220 carriers undergoing RRBSO supports the discontinuation of post-RRBSO serum CA125 monitoring in BRCA mutation carriers.

Interleukin 16 expression changes in association with ovarian malignant transformation

OBJECTIVE

Long-term unresolved inflammation has been suggested as a risk factor for the development of various malignancies. The goal of this study was to examine whether the expression of interleukin (IL)-16, a proinflammatory cytokine, changes in association with ovarian cancer (OVCA) development.

STUDY DESIGN

In an exploratory study, changes in IL-16 expression in association with OVCA development and progression were determined using ovarian tissues and serum samples from healthy subjects (n = 10) and patients with benign (n = 10) and malignant ovarian tumors at early (n = 8) and late (n = 20) stages. In the prospective study, laying hens, a preclinical model of spontaneous OVCA, were monitored (n = 200) for 45 weeks with serum samples collected at 15-week interval. Changes in serum levels of IL-16 relative to OVCA development were examined.

RESULTS

The frequency of IL-16-expressing cells increased significantly in patients with OVCA (P < .001) compared to healthy subjects and patients with benign ovarian tumors. The concentration of serum IL-16 was higher in patients with benign tumors (P < .05) than in healthy subjects and increased further in patients with early-stage (P < .05) and late-stage (P < .03) OVCA. Increase in tissue expression and serum levels of IL-16 in patients with early and late stages of OVCA were positively correlated with the increase in ovarian tumor-associated microvessels. Prospective monitoring showed that serum levels of IL-16 increase significantly (P < .002) even before ovarian tumors become grossly detectable in hens.

CONCLUSION

This study showed that tissue expression and serum levels of IL-16 increase in association with malignant ovarian tumor development and progression.

Klinik und Genetik des familiären Brust- und Eierstockkrebses

Während mit der Entdeckung der Hochrisikogene „breast cancer 1“ (BRCA1) und „breast cancer 2“ (BRCA2) in den Jahren 1994/1995 die Erforschung des hereditären Mamma- und Ovarialkarzinoms zunächst beendet schien, belegen neuere Ergebnisse, dass das hereditäre Mamma- und Ovarialkarzinom eine extreme genetische Heterogenität aufweist. Die genetisch definierten Subtypen zeigen außerdem eine unterschiedliche phänotypische Ausprägung hinsichtlich der histopathologischen Charakteristika, des Krankheitsverlaufs und des Therapieansprechens. Dies erfordert eine Einbettung der Gendiagnostik in ein strukturiertes und standardisiertes Betreuungskonzept, das es erlaubt prospektive Daten zur Tumorinzidenz und zum Verlauf zu erfassen sowie in prospektiven Studien die Wertigkeit der verschiedenen diagnostischen, präventiven und neuen therapeutischen Optionen zu validieren. Das deutsche Konsortium widmet sich dieser Aufgabenstellung, um den betreffenden Familien effiziente Präventions- und Interventionsstrategien anbieten zu können. Dabei kommt der Zusammenarbeit mit der Selbsthilfe (http://www.BRCA-Netzwerk.de) mittlerweile eine große Bedeutung zu, die uns immer wieder vor Augen hält, wie wichtig es ist, den in diesem Artikel aufgeworfenen Fragestellungen nachzugehen.

Characterization of Ovarian Tumors and Staging Ovarian Cancer With 3-Dimensional Power Doppler Angiography: Correlation With Pathologic Findings

Objective

The aims of this study were to evaluate ovarian tumors with 3-dimensional power Doppler angiography (3-DPDA), to determine its correlation with histology findings, and to explore its role in staging patients with ovarian cancer.

Methods

Three hundred eighteen women with an unknown unilateral pelvic mass were referred for preoperative evaluation by 3-DPDA angiography. Patients’ ages ranged from 18 to 72 years (47.4 ± 13.8 years). Sonographic criteria used for the characterization of ovarian tumors were based on a system that included morphological characteristics, histological evaluation, and Power Doppler imaging.

Results

Two hundred twenty-five tumors were histopathologically diagnosed as benign and 93 as malignant. Sensitivity and specificity of the 3-DPDA of ovarian masses reached 93.5% and 92.9%, respectively, whereas positive predictive value was 84.5% and negative predictive value was 97.2%.

Conclusions

Three-dimensional power Doppler sonography is an effective imaging technique for discriminating ovarian neoplasms and classifying them according to histopathology.

Risk-reducing Surgery in Women at Risk for Familial Breast or Ovarian Cancer

An estimated 5 % of breast cancers and 10 % of ovarian cancers may be due to inherited autosomal dominant breast and ovarian cancer alleles BRCA1 und BRCA2. According to population-based studies 1 or 2 women per 1000 carry such a risk allele. The cumulative cancer risk for healthy women with a BRCA-mutation is between 60 and 85 % for breast cancer and between 20 and 60 % for ovarian cancer. Recent studies have reported an increased risk for contralateral breast cancer in women after unilateral breast cancer. Since 1997 the German Cancer Aid has supported an interdisciplinary approach for high-risk women consisting of genetic testing, counselling and prevention in 12 specialised centres. Since 2005 this concept has received additional support from health insurance companies, and results have been assessed with regard to outcomes (e.g. reduced mortality due to more intensive early diagnosis). The number of centres has increased to 15 at various university hospitals. These interdisciplinary centres offer women the opportunity to participate in a structured screening programme for the early diagnosis of breast cancer and provide non-directive counselling on the options for risk-reducing surgery, e.g., prophylactic bilateral salpingo-oophorectomy, prophylactic bilateral mastectomy or contralateral prophylactic mastectomy after unilateral breast cancer. Such surgical interventions can significantly reduce the risk of disease, the respective disease-specific mortality and - particularly prophylactic bilateral salpingo-oophorectomy - total mortality in BRCA-mutation carriers.

Screening for gynaecologic cancers in genetically predisposed women

Hereditary breast and ovarian cancer syndrome and hereditary non-polyposis colon cancer syndrome are the two most important syndromes responsible for inherited cancers in gynaecology. Genetic testing is available for both these syndromes. Breast cancer gene testing is affordable and easy in women with ancestry where the mutation patterns are known, whereas other population groups need full gene screening. Hereditary non-polyposis colon cancer syndrome can now be diagnosed more frequently with the use of immunohistochemistry. Ovarian cancer risk is high in hereditary breast and ovarian cancer syndromes, and advanced screening techniques should be used when preventive surgery is not an option. Early detection techniques offer less protection than prophylactic removal, but enable women to retain their reproductive organs. Oophorectomy has the advantage of reducing breast cancer risk. In colorectal cancer syndromes, the risk for endometrial and ovarian cancer is much elevated. These risks should be recognised and addressed as these diseases are easy to prevent.

Hereditary breast and ovarian cancer: new genes, new treatments, new concepts

BACKGROUND

Every year, 60,000 women in Germany are found to have breast cancer, and 9000 to have ovarian cancer. Familial clustering of carcinoma is seen in about 20% of cases.

METHODS

We selectively review relevant articles published up to December 2010 that were retrieved by a search in PubMed, and we also discuss findings from the experience of the German Consortium for Hereditary Breast and Ovarian Cancer.

RESULTS

High risk is conferred by the highly penetrant BRCA1 and BRCA2 genes as well as by other genes such as RAD51C. Genes for breast cancer that were originally designated as moderately penetrant display higher penetrance than previously thought in families with a hereditary predisposition. The role these genes play in DNA repair is thought to explain why tumors associated with them are sensitive to platin derivatives and PARP inhibitors. In carriers of BRCA1 and BRCA2, prophylactic bilateral mastectomy and adnexectomy significantly lowers the incidence of breast and ovarian cancer. Moreover, prophylactic adnexectomy also lowers the breast-and-ovarian-cancer-specific mortality, as well as the overall mortality. If a woman bearing a mutation develops cancer in one breast, her risk of developing cancer in the other breast depends on the particular gene that is mutated and on her age at the onset of disease.

CONCLUSION

About half of all monogenically determined carcinomas of the breast and ovary are due to a mutation in one or the other of the highly penetrant BRCA genes (BRCA1 and BRCA2). Women carrying a mutated gene have an 80% to 90% chance of developing breast cancer and a 20% to 50% chance of developing ovarian cancer. Other predisposing genes for breast and ovarian cancer have been identified. Clinicians should develop and implement evidence-based treatments on the basis of these new findings.

Contrast-enhanced sonography depicts spontaneous ovarian cancer at early stages in a preclinical animal model

OBJECTIVE

Our goal was to examine the feasibility of using laying hens, a preclinical model of human spontaneous ovarian cancer, in determining the kinetics of an ultrasound contrast agent indicative of ovarian tumor-associated neoangiogenesis in early-stage ovarian cancer.

METHODS

Three-year-old White Leghorn laying hens with decreased ovarian function were scanned before and after intravenous injection of a human serum albumin-perflutren contrast agent at a dose of 5 μL/kg body weight. Gray scale morphologic characteristics, Doppler indices, the arrival time, peak intensity, and wash-out of the contrast agent were recorded and archived on still images and video clips. Hens were euthanized thereafter; sonographic predictions were compared at gross examination; and ovarian tissues were collected. Archived clips were analyzed to determine contrast parameters and Doppler intensities of vessels. A time-intensity curve per hen was drawn, and the area under the curve was derived. Tumor types and the density of ovarian microvessels were determined by histologic examination and immunohistochemistry and compared to sonographic predictions.

RESULTS

The contrast agent significantly (P < .05) enhanced the visualization of microvessels, which was confirmed by immunohistochemistry. Contrast parameters, including the time of wash-out and area under the curve, were significantly different (P < .05) between ovaries of normal hens and hens with ovarian cancer and correctly detected cancer at earlier stages than the time of peak intensity.

CONCLUSIONS

The laying hen may be a useful animal model for determining ovarian tumor-associated vascular kinetics diagnostic of early-stage ovarian cancer using a contrast agent. This model may also be useful for testing the efficacy of different contrast agents in a preclinical setting.

SGO White Paper on ovarian cancer: etiology, screening and surveillance

Ovarian cancer is a heterogeneous, rapidly progressive, highly lethal disease of low prevalence. The etiology remains poorly understood. Numerous risk factors have been identified, the most prominent involving an inherited predisposition in 10% of cases. Women with germline mutations associated with Hereditary Breast/Ovarian Cancer and Lynch syndromes have dramatically elevated risks (up to 46% and 12%, respectively). Risk-reducing salpingo-oophorectomy is the best method to prevent ovarian cancer in these high-risk women. Significant risk reduction is also seen in the general population who use oral contraceptives. Since up to 89% patients with early-stage disease have symptoms prior to diagnosis, increased awareness of the medical community may facilitate further workup in patients who otherwise would have had a delay. Despite enormous effort, there is no proof that routine screening for ovarian cancer in either the high-risk or general populations with serum markers, sonograms, or pelvic examinations decreases mortality. Further evaluation is needed to determine whether any novel biomarkers, or panels of markers, have clinical utility in early detection. Prospective clinical trials have to be designed and completed prior to offering of any of these new diagnostic tests. CA125 is currently the only biomarker recommended for monitoring of therapy as well as detection of recurrence. This commentary provides an overview on the background, screening and surveillance of ovarian cancer.

Risk-reducing salpingo-oophorectomy in BRCA1 and BRCA2 mutation carriers

BACKGROUND

Risk-reducing salpingo-oophorectomy (RRSO) is often recommended to carriers of deleterious breast cancer gene 1/2 (BRCA1/2) mutations in order to reduce their breast cancer risk by 50% and their ovarian cancer risk by approximately 95%. To evaluate the acceptance, timing, histopathology findings and follow-up results we retrospectively analyzed a cohort of BRCA1/2 mutation carriers who underwent risk-reducing salpingo-oophorectomies.

METHODS

Between 1996 and 2009, 306 women who tested positive for a BRCA1 or BRCA2 mutation were counseled for preventive options. RRSO was recommended to all mutation carriers at age 40 or 5 years prior to the earliest occurrence of ovarian cancer in the family. Data from 175 BRCA mutation carriers (92 BRCA1 and 83 BRCA2), who decided to undergo a RRSO, were analyzed. Data were collected from study entry until recent follow-up.

RESULTS

Fifty-seven percent of BRCA mutation carriers opted for RRSO. Mean age at time of surgery was 47 years. Overall, one occult carcinoma of the fallopian tube was detected at the time of surgery in a 57-year-old woman and one primary peritoneal carcinoma occurred 26 months after RRSO in a 59-year-old woman.

CONCLUSION

Risk-reducing salpingo-oophorectomy is widely accepted. Recommendation of surgery at the age of 40 seems to be safe and the frequency of extraovarian primary peritoneal carcinoma after surgery is low.

Detection of tumor-associated neoangiogenesis by Doppler ultrasonography during early-stage ovarian cancer in laying hens: a preclinical model of human spontaneous ovarian cancer

OBJECTIVE

Tumor-associated neoangiogenesis (TAN) is one of the earliest events in ovarian tumor growth and represents a potential target for early detection of ovarian cancer (OVCA). Because it is difficult to identify patients with early-stage OVCA, the goal of this study was to explore a spontaneous animal model of in vivo ovarian TAN associated with early-stage OVCA detectable by Doppler ultrasonography (DUS).

METHODS

White Leghorn laying hens were scanned transvaginally at 15-week intervals up to 45 weeks. Gray scale ovarian morphologic characteristics and Doppler indices were recorded. Hens were euthanized at diagnosis for ultrasonographic morphologic/vascular abnormalities or at the end of the study (those that remained normal). Ovarian morphologic and histologic characteristics were evaluated. Vascular endothelial growth factor (VEGF) and alpha(v)beta(3)-integrin expression was assessed by immunohistochemical analysis. Doppler ultrasonographic observations were compared with histologic and immunohisto-chemical findings to determine the ability of DUS to detect ovarian TAN.

RESULTS

Significant changes in ovarian blood flow parameters were observed during transformation from normal to tumor development in the ovary (P < .05). Tumor-related changes in ovarian vascularity were identified by DUS before the tumor became detectable by gray scale imaging. Increased expression of VEGF and alpha(v)beta(3)-integrins was associated with tumor development. Ovarian TAN preceded tumor progression in hens.

CONCLUSIONS

The results suggest that ovarian TAN may be an effective target for the detection of early-stage OVCA. The laying hen may also be useful for studying the detection and inhibition of ovarian TAN using various means, including the efficacy of contrast agents, targeted molecular imaging, and antiangiogenic therapies.

Beyond CA125: the coming of age of ovarian cancer biomarkers. Are we there yet?

Ovarian cancer (OC) is the fourth leading cause of cancer deaths among women in the United States, despite its relatively low incidence of 50 per 100,000. Even though advances in therapy have been made, the OC fatality-to-case ratio remains exceedingly high, due to the lack of accurate tools to diagnose early-stage disease when cure is still possible. The most studied marker for OC, CA125, is only expressed by 50-60% of patients with early stage disease. Large efforts have been deployed to identify novel serum markers, yet no single marker has emerged as a serious competitor for CA125. Various groups are investing in combination approaches to increase the diagnostic value of existing markers, but many markers may still lie in under-explored areas of ovarian cancer biology, such as tumor vasculature environment and post-translational modifications (glycomics).

Muscarinic receptor subtypes in the lower urinary tract

Acetylcholine acting on muscarinic M(3) receptors on the detrusor muscle is the principal stimulus for inducing the contractile response for urinary bladder voiding. The urinary bladder expresses, however, all cloned muscarinic receptor subtypes (M(1)-M(5)). In terms of quantity, the M(2) subtype dominates over the M(3) subtype in the detrusor, and its role in contraction seems to be primarily indirect, by blocking stimuli from cAMP-coupled receptors that induce relaxation. The excitatory M(1) and inhibitory M(2) and/or M(4) subtypes are also expressed prejunctionally. Muscarinic M(1) and M(2)/M(4) autoreceptors facilitate and inhibit, respectively, the release of acetylcholine. The urothelium had been considered to be a passive barrier; however, during the last decade, it has been shown that the urothelium is of importance for bladder function. In a state of bladder pathology, muscarinic receptor changes occur in the detrusor, prejunctionally, and in the urothelium, but the character of the change differs between disorders. The urothelium expresses all subtypes of muscarinic receptors, and upon stimulation it releases factors affecting bladder afferents and smooth muscle. During inflammation, the expression of muscarinic M(5) receptors is increased, particularly in the urothelium, together with a cholinergic-induced production of nitric oxide in the mucosa. The present review describes signalling mechanisms, expression and functional effects of muscarinic receptors in the lower urinary tract. Their roles in physiological and pathophysiological conditions, as well as clinical implications of the occurrence of different muscarinic receptors, are discussed.

Hereditary ovarian carcinoma: heterogeneity, molecular genetics, pathology, and management

Hereditary ovarian cancer accounts for at least 5% of the estimated 22,000 new cases of this disease during 2009. During this same time, over 15,000 will die from malignancy ascribed to ovarian origin. The bulk of these hereditary cases fits the hereditary breast-ovarian cancer syndrome, while virtually all of the remainder will be consonant with the Lynch syndrome, disorders which are autosomal dominantly inherited. Advances in molecular genetics have led to the identification of BRCA1 and BRCA2 gene mutations which predispose to the hereditary breast-ovarian cancer syndrome, and mutations in mismatch repair genes, the most common of which are MSH2 and MLH1, which predispose to Lynch syndrome. These discoveries enable relatively certain diagnosis, limited only by their variable penetrance, so that identification of mutation carriers through a comprehensive cancer family history might be possible. This paper reviews the subject of hereditary ovarian cancer, with particular attention to its molecular genetic basis, its pathology, and its phenotypic/genotypic heterogeneity.

Time to stop ovarian cancer screening in BRCA1/2 mutation carriers?

Women at high risk of ovarian cancer due to a genetic predisposition may opt for either surveillance or prophylactic bilateral salpingo-oophorectomy (pBSO). Main objective of our study was to determine the effectiveness of ovarian cancer screening in women with a BRCA1/2 mutation. We evaluated 241 consecutive women with a BRCA1 or BRCA2 mutation who were enrolled in the surveillance program for hereditary ovarian cancer from September 1995 until May 2006 at the University Medical Center Groningen (UMCG), The Netherlands. The ovarian cancer screening included annual pelvic examination, transvaginal ultrasound (TVU) and serum CA125 measurement. To evaluate the effectiveness of screening in diagnosing (early stage) ovarian cancer sensitivity, specificity, positive and negative predictive values (PPV and NPV) of pelvic examination, TVU and CA125 were calculated. Three ovarian cancers were detected during the surveillance period; 1 prevalent cancer, 1 interval cancer and 1 screen-detected cancer, all in an advanced stage (FIGO stage IIIc). A PPV of 20% was achieved for pelvic examination, 33% for TVU and 6% for CA125 estimation alone. The NPV were 99.4% for pelvic examination, 99.5% for TVU and 99.4% for CA125. All detected ovarian cancers were in an advanced stage, and sensitivities and positive predictive values of the screening modalities are low. Restricting the analyses to incident contacts that contained all 3 screening modalities did not substantially change the outcomes. Annual gynecological screening of women with a BRCA1/2 mutation to prevent advanced stage ovarian cancer is not effective.

The early detection of ovarian cancer: from traditional methods to proteomics. Can we really do better than serum CA-125?

Ovarian cancer is the leading cause of death from gynecologic malignancy in the United States. More than 80% of patients present with advanced disease, with 5 year survival rates between 15% and 45%. In contrast, the survival rate for stage I disease, with malignancy confined to the ovary, is approximately 95%. Given the discrepancy in survival outcomes between early- and late-stage disease, strategies that would allow for the detection of ovarian cancer in its early stages would hold promise to significantly improve the mortality rate from ovarian cancer. Unfortunately, current screening methods for the detection of early stage ovarian cancer are inadequate. However, several recent proteomics-based biomarker discovery projects show promise for the development of highly sensitive and specific markers for gynecological malignancies, including ovarian cancer. In this review, we hope to provide an overview of the early detection ovarian cancer from traditional methods to recent promises in the proteomics pipeline.

Factors influencing the use and accuracy of frozen section diagnosis of epithelial ovarian tumors

OBJECTIVE

The objective of the study was to study factors influencing the use and accuracy of frozen section diagnosis (FSD) of ovarian tumors.

STUDY DESIGN

Surgery was performed in 414 patients with epithelial ovarian tumors between 2001 and 2006. Factors were identified by univariate and multivariate analysis.

RESULTS

FSD was requested in 274 patients: 152 benign, 55 borderline, and 67 malignant tumors. Age 50 years or older, tumor size 10 cm or greater, and preoperative evidence of malignancy were associated with FSD request. The sensitivity and specificity of FSD for benign, borderline, and malignant tumors were 97% and 81%, 62% and 96%, and 88% and 99%, respectively. The histologic type (mucinous), tumor size (less than 10 cm), the borderline component (less than 10%), and the pathologist's experience predicted misdiagnosis of borderline tumors. Spread outside the ovary was the only significant predictor of accurate FSD of malignant tumors.

CONCLUSION

FSD is less accurate for borderline than benign and malignant ovarian tumors. The pathologist's experience is a major determinant of diagnostic accuracy.

Detection of ovarian tumors in chicken by sonography: a step toward early diagnosis in humans?

OBJECTIVE

Animal models of spontaneous ovarian cancer are important for understanding early tumor development. Ovarian imaging may play an important role in following changes in tumor development. Laying hens are the only animals that develop spontaneous ovarian cancer similar to humans. The aim of this study was to determine the feasibility of detecting ovarian tumors in laying hens using sonography.

METHODS

Ovaries of commercial strains of White Leghorn laying hens (n = 29, 2.5-3.0 years old) were examined by transvaginal 2-dimensional gray scale and color Doppler sonography. Sonographic evaluations were compared with ovarian anatomy and histologic features.

RESULTS

Results of in vivo sonography and ovarian anatomic and histologic examinations were consistent. The presence of gross ovarian tumors was correctly detected in all hens by sonography. The resistive and pulsatility index values associated with ovarian tumors were lower than for normal ovaries (P < .001) suggesting that blood flow velocity was increased in ovarian tumors. Values associated with abnormal ovarian histologic findings but no gross tumors were intermediate.

CONCLUSIONS

Transvaginal sonography can be used to determine ovarian status in hens. It offers the ability to make repeated examinations on the same hen to monitor early changes in the ovary associated with ovarian cancer.