Management of ovarian carcinoma. Current concepts and future prospects

Surgical training in gynecologic oncology: Past, present, future

The purpose of this paper is to review the surgical care related to training in gynecologic oncology, from past, present and future perspectives. A marked decline in the incidence of cervical cancer as well as improvements in radiation therapy have led to a reduction in the numbers of radical hysterectomies and exenterations being performed. Utilization of neoadjuvant chemotherapy is reducing the extent of cytoreductive operations, including intestinal surgery. The incorporation of sentinel lymphatic mapping has reduced the number of pelvic, paraaortic and inguinal lymphadenectomies being performed. Coupled with these changes are other factors limiting time for surgical training including an explosion in targeted anticancer therapies and more individualized options beyond simple cytotoxic therapy. With what is likely to be a sustained impact on training, gynecologic oncologists will still provide a broad range of care for women with gynecologic cancer but may be quite limited in surgical scope and rely on colleagues from other surgical disciplines. Enhancement of surgical training by off-service rotations, simulation, attending advanced surgical training courses and/or a longer duration of training are currently incorporated into some programs. Programs must ensure that fellows take full advantage of the clinical materials available, particularly those related to the potential deficiencies described. Changing required research training to an additional elective year could also be considered. Based on the perspectives noted, we believe it is time for our subspecialty to reevaluate its scope of surgical training and practice.

Allogeneic hematopoietic stem cell transplantation in ovarian carcinoma: results of five patients

Allogeneic hematopoietic stem cell transplantation is often used to treat hematologic malignancies. The efficacy of this procedure is due to both myeloablative conditioning and graft-versus-leukemia (GVL). However, the disadvantages of allogeneic transplantation include graft-versus-host disease (GVHD), relapse from the original tumor, and patient susceptibility to opportunistic infections. Lately, allogeneic transplantation has been developed to treat solid tumors, with the expectation that graft-versus-tumor (GVT), like GVL, will have a significant anti-tumor effect. This effect has been demonstrated in renal carcinomas, and with less evidence in breast cancers. Five patients with malignant ovarian tumors resistant to chemotherapy underwent allogeneic transplantation, four from bone marrow, and one from peripheral blood stem cells. All donors were HLA-identical siblings. One patient received a myeloablative conditioning regimen, while the other four received a non-myeloablative regimen. Two patients received donor lymphocyte infusions (DLI). Four of the patients presented with acute or chronic GVHD associated with tumor regression of at least 50%. These tumor regressions were measured by CA-125 levels and CT scans. The fifth patient died of rapid progression just after transplantation. Of the four transplantation survivors, three received a non-myeloablative regimen which did not seem to reduce treatment effectiveness. While it did reduce toxicity, one of these patients died of GVHD after 127 days. DLI was administered to two patients. These infusions seemed to promote GVHD which was able to control disease progression for one patient and had no apparent effect on the other. Allograft of hematopoietic stem cells might be of interest in ovarian cancer. The results in one patient also suggest that DLI may be an effective immunotherapy, although doses and timing need to be determined. The number of cases presented is small, however, and clinical experience on a larger scale will be required to determine the real clinical efficacy of graft versus cancerous ovarian cells.

Enzymatic tumour markers in ovarian cancer: a multiparametric study

The serum concentration of some enzymes, namely placental alkaline phosphatase, lactate dehydrogenase, 5' nucleotidase and amylase, was determined by commercially available kit in 50 ovarian cancer patients and 31 patients with benign gynaecological disease before initiation of any treatment. The values were compared with those of 30 healthy women. Multivariate analysis showed a statistically significant difference between healthy women and ovarian cancer patients. These results indicate that by using discriminating function of the above four enzyme variables it is possible to screen ovarian cancer in outpatient obstetric and gynaecological clinics (sensitivity 96%, specificity 83.3%, relative risk 11.7). Hence this system can serve as a suitable marker for ovarian cancer.

Carboplatin and retroperitoneal fibrosis

A patient treated for ovarian epithelial cancer by total abdominal hysterectomy (TAH), bilateral salpingo-oophorectomy (BSO), total omentectomy and five courses of single agent carboplatin chemotherapy, developed retroperitoneal fibrosis. This was diagnosed at exploratory laparotomy 6 months after completing treatment. No predisposing drug history existed in this patient. We believe that there have been no previous reports of an association between retro peritoneal fibrosis and carboplatin treatment.

Ovarian cancer, Part I: Biology

The ovary is among the more complex organs of the body and its functions are achieved by numerous cell types. All of these cell types have some tendency to undergo malignant transformation, but the vast majority of ovarian cancers are believed to be the result of malignant transformation of the ovarian surface epithelium. The concept that most ovarian cancer arises from this modified peritoneal mesothelium is credited to Sir Spencer Wells in 1872. Ovarian cancer is the most frequently fatal gynecologic malignancy, and approximately 20,000 cases per year are diagnosed in the United States. Progress in understanding the biology of this disease, including factors involved in its etiology, progression, and tendency to change from a relatively chemotherapy-sensitive tumor to one with marked drug resistance, has been slow. In this review, the complex features of the normal ovarian surface epithelial cells are considered in relation to the etiology and progression of the disease. The hypothesis that incessant or repetitious ovulation contributes to the initiation of the disease is explored in detail based on experimental data, epidemiologic information, and the potential for antioncogene inactivation in this interesting cell type. Lastly, based on the experimental data available, potential mechanisms of resistance to platinum, the cornerstone of aggressive ovarian cancer therapy, are discussed, as are approaches to overcoming drug resistance. It is hoped that the reader will be left with the feeling that the pace of our understanding of the biology of ovarian cancer is increasing at such a rate that answers to the questions of etiology and why chemotherapy often fails will be known in the foreseeable future.

Characterization of in vitro chemosensitivity of perioperative human ovarian malignancies by adenosine triphosphate chemosensitivity assay

We report the in vitro chemosensitivity of primary and recurrent human ovarian tumor samples analyzed by adenosine triphosphate chemosensitivity assay. We defined sensitivity as a greater than or equal to 70% decrease in intracellular adenosine triphosphate versus control at 20% of the reported peak plasma concentration per agent tested. Twenty of 21 assays (95.24%) were completed successfully. Single-agent and combined dose-response patterns consisting of decreasing viability with increasing drug concentration were observed consistently. Thirteen primary tumors were assayed, with 15.4% sensitive to cisplatin, 7.7% sensitive to 4-hydroxycyclophosphamide and 53.8% sensitive to their combination. Seven recurrent tumors were assayed, with 14.3% sensitive to cisplatin, 28.6% sensitive to 5-fluorouracil, and 42.9% sensitive to their combination. Dose-response characteristics and in vitro sensitivity rates reported in this article are consistent with reports of patient response in the literature. We conclude that adenosine triphosphate chemosensitivity assay is an efficient and reliable instrument for the in vitro chemosensitivity assessment of human tumors and warrants further clinical investigation.

Improved prognosis of ovarian cancer in The Netherlands during the period 1975-1985: a registry-based study

Survival of 568 patients with ovarian cancer, diagnosed in 1975-1985, was studied by means of a population-based registry in the Southeast Netherlands. Patients diagnosed in the period 1981-1985 had a significantly better prognosis than patients diagnosed in 1975-1980. This improvement of survival declined with advancing age of the patients. In women younger than 60 years, mortality from ovarian cancer decreased, while incidence remained stable. Apart from the effect of new treatment methods, consisting of more extensive tumor reduction and cisplatin-based combination chemotherapy, advances in supportive care as well as a trend toward earlier diagnosis, possibly in combination with an increasing proportion of less malignant tumors, may explain the improvement in prognosis. Survival was strongly related to stage at diagnosis and to age, the prognosis of younger patients being more favorable. Patients with tumors of either germ cell or stromal origin generally survived longer than patients with epithelial tumors, but this difference disappeared after adjustment for stage and age. Patients still alive after 6 years did not have a survival significantly different from that of the general female population.

Ovarian carcinoma during pregnancy: a study of 23 cases in Israel between the years 1960 and 1984

Data from a study on malignant ovarian tumors in pregnancy in Israel are presented. During the 25-year period of the survey, 23 new cases of malignant ovarian tumors during pregnancy were diagnosed, representing an incidence of 0.12/100,000 females over the age of 14; over half of the patients were in their third decade of life at the time of diagnosis of the tumor. Ovarian malignant tumors during pregnancy are more prevalent in Jewish women of European-American origin than in those of Asian-African descent. Borderline carcinomas were found in 35% of our patients; epithelial invasive tumors were found in 30%; the other tumors were dysgerminoma (17%), granulosa cell tumor (13%), and undifferentiated carcinoma (5%). Most of the patients (74%) were diagnosed in stage I. In three cases, ovarian cancer was diagnosed during surgery for tubal pregnancy, and in two during cesarean section at term. In early-stage disease and low-potential-malignancy tumors, surgery can be conservative; thus, 14 of 23 bore a live child. In advanced disease, aggressive surgery, chemotherapy, and/or radiotherapy should be instituted. Factors affecting prognosis were age of patient, histologic type of tumor, and clinical stage of disease. Overall, the survival is much better than that for ovarian tumors in general, because most of the tumors are of low potential malignancy and are diagnosed at an early stage.

Characterization of a human ovarian carcinoma cell line with estrogen and progesterone receptors

The potential significant therapeutic and prognostic roles for the sex steroid receptors in ovarian cancer are recognized. The authors present in detail the biochemical, morphologic, cytogenetic, and growth characteristics of an ovarian carcinoma cell line, BG-1, which has functional estrogen and progesterone receptors (23 and 300 fmol/mg protein, respectively) in clinically significant levels. In particular, BG-1 has a DNA index of 1.14, a stable karyotype with specific translocations, and produces and secretes CA 125 into the media.

Total abdominal irradiation in stage I and II carcinoma of the ovary

In the period from 1981 to 1986, 85 patients with ovarian carcinoma stage I and II were treated in a prospective study. All patients underwent primary surgery: bilateral salpingo-oophorectomy, hysterectomy and omentectomy followed by a staging procedure. In 46 patients, the staging was completed by a retroperitoneal lymph-node dissection, whereas in 39 patients, this procedure was omitted. Total abdominal irradiation (25 Gy/1.50 Gy per fraction) was followed by a pelvic boost dose (25 Gy/1.75 Gy per fraction). Patients with stage I and IIa well differentiated tumours received no adjuvant radiotherapy and are not reported here. The 5-year actuarial recurrence-free survival rate for the irradiated group was 75%. Stage according to FIGO appeared to be of significant prognostic influence. There was no difference in survival between completely and incompletely staged patients. Serious (small) bowel complications occurred however in 6 out of 45 patients who had undergone complete staging.

Malignant ovarian tumors in children and adolescents

Eighteen patients aged 4 to 18 years (median, 10 years) were treated at the Children's Cancer Research Center of The Children's Hospital of Philadelphia (CHP) from September 1973 to September 1983 for malignant ovarian tumors. The pathologic categories were endodermal sinus tumor (eight patients), embryonal carcinoma (three patients), pure dysgerminoma (three patients), adenocarcinoma (three patients), and malignant granulosa-cell tumor (one patient). In 1973 and 1975, respectively, two patients with endodermal sinus tumors were treated with surgical removal with or without radiation therapy (RT) and chemotherapy with vincristine (Vc) and actinomycin D+ cyclophosphamide + Adriamycin (Adria Laboratories, Columbus, OH) (ACAdr); both developed local recurrence within 12 months and died of tumor. Since 1977, four of six patients with endodermal sinus tumors have been managed successfully with surgery followed by chemotherapy with cisplatin (P), bleomycin (B), vinblastine (Vb), and ACAdr; none received RT. One died of recurrent tumor and the other died of congestive heart failure attributed to Adriamycin (Adr). All three patients with embryonal carcinoma were well after surgical excision alone (one patient) or surgery and chemotherapy with cisplatin + bleomycin + vinblastine (PBVb) + ACAdr (two patients). Treatment of the remaining seven patients included excision alone (two patients) or excision and chemotherapy (five patients) with various combinations of Vc, ACAdr, and P. One patient with granulosa-theca cell tumor also received whole abdominal RT (3000 rad by external beam), and died of congestive heart failure attributed to Adr. The other six children were free of detectable tumor 16 months to 8 years from diagnosis. Chemotherapy with PBVb and actinomycin D + cyclophosphamide (AC) should be used in the postoperative management of young persons with malignant ovarian tumors. Adr is of doubtful value and may be considerably toxic. RT is of limited use and usually is not indicated.

Sequential multi-agent chemotherapy and whole abdominal irradiation for stage III ovarian carcinoma

Modern therapy for stage III ovarian carcinoma patients usually involves one or more laparotomies with maximal resection of tumor, and intensive multi-agent chemotherapy. However, with long-term follow-up only 10-15% of patients remain free of disease. In the hope of improving outcome, we have treated 17 women with sequential multimodality therapy, including initial surgical resection (if possible), cyclophosphamide-adriamycin +/- cis-platinum, second-look surgery, and whole abdominal irradiation. Seven patients are currently alive without disease, with median follow-up of 52 months since initiation of radiation and 60 months since initiation of chemotherapy. Disease-free survival correlated with residual tumor at the start of radiotherapy: none (4/4); microscopic, less than or equal to 5 mm (3/4); greater than 5 mm or no surgery (0/9). Survival also correlated with tumor grade: grade 1 (2/2); grade 2 (2/3); grade 3 (3/11). Hematological tolerance of radiotherapy was dependent upon the number of chemotherapy cycles: ten of 11 patients receiving less than or equal to eight cycles completed radiotherapy without excessive delay, compared with only one of five receiving greater than eight cycles. There were no treatment-related deaths and only one patient required laparotomy for bowel obstruction. We conclude that intensive multimodal treatment may be tolerated moderately well if the amount of chemotherapy is limited, and that further studies are justified.

The predictive value of steroid hormone receptor analysis in breast, endometrial and ovarian cancer

The predictive value of female sex steroid, estrogen and progesterone, receptor (ER and PR, respectively) assays in breast, endometrial and ovarian cancer is reviewed with emphasis on comparative aspects of these malignant tumors in relation to their hormone dependency. The endocrine etiology of these three tumor types seems to be at least partly different, and so is the expression of these receptors in normal and malignant tissues of the breast, endometrium and ovary. There is a tendency for decreased receptor concentrations and disappearance of these receptors in association with advancement of these malignancies. There is also a decrease in the presence and concentrations of ER and PR in relation to loss of differentiation in breast and endometrial cancer. Receptor analyses have an established position in the selection of patients with advanced breast cancer for endocrine treatment, and they give promise of a similar application in endometrial cancer and in endometrioid cancer of the ovary. It is not clear whether the disease-free interval is related to the presence or concentrations of ER or PR as such in the tumor tissue. There is better survival in breast cancer patients with receptor-positive tumors, which might be due to a response to endocrine treatment. The same seems to be true for patients with endometrial cancer. Future progress in the application of female sex steroid receptor analyses in breast, endometrial and ovarian cancer needs additional controlled clinical trials and more highly developed receptor assays.

Phase II trial of medroxyprogesterone acetate in advanced ovarian cancer: an EORTC Gynecological Cancer Cooperative Group Study

Progestin therapy of ovarian carcinoma in the past has been reported to lead to varying response rates. A multicenter phase II study of high-dose MPA was conducted in 53 patients with epithelial ovarian cancer who had received adequate trials of conventional therapy with cytotoxic agents. Forty-one patients were included for response and toxicity evaluations. Only one partial response has been recorded with a duration of 20 weeks. Stabilization of disease was observed in 7 patients. The present investigation shows that MPA given at the present high dose is not effective in patients extensively pretreated with chemotherapy.

The value of the monoclonal antibody (cancer antigen 125) in serial monitoring of ovarian cancer: a comparison with circulating immune complexes

The use of circulating immune complexes and a commercial monoclonal antibody to ovarian cancer (CA 125 kit) in monitoring progress in patients with ovarian cancer has been assessed. While changes in immune complexes were apparent in some patients with active progression of disease, the marked change in values and linear trend make the use of CA 125 a useful clinical marker.

The role of cytoreductive surgery in advanced carcinoma of the ovary: an analysis of primary and second surgery

Second operations were performed as part of planned management in 53 patients 5-7 months after starting apparently successful chemotherapy. The survival of these patients is compared with 56 other patients who did not have a second laparotomy but appeared to be responding to chemotherapy equally well. Survival advantage was seen for those who had a partial remission followed by a further debulking procedure later. However, those patients who have a clinical complete remission do not seem to benefit from a second surgical intervention.

Predictive value of CA 125 antigen levels in second-look procedures for ovarian cancer

Serum CA 125 levels were evaluated in 44 patients undergoing 56 second-look or subsequent laparoscopies (43) and laparotomies (13) for ovarian cancer. In each patient studied, a previous CA 125 level had been greater than or equal to 35 U/ml. Clinical or radiologic evidence of tumor was absent in all patients at the time of surgical evaluation. CA 125 levels were less than 35 U/ml in 36 cases (64%); 14 patients were free of tumor, while 22 were found to have tumor at surgery. CA 125 levels were greater than or equal to 35 U/ml in 20 cases; 18 had tumor at surgery, one has had recurrence of tumor, and the other remains clinically free of tumor at 3 months. A CA 125 level less than 35 U/ml was not predictive of the presence of intraperitoneal tumor; however, when tumor was present in this group of patients, the largest tumor mass did not exceed 1 cm. In contrast, a CA 125 level greater than or equal to 35 U/ml was a strong predictor of the presence of intraperitoneal tumor or future recurrence. These data suggest that second-look procedures may not be required in the select group of patients with CA 125 levels greater than or equal to 35 U/ml.

Intracavitary chemotherapy

Pharmacokinetic modeling has suggested, and clinical investigations have confirmed, that intracavitary drug administration can result in a much greater drug exposure for the cavity into which the agent is instilled compared to the plasma. Both the safety and the efficacy of several agents administered individually or in combination have now been demonstrated. Several malignancies, in particular ovarian carcinoma and malignant mesothelioma, which remain confined to body cavities for much of their natural history, might be most rationally treated by the intracavitary treatment approach. Early clinical trials have demonstrated significant activity of intracavitary chemotherapy in both of these malignancies. Optimal drugs and dosages as well as appropriate scheduling for the various tumors involving body cavities remain to be defined. Whether or not combination intracavitary chemotherapy will significantly improve survival of patients with malignant disease confined to body cavities must await carefully controlled clinical trials comparing this treatment approach to standard systemically administered chemotherapy.

Ovarian cancer: diagnosis and management

Ovarian cancer is the leading cause of death from gynecological cancer in the United States. Early diagnosis is a matter of chance rather than a scientific method. Although it is stated that there are no symptoms in the early stage of ovarian cancer, a careful history often reveals vague gastrointestinal symptoms that have been persistent. Surgery is the treatment of choice for ovarian cancer, with chemotherapy employed as adjunctive therapy. Radiation therapy has limited application in treating common epithelial cancers but is valuable in the management of germ cell and gonadal stromal tumors. Of the numerous laboratory tests available, only immunologic assay appears to have the potential for making an early diagnosis and monitoring treatment.

Randomised trial comparing two combination chemotherapy regimens (Hexa-CAF vs CHAP-5) in advanced ovarian carcinoma

186 patients with advanced epithelial ovarian carcinoma were treated with either a combination of hexamethylmelamine, cyclophosphamide, methotrexate, and 5-fluorouracil (Hexa-CAF) or cyclophosphamide and hexamethylmelamine alternating with doxorubicin and a 5-day course of cisplatin (CHAP-5). Treatment with CHAP-5 resulted in more complete remissions as determined by laparatomy or peritoneoscopy (p = 0.004), better overall response (p = 0.0001), and longer overall survival and progression-free survival (p less than 0.002). Therapy, histological grade, and Karnofsky index were reliable predictors of overall response, whereas therapy, FIGO-stage, and size of residual tumour before chemotherapy were independent predictors for complete remission and for prolonged survival. Peripheral neurotoxicity was a major problem in patients assigned to the CHAP-5-group and was likely to be due to the simultaneous administration of hexamethylmelamine and cisplatin. The CHAP-5 regimen is one of the most effective regimens for the initial treatment of ovarian cancer.

Current status of systemic chemotherapy in the treatment of advanced ovarian cancer with emphasis on CHAP-5

In patients with advanced ovarian cancer, initial treatment with combination chemotherapy, including cyclophosphamide and cis-platinum diamminedichloride (cis-platinum), produces response and progression-free survival results which are superior to those achieved with alkylating single-agent chemotherapy. Unfortunately most schedules have not resulted in a statistically significant improvement of overall survival. So far one of the most effective combination regimens is the four-drug regimen CHAP-5 that consists of cyclophosphamide, hexamethylmelamine, adriamycin, and cis-platinum. This regimen is the first schedule to result in significant improved survival times compared with a second combination schedule, i.e. Hexa-CAF, which is at least as good as alkylating therapy alone. The CHAP-5 regimen was rather toxic but it was manageable and easy to apply in daily practice. Further improvement of the treatment results in advanced ovarian carcinoma will be difficult because no effective new drugs are available. In future clinical research it must be tried to decrease the toxicity and morbidity of the current schedules without reducing efficacy and survival.

Developing new drugs for ovarian cancer: a challenging task in a changing reality

Recent therapeutic and technological advances have profoundly modified the parameters of new drug testing in ovarian cancer. The potential of compounds tested today in this disease therefore needs to be assessed according to this changing reality. Previous treatment with or without cisplatin is the criterion we have applied in our review of the single agent clinical data. Results obtained with older compounds have also been, when possible, reassessed in order to facilitate a comparative interpretation of recent trials. A brief overview of the most recently developed laboratory screening models has been conducted in order to stress their close relationship and their crucial role in future new drug development.

Chemotherapy in advanced ovarian cancer

The chemotherapy of advanced ovarian cancer is reviewed. Treatment with single agents results in low remission rates and few complete remissions. The results have been improved with modern combination chemotherapy, which includes cisplatin, although a longer follow up is needed for definite conclusions to be made concerning survival. Toxicity and drug resistance remain important problems. The future prospects of treatment with emphasis on intraperitoneal chemotherapy are discussed.

Comparison of melphalan with cyclophosphamide, methotrexate, and 5-fluorouracil in patients with ovarian cancer

Melphalan (L-PAM) was compared to (C) cyclophosphamide, (M) methotrexate, and (F) 5-fluorouracil (CMF) in 413 patients with advanced ovarian carcinoma. L-PAM was given 3.5 mg/m2 twice daily for 5 days every 5 weeks. CMF doses were: C, 400 mg/m2; M, 15 mg/m2; and F, 400 mg/m2 IV on days 1 and 8 every 28 days. Three hundred seventy-five patients have been analyzed (L-PAM, 190; CMF, 185). One hundred fifty-three patients (41%) had measurable disease, 109 (29%) had evaluable disease, and 113 (30%) had nonmeasurable, nonevaluable disease. Response rates for patients with measurable and evaluable disease combined were similar: L-PAM, 32/130 (24%) (15% complete response); CMF, 47/132 (35%) (18% complete response). Patients with Stage IV measurable disease had a greater response rate to CMF, 22/52 (42%) versus L-PAM, 6/39 (15%). Survival and time to treatment failure were similar for both treatment regimens. Survival was improved in responders. Medians are: complete response, 28.1 months; partial response, 12.3 months; and no response, 6.7 months. Disease stage, performance status and age were identified as important prognostic variables for both survival and time to treatment failure.

Cytosol and nuclear estrogen and progestin receptors and 17 beta-hydroxysteroid dehydrogenase activity in non-diseased tissue and in benign and malignant tumors of the human ovary

Significant but low concentrations (mean 8 fmol/mg cytosol protein) of cytosol estrogen receptors were found in 57% of non-diseased ovarian tissues, and higher concentrations (mean 211) of cytosol progestin receptors in all these tissues. An approximately similar distribution was found for the presence of nuclear female sex steroid receptors; the mean concentrations were 159 and 1149 sites/cell, for estrogen and progestin receptors, respectively. There were no major differences in these parameters between pre- and postmenopausal non-diseased ovaries. The activities of ovarian 17 beta-hydroxysteroid dehydrogenase (17-HSD) did not display correlations between circulating progesterone concentrations in pre- or postmenopausal women with non-diseased ovaries. The majority of benign epithelial tumors contained significant concentrations of cytosol estrogen receptors, and all showed cytosol progestin receptors. The concentration of estrogen receptors was identical to that seen in non-diseased ovaries (mean 9 fmol/mg cytosol protein), whereas that of progestin receptor was significantly lower (mean 95). Nuclear female sex steroid receptors were measured in all benign tumors, and their concentrations were significantly higher than in normal ovaries (440 and 3218 sites/cell for estrogen and progestin receptors, respectively). No difference in 17-HSD activities were detected between normal ovaries and benign tumors. In malignant ovarian tumors, the picture was different from that found in normal ovarian tissues and benign tumors. Cytosol estrogen receptor was found in 89% of malignant epithelial tumors, and its concentration was significantly higher (mean 64 fmol/mg cytosol protein). Cytosol progestin receptor was found in 91%, and its concentration (mean 75) was significantly lower than in normal ovarian tissue or benign ovarian tumors. Nuclear female sex steroid receptor concentrations were intermediate between those seen in non-diseased ovaries an in benign tumors. 17-HSD activity was significantly lower than in other tissue categories studied. In the small group (16) of non-epithelial ovarian carcinomas cytosol estrogen receptors were not found, whereas the results of other measurements did not display any coherent picture. Breast and endometrial carcinoma metastatic to the ovary showed receptor patterns which were typical of the primary tumors. When the different clinical stages (I-IV) of malignant epithelial ovarian tumors were compared, 17-HSD activity was significantly higher in the least advanced clinical stage (I), whereas no significant differences were found in the other parameters measured.(ABSTRACT TRUNCATED AT 400 WORDS)

Estrogen and progesterone receptors in human ovarian tumors

Estrogen and progesterone receptors were measured in cystosols prepared from 32 normal ovaries and 25 benign and 49 malignant ovarian tumors. In normal ovarian tissue, estrogen and progesterone receptors were detected in 22 and 75% of specimens, respectively. Estrogen receptors were present in low concentrations ranging from 2 to 9 fmol/mg cytosol protein. The estrogen receptor content and distribution were similar in benign tumors (20%), but progesterone receptors were significantly decreased in 16% of specimens (P less than 0.001). In malignant ovarian tissues, estrogen receptors were present in 57% of specimens in concentration ranging from 1 to 132 fmol/mg cytosol protein. Of these, 72% of tissues had estrogen-receptor concentrations greater than 10 fmol/mg cytosol protein. The presence of estrogen receptors in ovarian cancer was significantly different from normal ovaries and benign tumor tissues (P less than 0.01). Progesterone receptors were detectable in 29% of ovarian cancer specimens. Estrogen and progesterone receptors were present alone or in combination, in 65% of ovarian cancers. The similarity in sex steroid content between ovarian and breast cancer warrants prospective studies of sex steroid receptor content in ovarian malignancies as a possible predictive index of survival and response to hormone therapy.

A study of the treatment of ovarian carcinoma

Between 1970 and early 1980, 213 patients were treated for ovarian carcinoma (stages Ib-IV) at the Department of Obstetrics and Gynecology, Graz University Medical School. Until mid 1976 patients were given postoperative radiotherapy; after that they were given combination chemotherapy (adriamycin and cyclophosphamide) according to Lloyd or Parker [18, 20, 21]. An analysis of the results led to the following conclusions: The operability at primary surgery is of prime importance, the best survival rates (regardless of postoperative management) being obtained in those patients in whom it is possible to do a pelvic clearance (removal of uterus, tubes and ovaries) with omentectomy. In patients who were operable postoperative chemotherapy was markedly superior to radiotherapy in terms of 1 year survival. But only slightly superior at 2 and 5 years. On the other hand, in patients who had palliative surgery postoperative radiotherapy seemed to give slightly better survival figures. Patients with early carcinoma (up to stage IIa) survived longer than those with late stages of carcinoma (IIb-IV) whether operable or not). The histology of the tumour had no discernible influence on the result both of chemotherapy and of radiotherapy. The patients with endometrioid and mucinous carcinomas had the highest survival rates irrespective of the postoperative treatment. However, the patients with serous cystadenocarcinomas survived longer than those with immature solid carcinomas. Patients who had no tumour at a second-look operation lived longer than those who had tumour at this time. Patients whose tumour recurred after the completion of postoperative radiotherapy and who were then given chemotherapy had the highest survival rates regardless of whether nor not the carcinoma was originally operable. It is felt that radiotherapy followed by chemotherapy should be used routinely especially in patients with late stages of ovarian carcinoma.

3H-estradiol and 3H-R5020 binding in cytosols of normal and neoplastic human ovarian tissue

High-affinity cytoplasmic estrogen and progesterone receptors in normal and abnormal ovarian tissues were studied. Estradiol receptor was detectable in 65% and progesterone receptor in 36% of the malignant tumors; 39% of all malignant ovarian tissues were estradiol- as well as progesterone-receptor-positive. Tumors were said to be receptor-positive when the receptors bound greater than 5 fM steroid/mg cytosol protein. No correlations were found between receptor status and histopathological diagnosis. In normal ovarian tissues collected at various phases of the menstrual cycle no changes in [3H]-estradiol and [3H]-R5020 binding could be detected. Analysis of the receptor concentration for both steroid hormones with regard to the menopausal status demonstrated highest levels in postmenopausal women. No significant difference could be found when two groups of patients with advanced ovarian carcinoma associated with the cytosol estrogen receptor status were compared in terms of two different therapeutic schemes (cytosolic chemotherapy with and without tamoxifen).

Improved therapy with cisplatin regimens for patients with ovarian carcinoma (FIGO Stages III and IV) as measured by surgical end-staging (second-look operation)

Between 1974 and 1982, 273 patients with epithelial cancer of the ovary (International Federation of Gynaecology and Obstetrics Stages III and IV) were randomized in four therapeutic trials. In Trial I Adriamycin plus cisplatin versus cisplatin alone versus thiotepa plus methotrexate was tested. The superiority of Adriamycin plus cisplatin in producing the best response rate led to its use as the reference arm in subsequent trials. All investigational arms included cisplatin plus other drugs (cyclophosphamide, Adriamycin, hexamethylmelamine, and thiotepa) in various combinations. Eligibility for second look required complete clinical remission and completion of at least 10 cycles of chemotherapy. To date, 73 second-look operations have been performed on randomized patients. An additional 43 nonrandomized patients underwent second-look procedures and are analyzed separately. Between 40% and 46% of patients treated with cisplatin regimens had no disease at second look. Cell differentiation and volume of postoperative disease did not influence response.

Malignant Brenner tumor of the ovary. Electron microscopic study of a case responsive to radiation and chemotherapy

A patient with malignant Brenner tumor of the ovary is presented. The tumor responded to combined therapy with radiation plus doxorubicin + cyclophosphamide despite earlier failure on a single alkylating agent (levophenylalanine mustard). The patient next exhibited a brief response to chemotherapy with hexamethylmelamine + cyclophosphamide + amethopterin + 5-fluorouracil. The histologic findings and ultrastructure of the tumor are discussed in detail. The morphologic features are consistent with the proposed origin of Brenner tumors from coelomic epithelium through a process of secondary urothelial metaplasia.

Computed tomography in ovarian carcinoma: patterns of disease and limitations

Between June 1977 and July 1980, a mixed group of 46 patients with ovarian carcinoma was examined by computed tomography (CT). CT was useful for demonstration of extent of disease within the abdomen and pelvis and may be used to provide an objective means for assessing response to treatment. The limitations of CT include failure to detect peritoneal deposits less than 2-3 cm in diameter, bowel infiltration and minor residual or recurrent disease. The patterns of disease as seen on CT are illustrated and its potential role is discussed.

Long-term follow-up and prognostic factors in ovarian carcinoma. The radiumhemmet series 1958 to 1973

Between 1958 and 1973, 2412 women with epithelial ovarian carcinoma were treated at Radiumhemmet. Of these tumors, 14.5 per cent were of borderline malignancy. The 5-year relative survival rate was 34 per cent among the patients with true malignant tumor and 93 per cent in the borderline cases. Even in advanced stages (IIb-IV) the 5-year survival rate was 78 per cent in the borderline cases. Advanced stage and high age at diagnosis, true malignancy and tumors of serous, clear cell or anaplastic type were associated with poor prognosis. The 5-year relative survival rate of patients with epithelial ovarian carcinoma in an early stage improved during the period, from 67 to 81 per cent.

Carcinoma of the ovary in stage III. Effects of postoperative chemotherapy, radiation therapy and repeat laparotomy

A prospective randomized trial was carried out in 153 patients with stage III malignant epithelial tumours for comparing the effects of irradiation or combination of chemotherapy and irradiation on prognosis and operability. No significant differences between these two treatment modalities were found. Of the patients primarily considered inoperable were 41 per cent operated upon after preoperative treatment. Minimum residual disease (0 to less than or equal to 2 cm) occurred in 38 per cent of the primarily operated and in 31 per cent of those operated upon after preoperative treatment. Preoperative irradiation in primarily inoperable patients enabled more effective surgical measures at relaparotomy. The size of the residual tumour after surgery and the tumor grade influenced the survival.

Progesterone regulation of the occupied form of nuclear estrogen receptor

Total concentrations of estrogen receptor in the uterine nuclear fraction are reduced rapidly after progesterone treatment of the proestrous hamster. Progesterone acts selectively on the occupied form of the nuclear estrogen receptor, with no effect on the concentration of an unoccupied form. This observation indicates that progesterone modulates the action of estrogen by controlling nuclear retention of the estrogen-receptor complex.

The occurrence of multiple steroid hormone receptors in disease-free and neoplastic human ovary

The cytoplasmic receptors for 17 beta-estradiol (ER), 5 alpha-dihydrotestosterone (AR), progesterone (PR), and cortisol (GR) have been quantified in 36 specimens from the human ovary (13 disease-free, 5 benign, and 18 malignant) by a dextran-coated charcoal (DCC) technique. The occurrence of receptor-positive biopsies were: ER 46%, AR 85%, PR 54%, GR 92%, in normal tissue; ER 40%, AR 100%, PR 20%, GR 50%, in benign tumors; and ER 67%, AR 72%, PR 50%, GR 88%, in malignant lesions. Furthermore, the simultaneous occurrence of ER and PR in malignant tumors was 50% yet all four receptors were found to be present only in 44% of the cases. The findings reported here on the strong correlation existing between ER and PR presence or amount agree with previous observations on normal and neoplastic specimens from human breast and endometrial tissues.