Common epithelial cancer of the ovary (2)

Prognostic Factors in Stage IV Ovarian Carcinoma Treated with Platinum-Based Regimens

Eight factors were analyzed for prognostic significance in univariate analyses in a series of 76 women with stage IV ovarian carcinoma treated with combination chemotherapies including cisplatin or carboplatin. The clinical objective and pathologic complete response rates were 51.2% and 27.3%, respectively. Median overall survival and progression-free survival were 15 and 7 months, respectively. No variables reached statistical significance. Trends toward better survival were noted for grades 1 and 2 for the adriamycin-containing regimen. Using progression-free survival as an end point, significant prognostic factors included complete clinical or pathologic response. Our data confirm that the standard approach is unlikely to modify the clinical outcome of stage IV ovarian cancer. New treatment modalities including high-dose-intensity regimens and neo-adjuvant chemotherapy delivered before surgery could improve clinical results. Moreover, biologic characterization of ovarian tumors may provide information to design specifically targeted treatment.

Timing of Surgery and the Role of Cytoreductive Chemotherapy in Patients with Advanced Ovarian Carcinoma

We retrospectively selected 27 consecutive patients with advanced ovarian carcinoma (15 stage III, 11 stage IV and 1 relapse) who had an unresectable intraabdominal tumor at presentation and prospectively evaluated the overall treatment outcome. Patients were initially treated with chemotherapy consisting of cisplatin-containing regimens in 20 cases, adriamycin and cyclophosphamide in 5, and melphalan in 2. Treatment was continued until maximal tumor response or progression. Following a median of 6 cycles of chemotherapy, all patients underwent debulking surgery. Six women were without evidence of disease and 13 had minimal residual disease after surgery, for an overall 70% rate of optimal debulking. Patients with evidence of disease at laparotomy were treated with 5 additional cycles of chemotherapy, and response was then assessed at laparotomy except for patients with progressive disease. Nine (33%) patients were pathologic complete responders at the end of the entire treatment program. Overall median survival time was 26 months, with a median relapse-free survival of 33 months. Tumor responses were not associated with any particular chemotherapy regimen. The results achieved in this series of patients together with the data from the literature suggests that use of a cytoreductive chemotherapy of short duration has the potential of increasing the rate of optimal debulking surgery. Furthermore, it may contribute to a better disease control in women with bulky ovarian carcinoma compared to the present strategy, which consists of surgery followed by chemotherapy.

Ovarian Cancer, the Revised FIGO Staging System, and the Role of Imaging

OBJECTIVE

It is now recognized that ovarian cancer includes a heterogeneous group of malignant epithelial tumors originating from the ovaries, fallopian tubes, or peritoneum. This development has prompted the International Federation of Gynecology and Obstetrics (FIGO) to issue a revised staging system that can provide prognostic information and guidance on personalized management of ovarian cancer.

CONCLUSION

We review the epidemiology of ovarian cancer, the new FIGO staging system, and the role of imaging in the assessment, staging, and follow-up of ovarian cancer.

TNFAIP8 as a predictor of metastasis and a novel prognostic biomarker in patients with epithelial ovarian cancer

Background:

Tumour necrosis factor-α-induced protein 8 (TNFAIP8) has been recently documented in various malignancies, but its role in epithelial ovarian cancer (EOC) remains unknown.

Methods:

Tumour necrosis factor-α-induced protein 8 expression was determined by real-time reverse transcription PCR and western blot analysis. Tumour tissues, consisting of serous, mucinous, endometrioid and clear cell histotypes, from 202 EOC patients (International Federation of Gynecologists and Obstetricians I–IV) who underwent primary cytoreduction were collected. Then, we examined the immunohistochemical expression of TNFAIP8 and evaluated its clinical significances.

Results:

Tumour necrosis factor-α-induced protein 8 overexpression was significantly associated with high histologic grade (P=0.005), large residual tumour size (P=0.014), recurrence (P=0.024) and response to chemotherapy (P<0.001). Multivariate analysis showed that TNFAIP8 overexpression was independently correlated with the presence of lymph node (odds ratio (OR): 4.129; 95% confidence interval (CI): 1.491–11.435; P=0.006) and intraperitoneal metastasis (OR: 2.209; 95% CI: 1.174–4.156; P=0.014). Moreover, results revealed that the status of TNFAIP8 expression was an independently prognostic factor for both cancer-specific survival (hazard ratio (HR): 1.852; 95% CI: 1.322–2.594; P<0.001) and disease-free survival (HR: 1.724; 95% CI: 1.235–2.407; P=0.001) in patients with EOC.

Conclusion:

The present data provide evidence that TNFAIP8 predicts EOC metastasis and poor survival, highlighting its potential function as a therapeutic target for EOCs.

Ovarian cancer

Ovarian cancer accounts for 4% of all cancers in women and is the leading cause of death from gynaecologic malignancies. Because early-stage ovarian cancer is generally asymptomatic, approximately 75% of women present with advanced disease at diagnosis. Survival is highly dependent on stage of disease: 5-year survival in patients with early-stage is 80-90% compared to 25% for patients with advanced-stage disease. For all patients, a comprehensive surgical staging should be performed to obtain the histological confirmation of diagnosis and to evaluate the extent of disease. Patients with early-stage should both be optimally staged and be treated with adjuvant platinum-based chemotherapy if they have a medium or high-risk tumour. For advanced disease the currently recommended management is primary cytoreductive surgery followed by platinum-paclitaxel combination chemotherapy. Appropriate salvage therapy is based on the timing and nature of recurrence and the extent of prior chemotherapy. Surgical resection should be considered in patients with long-term remission, especially in those with isolated recurrences and good performance status. Platinum-based combination represents the standard second-line chemotherapy in patients with platinum-sensitive relapsed ovarian cancer. Salvage chemotherapy in platinum-refractory patients usually results in low response rates and short survival.

The interval from surgery to chemotherapy in the treatment of advanced epithelial ovarian carcinoma

BACKGROUND

To study the effect of the interval between surgery and the start of chemotherapy in the treatment of patients with advanced ovarian cancer.

METHODS

We stratified patients according to the start of platinum-based chemotherapy in group 1 (within 4 weeks from surgery), group 2 (between 4 and 8 weeks) and group 3 (between 8 and 12 weeks).

RESULTS

Three hundred and ninty-four stage III ovarian cancer patients were analysed. In the multivariate analysis there were no differences in survival according to the interval between surgery and chemotherapy among the three groups. The independent prognostic variables were type of procedure (p = 0.014), performance status (p = 0.040) and post-chemotherapy CA-125 (p < 0.0001).

CONCLUSIONS

The interval between surgery and chemotherapy does not affect outcome.

Expression of the endothelial cell differentiation gene 7 (EDG-7), a lysophosphatidic acid receptor, in ovarian tumor

AIM

Lysophosphatidic acid (LPA) has received attention as a mitogen because the physiologically active lipid stimulates ovarian cancer cell growth by interacting with specific receptors, the endothelial cell differentiation gene (EDG) family. In the present study, we have investigated the expression of EDG-7 mRNA, part of the EDG family, in both human ovarian cancers and established human ovarian cancer cell lines.

METHODS

RNA was extracted from six ovarian cancer cell lines and multiple cancerous and normal ovarian tissues. The expression of EDG-7 mRNA was measured using reverse transcription-polymerase chain reaction and northern blotting, using reduced glyceraldehyde-phosphate dehydrogenase and S26 as internal controls.

RESULTS

Of the cell lines tested, EDG-7 mRNA was expressed most intensely in CRL-11731 and CRL-1572 and at a lesser but still substantial level in CRL-11732. The expression of EDG-7 mRNA was limited in MCAS, CRL-11730 and TYKnu. In the ovarian cancer tissues, EDG-7 mRNA was expressed most highly in endometrioid adenocarcinoma and serous cystadenocarcinoma. The expression of EDG-7 mRNA was limited in clear cell adenocarcinoma and undetectable in mucinous cystadenocarcinoma.

CONCLUSIONS

The intense EDG-7 expression in ovarian cancers suggests that the relation between LPA and EDG-7 (an LPA receptor) is involved in cancer cell growth and proliferation in some histologic subtypes of ovarian cancer.

Neoadjuvant chemotherapy for epithelial ovarian cancer—role of apoptosis

BACKGROUND

Ovarian cancer is one of the most frequently fatal gynecological cancers because most cases are diagnosed at an advanced stage. Loss of growth control and a marked resistance to apoptosis are considered major mechanisms driving tumor progression. Little is known about the effect of various treatment regimens on the distribution of molecular markers of apoptosis in epithelial ovarian cancer. The objective of this study was to compare the expression levels of both proapoptotic and antiapoptotic proteins p53, p73, Bcl-2, Bcl-XL and survivin in the ascitic cells and tumor samples of patients undergoing treatment with two different regimens.

METHODS

A total of 24 patients with untreated epithelial ovarian cancer were randomized into two groups of 12 each. Group 1 patients received three cycles of chemotherapy prior to surgery and three cycles after surgery and group 2 patients received six cycles of chemotherapy prior to surgery. The expression of apoptosis-related proteins was analyzed in ascitic fluid and tumor samples by Western blotting and immunohistochemistry. The apoptotic index was also determined in these samples by the TUNEL assay.

RESULTS

Significant decreases in antiapoptotic bcl-2 and survivin were seen, accompanied by increases in apoptotic index in tumors that had undergone chemotherapy as compared to the baseline ascites samples. No significant change in bcl-XL was observed. A significant decrease in proapoptotic p53 was also seen. No expression of p73 was observed in tumors or ascites. The findings were similar in groups 1 and 2 patients and were not statistically significantly different, perhaps due to the small sample size (n=12) of each group.

CONCLUSIONS

The above findings indicate that chemotherapy in ovarian carcinoma leads to an increase in apoptosis by a p53-independent pathway, which involves the downregulation of antiapoptotic Bcl-2 and survivin but not Bcl-XL. Furthermore, administering neoadjuvant chemotherapy (six cycles) as an alternative form of therapy for advanced epithelial ovarian cancer is more effective in inducing apoptosis than three cycles. However, the findings of this study need to be corroborated using a larger sample.

Systematic review of adjuvant care for women with Stage I ovarian carcinoma

BACKGROUND

Several adjuvant care interventions to treat women with Stage I ovarian carcinoma have been studied. The aim of the current systematic review was to determine the optimal strategy for adjuvant care for women with Stage I ovarian carcinoma.

METHODS

A systematic search was conducted to find randomized controlled trials published between 1965 and April 2004 that examined adjuvant therapy (e.g., chemotherapy and radiotherapy) for women with Stage I ovarian carcinoma.

RESULTS

Thirteen randomized controlled trials were identified that compared adjuvant therapies for women with Stage I ovarian carcinoma. Eight of these trials reported results only for patients with Stage I disease. The majority of patients in the five randomized trials that compared adjuvant chemotherapy with no chemotherapy did not receive lymphadenectomy as part of their surgical staging. The pooled results for Stage I patients indicated a survival benefit (relative risk [RR], 0.74; 95% confidence interval [CI], 0.58-0.94; P = 0.01), and a benefit in terms of a reduced risk of developing disease recurrence (RR, 0.70; 95% CI, 0.58-0.86; P = 0.0004) favoring adjuvant chemotherapy. Platinum-based adjuvant chemotherapy was reported to improve overall 5-year survival (absolute survival difference 8%; 95% CI, 2-12%; hazard ratio, 0.67; 95% CI, 0.50-0.90; P = 0.008).

CONCLUSIONS

Adjuvant platinum-based chemotherapy for women with Stage I ovarian carcinoma improved survival and reduced the risk of recurrent disease. The optimally staged group accounted for approximately 10% of women with Stage I disease. The role of adjuvant chemotherapy in optimally staged patients (especially those with good prognostic factors) has not been assessed adequately.

Influence of hospital procedure volume on ovarian cancer survival in Japan, a country with low incidence of ovarian cancer

The survival of ovarian cancer patients has been reported to be superior at hospitals with a high volume of operations. A population-based study was carried out to assess whether this is true in Japan, where the incidence rate is relatively low as compared with other developed countries. The Osaka Cancer Registry's data were used to investigate associations between hospital procedure volume and survival of ovarian cancer patients. Hospitals were ranked according to the number of operations for ovarian cancer performed per year (high/medium/low/very low). Survival analysis was restricted to the reported 2450 cases who lived in Osaka Prefecture (except for Osaka City) diagnosed in 1975-1995, or those who resided in Osaka City in 1993-1995, since active follow-up data on vital status 5 years after the diagnosis were available. The relative 5-year survival for all ovarian cancer cases was 38.8%, and the survival was higher with greater hospital volume (22.3% / 34.2% / 46.2% / 55.0%). After adjustment for age, histologic type and cancer stage by the Cox regression model, patients receiving care in very-low-volume hospitals were seen to have a 60% higher risk of death than patients receiving care in high-volume hospitals (P < 0.01). Although some limitations existed in this study, the results indicated that further centralization of operative treatment in high-volume hospitals might improve survival of ovarian cancer patients in Japan.

Ovarian cancer incidence and survival by histologic type in Osaka, Japan

The incidence of ovarian cancer among Japanese has increased since the 1970s. Histologic diversity is a characteristic of this cancer. However, there has been no population-based study made on the incidence and survival by histologic type. Osaka Cancer Registry's data was used for incidence and survival analyses of ovarian cancer by histologic type in this study. Seven thousand one hundred sixty-seven incident cases were registered during the period 1975 to 1998. According to the IARC's histologic classification, types of ovarian cancer were classified into five categories. Survival analysis was restricted to the reported 2431 cases who lived in Osaka Prefecture (except for Osaka City) and were diagnosed in 1975-1994, since active follow-up data on vital status 5 years after the diagnosis were available. The age-standardized incidence rate of ovarian cancer increased from 4.0 to 5.4 per 100,000 women (standard: world population) in Osaka during the period 1975-1998. Carcinoma, the major histologic category, also increased (from 3.4 to 4.8 per 100,000 women), while sex cord-stromal tumors decreased after 1980 and germ cell tumors remained stable. The 5-year relative survival was 36.4% for ovarian cancer patients diagnosed in 1975-1994. The survival for carcinoma was 38.3%, which was lower than that in sex cord-stromal tumors or germ cell tumors (55.3% and 58.6%, respectively). The increase in the incidence of ovarian cancer was caused by the increase in carcinoma. The relative 5-year survival of ovarian cancer improved over the period, but was different by histologic type.

Phosphatidylinositol 3-kinase-dependent, MEK- independent proliferation in response to CaR activation

Although ovarian surface epithelial (OSE) cells are responsible for the majority of ovarian tumors, we know relatively little about the pathway(s) that is responsible for regulating their proliferation. We found that phosphatidylinositol 3-kinase (PI3K) is activated in OSE cells in response to elevated extracellular calcium, and the PI3K inhibitors wortmannin and LY-294002 inhibited extracellular signal-regulated kinase (ERK) activation by approximately 75%, similar to effects of the mitogen-activated protein kinase/ERK kinase inhibitor PD-98059. However, in assays of proliferation, we found that PD-98059 inhibited proliferation by approximately 50%, whereas wortmannin inhibited >90% of the proliferative response to elevated calcium. Expression of a dominant negative PI3K totally inhibited ERK activation in response to calcium. These results demonstrate that ERK activation cannot account for the full proliferative effect of elevated calcium in OSE cells and suggest the presence of an ERK-independent, PI3K-dependent component in the proliferative response.

Multivariate analysis of the prognostic significance of DNA-ploidy and S-phase fraction in ovarian cancer determined by flow cytometry following detection of cytokeratin-labeled tumor cells

OBJECTIVE

The outcome of patients with advanced ovarian cancer is poor despite aggressive therapy including surgery and multiagent chemotherapy. Valid prognostic factors are necessary to estimate the course of the disease and to define biologically similar subgroups for analysis of therapeutic efficacy.

METHODS

This study is the first published prospective study concerning the prognostic significance of DNA-ploidy and S-phase fraction in ovarian cancer following enrichment of tumor cells by cytokeratin labeling. Epithelial cells were labeled by FITC-conjugated cytokeratin antibody (CK 5, 6, 8, and 17) prior to flow cytometric cell cycle analysis in 129 fresh specimens of primary ovarian cancer.

RESULTS

Recurrence-free survival of patients with DNA-diploid primary ovarian cancer was significantly better compared to that of patients with DNA-aneuploid tumors in univariate analysis (47% vs 18%, P = 0.01). The tumor-dependent overall survival of patients with DNA-diploid tumors was 57% compared to 30% with DNA-aneuploid tumors (P = 0.04). In FIGO stage III ovarian cancer DNA-ploidy, optimized by cytokeratin gating for tumor cells, achieved independent prognostic significance. No significance was found for S-phase fraction. However, despite convincing methodological advantages in the detection of DNA-aneuploid subpopulations the clinical significance of cytokeratin gating of epithelial cells was only marginal.

CONCLUSION

DNA-ploidy has been shown to be as powerful or even more so in comparison to postoperative residual tumor in multivariate analysis for predicting clinical outcome in advanced ovarian cancer. Thus, determination of DNA-ploidy should be introduced to currently recruiting phase III studies for therapy of ovarian cancer for better definition of prognostic subgroups.

Thymidine labeling index in epithelial ovarian cancer

OBJECTIVE

The aim of this study is to determine the thymidine labeling index and its prognostic role in patients with ovarian cancer.

METHODS

Tumor cell proliferation in 32 patients with primary ovarian cancer admitted to Istanbul Medical Faculty, Department of Obstetrics and Gynecology, between 1993 and 1997 was investigated using the [3H]thymidine labeling index (TLI). TLI results were compared with other clinical and histopathologic prognostic parameters.

RESULTS

The mean and median TLI values of the patients were 9.3+/-6.2% and 9.20% (range: 0.4-23.0%), respectively. Sixteen patients showed high proliferation rates (mean TLI: 14.3%). These patients had an overall survival rate of 46.7% at 3 years. The mean TLI level and overall survival at 3 years in the low proliferation rate group were 4.4 and 68.8%, respectively. Patients with a high TLI had a significantly shorter survival compared to those with a low TLI (P<0.01). There was tendency towards a higher TLI with advanced stage (P>0.05). However, there was no statistically significant correlation between TLI and other prognostic parameters.

CONCLUSION

TLI may have a predictive value in determining the outcome of patients with ovarian cancer. Further larger scale studies are needed before definite conclusions can be made about its role as a prognostic factor in this disease.

Signal transduction mechanisms linking increased extracellular calcium to proliferation in ovarian surface epithelial cells

Although ovarian surface epithelial (OSE) cells are the cell type responsible for malignant ovarian carcinoma, relatively little is known about either the extracellular stimuli or the intracellular signaling mechanisms responsible for regulating proliferation in these cells. We have demonstrated that OSE cells proliferate in response to elevation of extracellular calcium and that OSE cells express functional calcium-sensing receptors (CaR). Here we show that agonists of the CaR increase the kinase activity of Src and ERKs (extracellular signal-regulated kinases) in rat OSE cells and promote association between tyrosine-phosphorylated Shc and p120rasGAP. Expression of an interfering mutant CaR inhibited the proliferative response to elevated extracellular calcium, as well as CaR agonist-induced tyrosine phosphorylation and ERK activation. Transfection with dominant negative mutants of Ras, Raf, and MKK1 also inhibited the increase in ERK activity in response to calcium, as did treatment with herbimycin, a selective inhibitor for Src family kinases. These results indicate that the ability of OSE cells to proliferate in response to increases in extracellular calcium involves cross-talk between the G-protein-coupled CaR and the activation of a tyrosine kinase-dependent Ras-Raf-ERK signaling pathway.

Ovarian serous borderline tumors: a critical review of the literature with emphasis on prognostic indicators

BACKGROUND

The behavior of ovarian serous borderline tumors (SBTs) and significance of various prognostic factors are unclear and difficult to evaluate because of inconsistencies and confusion in the literature. Recent studies have suggested that the morphological features of the primary tumor (presence or absence of micropapillary features) and the peritoneal "implants" (presence or absence of invasive features) can reliably subclassify SBTs into benign and malignant types. The aim of the current review was to test two hypotheses. First, that the alleged malignant behavior of SBTs is poorly documented, and second, that the morphological features of the primary ovarian tumors and the associated peritoneal implants are sufficient to separate SBTs into benign and malignant types, thereby obviating the need for the category.

METHODS

245 studies reporting approximately 18,000 patients with borderline ovarian tumors were reviewed. After excluding series that lacked clinical follow-up or were not analyzable for other reasons, there remained 97 reports that included 4,129 patients. In addition to recurrences and survival, we evaluated the type of peritoneal implants, microinvasion, lymph node involvement, late recurrences, and progression to carcinoma, as these features have served as the underpinning of the concept of "borderline malignancy" or "low malignant potential."

RESULTS

Among 4,129 patients with SBTs reviewed, the recurrence rate after a mean follow-up of 6.7 years was 0.27% per year for stage I tumors, the disease-free survival was 98.2%, and the overall disease-specific survival rate was 99.5%. For patients with advanced-stage tumors, the recurrence rate was 2.4% per year. However, the majority (69%) of reported recurrences were not pathologically documented, and only 26 cases (8.4% of all recurrences) were documented to have recurred from an adequately sampled ovarian tumor. The most reliable prognostic indicator for advanced stage tumors was the type of peritoneal implant. After 7.4 years of follow-up, the survival of patients with noninvasive peritoneal inplants was 95.3%, as compared with 66% for invasive implants (P < .0001). Microinvasion in the primary ovarian tumor was associated with a 100% survival rate at 6.7 years, and lymph node involvement was associated with a 98% survival rate at 6.5 years. The few reported cases of stage IV disease, progression to invasive carcinoma, and very late (>20 years) recurrences were poorly documented. The survival for all stages among approximately 373 patients in 6 prospective randomized trials followed for a mean of 6.7 years was 100%.

CONCLUSION

Surgical pathological stage and subclassification of extraovarian disease into invasive and noninvasive implants are the most important prognostic indicators for SBTs. Survival for stage I tumors is virtually 100%. Survival for advanced stage tumors with noninvasive implants is 95.3%, whereas survival for tumors with invasive implants is 66%. Invasive implants behave as carcinomas and are most likely metastatic. The precise nature of so-called noninvasive implants is not clear, but they behave in a benign fashion. The presence of a micropapillary architecture in the primary ovarian tumor is a strong predictor of invasive implants. These data support the recommendation that ovarian tumors with a micropapillary architecture be designated "micropapillary serous carcinomas," and those lacking these features, "atypical proliferative serous tumors."

Screening for gynecological malignancy

Treatment for gynecological malignancy depends for its efficacy at least in part on the stage at presentation. Earlier diagnosis would allow the opportunity for more effective and potentially curative treatment. As a consequence, and in common with initiatives for many other cancers, a search for effective methods of screening is a high priority for the detection of early gynecological cancer. Such methods already exist for cervical cancer, and in many countries screening programs are in place to provide such early diagnosis. Patients with endometrial cancer often present symptomatically at stage I and as a consequence the value of screening of asymptomatic patients may be of lesser importance than for other cancers. Ovarian cancer, however, characteristically presents late and is insidious in onset and progress. Transvaginal ultrasound, together with serum tumor markers, may offer the possibility of early diagnosis and modification of therapy with the potential for improved outcome. However, the evidence from the literature is at present confusing, and it is worthwhile to review the current status of research data to evaluate the place of screening procedures for ovarian and other gynecological malignancies.

Epithelial ovarian carcinoma in the reproductive age group

BACKGROUND

A retrospective review of women age < or = 40 years with epithelial ovarian carcinoma was undertaken to determine whether patient age and tumor grade are independent prognostic factors for survival, to investigate the survival rate for young women with ovarian carcinoma, and to characterize these young women in terms of reproductive capability.

METHODS

The tumor registry of the Massachusetts General Hospital was used to identify cases of ovarian carcinoma diagnosed between January 1980 and July 1996. Patient records and pathology were reviewed. Survival rates were calculated by the Kaplan-Meier method and Cox proportional hazards models were used to determine the independent effect of each variable on survival.

RESULTS

Ninety-two tumors epithelial tumors were identified with 46 (50%) classified as borderline. In the univariate analysis, stage (P < 0.001), grade (P < 0.001), residual disease (< or = 2 cm vs. > 2 cm, P < 0.001), and age (< 30 years vs. 31-40 years; P = 0.019) were found to be significant prognostic factors for survival. However, in the multivariate analysis only tumor grade (with borderline tumors assigned a grade of 0) and stage were significant predictors of survival (P < 0.01 for both). The 5-year survival rate for carcinoma patients with advanced disease was 22.9%. Patients with borderline tumors were more likely be diagnosed during an evaluation for infertility and were more likely to have successful live births after carcinoma treatment.

CONCLUSIONS

Young women with advanced epithelial carcinoma have a 5-year survival rate similar to that quoted in the literature, despite the use of more aggressive chemotherapeutic regimens. Patients with borderline tumors of any stage have an excellent prognosis for preserving fertility options.

Recurrent psammocarcinoma of the peritoneum with complete response to tamoxifen therapy

Psammocarcinoma is a rare type of serous carcinoma arising from the ovary or peritoneum, characterized by massive psammoma body formation, invasiveness, and low-grade cytological features. A case of primary peritoneal psammocarcinoma is presented. Aspects of clinical presentation, diagnosis, and management are described. Emphasis is placed on successful management of recurrent disease using tamoxifen therapy.

Mucin carbohydrate antigens (T, Tn, and sialyl-Tn) in human ovarian carcinomas: relationship with histopathology and prognosis

Altered glycosylation of mucins leading to the expression of T, Tn, and sialyl-Tn antigens has been shown in ovarian carcinoma, but its relationship with prognosis is still unclear. We investigated immunohistochemically the expression of these antigens in 38 (17 serous and 21 mucinous) ovarian carcinomas to assess their potential prognostic value as compared with stage of disease, histopathology of tumors, and survival time of patients. Eight benign ovarian tumors (four serous and four mucinous), and four normal ovarian tissues also were studied. Of the 38 carcinomas, 25 (66%) expressed T, 27 (71%) expressed Tn, and 33 (87%) expressed sialyl-Tn antigens. Most cases (83%) expressed two or all of the three types of antigens simultaneously. Normal ovarian epithelia showed no staining for these antigens, and benign ovarian tumors were either negative or occasionally expressed weak staining in less than 25% of epithelial cell areas. Statistical analyses showed strong associations between Tn and sialyl-Tn antigen expressions and disease stage as well as histological grade. In 19 ovarian carcinoma patients with available survival data, the overall survival times of patients with high Tn or sialyl-Tn antigen expression were significantly worse than those of the patients with negative and low expression (P < .05 and P < .01). In multivariate stepwise regression analysis, disease stage (P = .000) and Tn antigen expression (P = .02) were found to be significant independent parameters associated with the overall survival time. These findings suggest that, with exception of T antigen expression, the expression of Tn and sialyl-Tn antigens in ovarian carcinomas may provide additional prognostic information on patient outcome.

Serum CA125 assay at the time of relapse has no prognostic relevance in patients undergoing chemotherapy for recurrent ovarian cancer: a multicenter Italian study

The present retrospective study assessed the prognostic value of serum CA125 assay at relapse in 73 patients with recurrent epithelial ovarian cancer. At the time of relapse, serum CA125 levels ranged from 7 to 7000 U ml-1. The 25%, 50% and 75% quantiles of CA125 levels were 76, 178 and 339 U ml-1, respectively. Antigen values were >35 U ml-1 in 67 (91.8%) of the 73 patients. Median time to recurrence was 16 months (range, 4-62 months). Serum CA125 levels at relapse were not related to site of recurrence, time to recurrence, FIGO stage, histologic type, tumor grade and residual disease after initial surgery. Sixty patients received salvage chemotherapy at relapse. In these patients survival after recurrence was significantly related to time to recurrence (< or = 6 months vs < 6 months, P = 0.0371; < or =12 months vs >12 months, P = 0.0014; < or =16 months vs >16 months, P = 0.0001), but not to CA125 level at relapse (at any cut-off value for the antigen: 35, 76, 178 and 339 U ml-1), site of recurrence, FIGO stage, histologic type, tumor grade and residual disease after initial surgery. In conclusion, time to recurrence was the only variable predictive of further survival in patients undergoing salvage chemotherapy for recurrent ovarian cancer, whereas serum CA125 level at relapse had no prognostic relevance.

A new cell line from human undifferentiated carcinoma of the ovary: establishment and characterization

A cell line designated CUMO-2 has been established from an undifferentiated ovarian carcinoma. The s.c. injection of cells into nude mice gave rise to fast-growing tumors, while the i.p. route induced a peritoneal carcinomatosis with ascites. Histopathologically, the transplanted s.c. tumors closely resembled the original tumor, but tumors developed in the peritoneal cavity were highly anaplastic. The epithelial nature of the cells was confirmed by ultrastructural analysis. Sequential cytogenetic analyses on early and late passages revealed highly aneuploid tumor cells with consistent structural aberrations of chromosomes 1, 3, 8 and 11. CUMO-2 cells were found to produce CA 125 in vitro and in vivo. Cytosol estrogen receptor (ER) was found but progesterone receptor (PR) was not measured. HLA typing indicated the presence of DR8 and DQw4. A gonadotropin-releasing hormone (Gn-RH) analog inhibited cell growth and Gn-RH receptor mRNA was detected by reverse transcription/polymerase chain reaction in this cell line. Administration of transforming growth factor beta 1 inhibited both cell growth and c-myc mRNA expression. This cell line demonstrated a conformational band shift in exon 7 of the p53 gene. It was a frameshift mutation.

Calcified brain metastases from ovarian carcinoma

A case of calcified brain metastases from ovarian carcinoma is reported. Lesions developing during chemotherapy were thought on Ct to be parasitic and, to avoid dissemination of pathogens, biopsy was postponed. When neurological deficits progressed, MRI showed perifocal oedema and contrast enhancement. It also showed a new noncalcified focus which was biopsied, proving to be a metastasis.

Tandem high-dose chemotherapy with ifosfamide, carboplatin, and teniposide with autologous bone marrow transplantation for the treatment of poor prognosis common epithelial ovarian carcinoma

BACKGROUND

A phase I or II trial was conducted to assess the toxicity and the efficacy of a tandem high dose chemotherapy combining ifosfamide, carboplatin, and teniposide in patients with poor prognosis ovarian carcinoma.

METHODS

Thirty-seven patients were scheduled to receive tandem high dose therapy combining ifosfamide 7500 to 11250 mg/m2, carboplatin 875 ot 1000 mg/m2 and teniposide 750 to 1000 mg/m2, followed by autologous bone marrow transplantation (ABMT). Eight patients were refractory to the platin-based regimen, 7 were treated in chemosensitive relapse, and 22 in partial or complete response (PR/CR) were treated. Sixty-six cycles were administered. Sixteen patients were evaluated for response.

RESULTS

The overall response rate was 56% (CR rate: 12%). Toxic effects consisted of mainly renal toxicity, esophagitis, and enterocolitis. Three patients died of therapy-related complications. Since the time of ABMT, the median overall survival (OS) duration of the whole population was 18 months and the survival rate was 14% at 60 months. For the 22 patients treated after PR or CR, the median OS duration was 24 months and the survival rate was 32% at 60 months. Tandem high dose therapy with ABMT was unable to circumvent resistance to conventional chemotherapy or to prolong the duration of survival for patients treated in chemosensitive relapse. For patients treated after CR or PR, the survival results were similar to that achieved with conventional therapy.

CONCLUSIONS

Prospective, randomized studies, including patients only after CR or with minimal residual disease, are urgently required to evaluate the activity of high dose therapy in the treatment of advanced ovarian carcinoma.

Carboplatin alone compared with its combination with epirubicin and cyclophosphamide in untreated advanced epithelial ovarian cancer: a Hellenic co-operative oncology group study

We compared, in a multicentric randomised prospective study, the efficacy and toxicity of carboplatin 400 mg/m2 as a single agent (CB) to a combination of carboplatin 300 mg/m2, epirubicin 50 mg/m2 and cyclophosphamide 500 mg/m2 (CB-EC) in advanced ovarian cancer patients. The treatment was scheduled to be administered every 3 weeks for six courses. Following initial laparotomy and cytoreductive surgery, 130 previously untreated patients entered the study. 73 patients were treated with carboplatin alone while 57 received the combination chemotherapy. In the majority of the patients, the regimens had to be given every 4 weeks due to myelosuppression. Nausea, vomiting and alopecia were more severe in the CB-EC arm. Overall, clinical complete response was observed in 73 (56%) and partial response in 20 (15%) patients. The median time to progression was 16.89 months and median survival was 29.54 months. No significant differences in response rate, time to progression, disease-free survival and overall survival were observed between the two treatment arms. The prognostic role of residual disease after initial surgery, complete remission at second-look laparotomy, tumour stage and performance status was confirmed.

Value of quantitative pathological variables as prognostic factors in advanced ovarian carcinoma

AIMS

To evaluate correlations among clinical, pathological, morphometric, stereological, and DNA flow cytometric variables and their prognostic value in advanced ovarian cancer.

METHODS

Tissue was collected from 180 patients with advanced ovarian cancer. All 180 had undergone debulking surgery and were being treated with cisplatin. Long term follow up was available for all patients. The mitotic activity index (MAI), volume % of epithelium (VPE), mean nuclear area (MNA), standard deviation of the nuclear area (SDNA), estimates of volume weighted mean nuclear volume (nu v), and variables obtained from minimum spanning tree (MST) analysis were assessed in the least differentiated tumour section in each case. DNA flow cytometry was also performed.

RESULTS

Quantitative pathological features differed significantly with respect to histological grade. The MAI, MNA, SDNA, and the number of points connected to three neighbours differed significantly among the different DNA ploidy groups. The VPE and number of points connected to two or three neighbours differed significantly between FIGO stages III and IV. Fifty two (29%) patients survived. FIGO stage, residual disease and SDNA had prognostic significance on both univariate and multivariate survival analysis. In patients with FIGO III stage disease and residual tumour nodes < or = 2 cm in diameter (67 patients, 29 (43%) survivors) a prognostic index was established based on SDNA and of the line length of the MST. The median survival time was not reached in a subgroup of patients with favourable prognosis (overall survival 57%). Median survival was 32 months for patients with an unfavourable index score (overall survival 28%).

CONCLUSION

Morphometric variables have important additional value in predicting prognosis in patients with advanced ovarian cancer.

Malignant ascites

Investigation and treatment of malignant ascites are often in the hands of the general surgeon and can be difficult. This article considers the aetiology and pathophysiology of malignant ascites and explores the best form of management. Established treatment modalities and new therapeutic options are reviewed and a new management regimen based on a knowledge of the tumour of origin is proposed, which aims to balance potential benefit against morbidity.

Cytoreduction of small intestine metastases using the Cavitron Ultrasonic Surgical Aspirator

The Cavitron Ultrasonic Surgical Aspirator was used to reduce the volume of the small intestine metastases in 37 patients. Thirty-four patients had epithelial carcinoma of the ovary, and one each had tubal adenocarcinoma, papillary peritoneal tumor, and mesothelioma. Thirty-one patients had stage IIIC disease, and six had stage IV. Initially, 18 patients had small bowel disease greater than 15 mm in diameter (of any single nodule), and 10 had disease 6-15 mm in diameter. After cytoreduction using standard means, 18 patients had disease greater than 15 mm in diameter, and 9 patients had disease 6-15 mm in greatest diameter. After using the Cavitron, 13 patients had no gross residual disease, and 24 patients had disease 1-5 mm in diameter. The Cavitron Ultrasonic Surgical Aspirator is invaluable to obtain minimal residual disease of small bowel metastases while avoiding intestinal resection.

An evaluation of prognostic factors in advanced ovarian cancer

A summary is presented of currently available prognostic factors in advanced ovarian cancer of the common epithelial types. The emphasis is on the most promising clinical, classical pathological, biochemical, immunohistochemical, molecular biological and quantitative pathological factors.

Soluble interleukin-2 receptor alpha is elevated in sera of patients with benign ovarian neoplasms and epithelial ovarian cancer

BACKGROUND

Previous studies have established that soluble interleukin-2 receptor alpha (sIL-2R alpha) levels are elevated in ascites and sera from individuals with advanced ovarian cancer (International Federation of Gynecology and Obstetrics [FIGO] Stage III/IV). This study was undertaken to evaluate sIL-2R alpha levels in individuals with benign ovarian neoplasms and early stage ovarian cancer (FIGO Stage I/II). Comparison with CA 125 levels was performed to assess screening potential.

METHODS

Sera from 92 healthy individuals, 61 with benign adnexal masses, 12 patients with FIGO Stage I/II ovarian cancers, and 27 patients with FIGO Stage III/IV ovarian cancers were assayed for sIL-2R alpha by enzyme-linked immunosorbent assay and CA 125 by radioimmunoassay.

RESULTS

The mean serum sIL-2R alpha levels for benign pelvic masses, and Stage I/II and Stage III/IV epithelial ovarian cancer were 1507 +/- 82, 1631 +/- 274, and 2596 +/- 384 U/ml, respectively. The difference between mean serum sIL-2R alpha levels in individuals with benign adnexal masses and Stage III/IV epithelial ovarian cancer was statistically significant (P < 0.05). In addition, of the four individuals with FIGO Stage I/II ovarian cancer who had CA125 levels below 35 U/ml, the accepted upper limit of normal, three patients had elevated serum sIL-2R alpha levels. Eleven of 12 patients (92%) with potentially curable Stage I/II disease had elevated serum levels of either sIL-2R alpha or CA125 and 8 of 12 (67%) had elevations of both sIL-2R alpha and CA125. Sensitivity and specificity of a combination of CA 125 and soluble IL-2R alpha were 88.5% and 27.1%, respectively.

CONCLUSION

Soluble interleukin-2 receptor alpha levels do not appear to differentiate between benign adnexal lesions and early malignancy; however, measurement of sIL-2R alpha levels in combination with CA125 warrants further evaluation to determine if together they will identify individuals with Stages I and II ovarian cancer.

Evaluation of tumor-associated glycoprotein-72 and CA 125 serum markers in patients with gynecologic diseases

OBJECTIVE

This study was performed to evaluate the clinical values of tumor-associated glycoprotein-72 serum levels alone or in combination with CA 125 in the diagnosis and monitoring of patients with ovarian cancer.

STUDY DESIGN

Serum samples from 293 patients, 142 with primary carcinoma and 151 with benign diseases of the genital tract, were evaluated for the presence of CA 125, tumor-associated glycoprotein-72, and carcinoembryonic antigen. All patients underwent surgery for the primary tumor, and stage was defined according to the classification of International Federation of Gynecology and Obstetrics.

RESULTS

When the measurement of serum tumor-associated glycoprotein-72 is combined with that of CA 125, the sensitivity for the detection of primary ovarian cancer increased from 60% to 73%, with no significant change in specificity, and resulted in a more accurate clinical assessment for detection of residual disease before the second-look procedure. In fact, when both markers were positive, 100% specificity was achieved; conversely, when both markers were negative, no residual disease was found.

CONCLUSION

These findings suggest that tumor-associated glycoprotein-72 may be considered as a supplementary serum marker for CA 125, providing further clinical information for the diagnosis of primary and recurrent ovarian cancer.

Ovarian tumors in a cohort of infertile women

BACKGROUND

Case reports and the results of a recent case-control study have raised questions about the potential neoplastic effects of medications used as treatment for infertility.

METHODS

We examined the risk of ovarian tumors in a cohort of 3837 women evaluated for infertility between 1974 and 1985 in Seattle. Computer linkage with a population-based tumor registry was used to identify women in whom tumors were diagnosed before January 1, 1992. Data on infertility testing and treatment were abstracted from the medical records of women who had ovarian cancer and those of a randomly selected comparison group. The risk of ovarian tumors associated with exposure to ovulation-inducing medications was assessed through an age-standardized comparison with the rate of ovarian tumors in the general population, and Cox regression analysis was used to compare the risk of cancer among women who received these medications with the risk among infertile women who did not receive them.

RESULTS

There were 11 invasive or borderline malignant ovarian tumors, as compared with an expected number of 4.4 (standardized incidence ratio, 2.5; 95 percent confidence interval, 1.3 to 4.5). Nine of the women in whom ovarian tumors developed had taken clomiphene; the adjusted relative risk among these women, as compared with that among infertile women who had not taken this drug, was 2.3 (95 percent confidence interval, 0.5 to 11.4). Five of the nine women had taken the drug during 12 or more monthly cycles. This period of treatment was associated with an increased risk of ovarian tumors among both women with ovarian abnormalities and those without apparent abnormalities (relative risk, 11.1; 95 percent confidence interval, 1.5 to 82.3), whereas treatment with the drug for less than one year was not associated with an increased risk.

CONCLUSIONS

Prolonged use of clomiphene may increase the risk of a borderline or invasive ovarian tumor.

The attitudes of women and feasibility of screening for ovarian and endometrial cancers in inner city practices

The study aimed to assess the attitudes of women and the feasibility of screening for ovarian and endometrial cancers using vaginal ultrasound should screening prove to be effective. A total of 4873 women aged 45-74 were registered with 9 general practices in inner London. Of these, 1469 (30%) were ineligible for screening for ovarian and endometrial cancers as they proved to be the wrong age, had moved, or had undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The proportion of ineligible women varied between practices (24-39%) (P < 0.001). The adjusted response rate to a questionnaire on attitudes to ovarian and endometrial screening was 56% (1833/3360). Of the women, 1395 (76%) were willing to be screened with a significant difference between age groups, those over 65, at increased risk, being less willing (P < 0.001). Non-caucasians were more willing to be screened (P < 0.001) but educational attainment did not influence attitude to screening. Those women who were not very worried about vaginal instrumentation were more willing to be screened than those who were very worried (P < 0.001). The uptake rate for ovarian and endometrial screening, which is currently of unproven value, was 43% (1480/3360) with a significant difference between practices (33-49%) (P < 0.01).

The epidemiology of ovarian carcinoma and the current status of tumor markers to detect disease

OBJECTIVES

The objectives of this manuscript are to review the epidemiologic characteristics of ovarian cancer and to summarize the current status of tumor markers to detect disease.

STUDY DESIGN

A review of the pertinent literature was done.

RESULTS

In general, ovarian cancer is most frequent in industrialized countries, with dietary fat and possible use of talc as additive factors. Ovulation appears to increase the risk as does family history, increasing age, infertility, and possibly the use of ovulatory drugs. Pregnancy and the use of oral contraceptives, as well as possibly breast-feeding, lower the risk. Tubal ligation or hysterectomy with ovarian preservation also lowers the risk. The lifetime risk is about 1.4% in the United States, and the risk increases with age. If one first-degree relative has ovarian cancer, the lifetime risk appears to rise to 5%, but this pooled estimate may be affected by self-reporting bias in some studies. CA 125, the most widely used marker, is nonspecific, being elevated in about 80% of cases of ovarian epithelial cancer but also elevated in a number of benign conditions, which reduces its potential effectiveness as a screening tool.

CONCLUSIONS

No single cause of ovarian cancer has been uncovered. Overall > 90% of ovarian cancers occur sporadically. Those with the hereditary ovarian cancer syndrome (multiple generations of breast and ovarian cancer) have a 50% risk and an autosomal dominant inheritance, but they constitute < 1% of cases. No ideal tumor marker for ovarian cancer screening is currently available. Further evaluation is needed to see whether the use of multiple tumor markers and/or vaginal ultrasonography might produce an acceptable cost-effective screening model. Current data do not support the utilization of prophylactic oophorectomy in women with one first-degree relative with ovarian cancer as a general strategy to prevent ovarian cancer. It is appropriate strategy for those with hereditary ovarian cancer syndrome.

Levels of soluble interleukin-2 receptor-alpha are elevated in serum and ascitic fluid from epithelial ovarian cancer patients

OBJECTIVE

The purpose of the study was to determine whether ovarian cancer patients have activated lymphocytes as indicated by the presence of soluble interleukin-2 receptor-alpha and to compare soluble interleukin-2 receptor-alpha with other markers in ovarian cancer.

STUDY DESIGN

Ascites and serum from patients with advanced active ovarian cancer was tested for the presence of elevated levels of soluble interleukin-2 receptor-alpha and compared with normal controls. Levels of soluble interleukin-2 receptor-alpha were also compared with levels of CA 125 and macrophage colony-stimulating factor in the same patients, to evaluate the correlation between different markers.

RESULTS

Elevated levels of soluble interleukin-2 receptor-alpha were detected in 86 of 86 (100%) ascites samples and 67 of 85 (79%) serum samples from patients with advanced epithelial ovarian cancer. In contrast, only 12 of 25 (48%) benign ascites samples and one of 88 (1%) serum samples from controls had elevated levels. There was no obvious correlation between levels of soluble interleukin-2 receptor-alpha and levels of CA 125; however, levels of soluble interleukin-2 receptor-alpha did correlate with levels of macrophage colony-stimulating factor. Concurrent measurement of serum-soluble interleukin-2 alpha and CA 125 levels detected 100% of patients with epithelial ovarian cancer.

CONCLUSION

The detection of elevated levels of soluble interleukin-2 receptor-alpha in serum and ascites indicates the presence of activated lymphocytes in patients with epithelial ovarian cancer. Ascites and serum levels of soluble interleukin-2 receptor-alpha are elevated in patients with advanced ovarian cancer and warrant assessment as a potential complementary marker to CA 125 for early detection of ovarian cancer and management of patients with advanced ovarian cancer.

Activation of c-erbB-2 and prognosis in ovarian carcinoma. Comparison with histologic type, grade, and stage

BACKGROUND

Prior reports suggested that measuring c-erbB-2 activation in ovarian carcinomas might be valuable in predicting prognosis. The authors attempted to confirm these studies while specifically excluding tumors of low malignant potential.

METHODS

The clinical and pathologic significance of c-erbB-2 oncogene activation was assessed in 56 ovarian carcinomas, none of which met histologic criteria for tumor of low malignant potential.

RESULTS

By using an immunohistochemical technique previously validated in molecular studies, c-erbB-2 oncogene overexpression was identified in 10 of the 56 carcinomas but did not correlate with histologic type, histologic grade, International Federation of Gynecology and Obstetrics (FIGO) stage, or prognosis. Adverse prognostic factors included histologic type (serous carcinoma), high grade, and high stage (FIGO Stages III and IV). Grade and stage were highly correlated with each other and were more important prognostic indicators than histologic type.

CONCLUSION

Measuring c-erbB-2 activation in ovarian carcinomas may not be of practical value in predicting prognosis when tumors of low malignant potential are excluded.

Phase II trial of flutamide in advanced ovarian cancer: an EORTC Gynaecological Cancer Cooperative Group study

New active non-toxic therapeutic regimens are warranted in ovarian cancer relapsing after platinum-based chemotherapy. Some investigators have determined that androgen receptors predominated over oestrogen and progesterone receptors in untreated common epithelial ovarian cancer tissue cytosols. In an effort to test its antitumoural activity, 68 pretreated patients with epithelial ovarian cancer were given flutamide 750 mg/day orally for at least 2 months. Of 32 patients who received a minimum of 2 months of therapy, pretreated with at least one platinum-based chemotherapy, and a median of two chemotherapy regimens, two (6.3%) objective responses (one complete and one partial) and nine (28%) disease stabilisations were observed; these lasted 44 and 72 weeks, respectively (for the complete and partial response), and for a median of 24 weeks for stabilisations (range 12-48+). Nausea and vomiting were the most frequent side-effects. These occurred in 19/55 (34.5%) patients evaluable for toxicity. Flutamide has to be considered ineffective in patients extensively pretreated with chemotherapy, and it is not devoid of side-effects.

Tumour kinetics, response to chemotherapy and survival in primary ovarian cancer

The analysis of thymidine labelling index (TLI) in relation to clinico-pathological variables and survival was carried out in 111 ovarian cancer patients. The significance of TLI in predicting response to aggressive first line chemotherapy regimens was examined. The overall median TLI value of 1.8% was used as a cut-off to discriminate slowly from highly proliferating cancers. 94 patients entered into two consecutive randomised trials, and were treated with six courses of cisplatin-based chemotherapy with or without doxorubicin. A significantly higher objective response of 60% was reported in the subset of patients with TLI > 1.8% as compared to 35% in patients with TLI < or = 1.8% (P = 0.03). In addition, patients achieving complete response had tumours with median TLI of 3.8% as compared to 2.4% for partial responders, 1.5% for patients with stable disease and 1.7% for those with progressive disease. A significant increase in tumour kinetics was observed in advanced cancers (P = 0.001), more undifferentiated tumours (P = 0.02) and postsurgical residual disease greater than 2 cm (P = 0.04). In univariate analysis, TLI failed to influence significantly clinical outcome: 26 versus 32 months median survival time for patients with high and low tumour TLI, respectively. In the Cox's regression model, the only independent prognostic variables were performance status and amount of residual disease after primary surgery (P = 0.000).

Synchronous dual primary ovarian and endometrial carcinomas

OBJECTIVES

The synchronous occurrence of carcinoma confined to the ovary and endometrium presents a diagnostic and therapeutic dilemma. These tumors have been variously staged as FIGO Stage IIA ovarian carcinoma, Stage III endometrial carcinoma, or synchronous dual primary carcinomas. Accumulating evidence suggests such patients have a favorable outcome. This retrospective study was undertaken to review our experience with these fascinating tumors.

METHODS

The clinical records and the pathologic findings of 16 patients with synchronous dual primary ovarian and endometrial carcinomas were reviewed.

RESULTS

The median age was 51 years. Abnormal uterine bleeding was the most common presenting symptom (70%). All patients had Stage I ovarian and endometrial carcinomas. Fourteen patients (88%) had endometrioid carcinoma in both sites, while two patients (12%) had dissimilar histology. For 15 patients (94%), the grade of both tumors was identical. Only three (19%) patients had myometrial invasion, with less than 50% involvement in each case. All patients underwent surgical staging, 11 (70%) of whom received adjuvant radiation or chemotherapy. The five patients treated with surgery alone had Grade 1 endometrioid tumors. The only relapse occurred in a patient with a clear cell component in both sites. No patient has died of disease.

CONCLUSIONS

Patients with synchronous dual primary carcinomas appear to have a more favorable prognosis than that expected with Stage IIA ovarian or Stage III endometrial carcinoma (100% vs. 63% or 42% survival at 3 years, respectively). The excellent survival for patients with Grade 1 dual endometrioid tumors treated with surgery alone suggests that adjuvant therapy may not be necessary for this sub-group.

Maximal cytoreductive surgery and high dose cisplatin chemotherapy for advanced ovarian cancer

Fifty-eight stage III patients treated at The Jikei University Hospital were analysed retrospectively, in order to clarify the combination effect of maximal cytoreductive surgery and high dose cisplatin based chemotherapy in advanced ovarian cancer. They were divided into 4 groups by treatment they received which was as follows: Group A (n = 25); total abdominal hysterectomy (TAH), bilateral salpingooophorectomy (BSO) and omentectomy (OMTX) done at primary surgery and followed by 5 courses of "low dose" CAP therapy (cyclophosphamide 200 mg/sq m, adriamycin 20 mg/sq m, cisplatin 35 mg/sq m every 4 weeks for 5 courses). Group B (n = 4); TAH, BSO and OMTX carried out at primary surgery and followed by "high dose" CAP therapy (cyclophosphamide 200 mg/sq m, adriamycin 20 mg/sq m, cisplatin 70 mg/sq m, every 4 weeks for 5 courses and every 8-12 weeks for 5 courses thereafter). Group C (n = 13) received TAH, BSO and OMTX at the primary operation and paraaortic and pelvic lymphadenectomy (LNX) at the second look operation (SLO) with "high dose" CAP therapy as did Group B. Group D (n = 16), TAH, BSO, OMTX, LNX with maximal efforts made to reduce the size of the residual tumor to less than 2 cm at the primary surgery followed by "high dose" CAP therapy. The 3 year and 5 year survival rate of each group were as follows: Group A 15.6%, 15.6%, Group B 25.0%, 0%, Group C 81.8%, 0% and Group D 50.8%, 38.1%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Intraperitoneal cisplatin and regional hyperthermia for ovarian carcinoma

PURPOSE

To review the theoretical basis and results of a Phase I study of concurrent intraperitoneal cisplatin and hyperthermia in the treatment of ovarian carcinoma.

METHODS AND MATERIALS

Previously treated patients with epithelial ovarian carcinoma received intraperitoneal instillation of cisplatin and 60 minutes of regional hyperthermia, with a goal temperature of 41.5 degrees C. Cisplatin dose started at 20 mg/m2 with escalation to the maximally tolerated dose. Six such cycles given every 3 weeks were planned. Pharmacokinetic studies with and without hyperthermia were performed.

RESULTS

Fifteen patients receiving 17 courses of treatment were evaluable. The maximally tolerated dose of cisplatin was between 80 and 120 mg/m2. The dose limiting toxicity was nephrotoxicity in all but one course. The median intraperitoneal temperature was 40.7 degrees C; the majority of treatments in which the goal temperature was not reached had power limited by patient discomfort. No major toxicities attributable to hyperthermia were noted. Pharmacokinetic studies noted no significant differences between treatments with vs. without hyperthermia, with intraperitoneal to plasma area under the curve ratios being 30-35. Ten patients had a decline in their CA-125 count during treatment, although in only two patients did this response persist beyond their course of treatment.

CONCLUSION

Intraperitoneal cisplatin and regional hyperthermia can be performed with reasonable toxicity. The maximally tolerated dose of 80-120 mg/m2 in pretreated patients (which is similar to those reported with cisplatin alone) and median intraperitoneal temperatures of 40.7 degrees C, however, are felt to be too low to be efficacious in a significant percentage of women with bulky recurrent disease. Further study using intravenous thiosulfate and controlled analgesia is being performed.

Cytogenetic studies of epithelial ovarian carcinoma

We performed cytogenetic studies of 36 human epithelial ovarian carcinomas using in situ culture and robotic harvest. We obtained analyzable metaphases of all 36 tumors (100%). One or more chromosomally abnormal clones were observed in 80% of tumors. Common clonal chromosome gains (each occurring in six or more cases) included +1, +2, +3, +6, +7, +9, and +12. Common clonal chromosome losses (occurring in 12 or more cases) included -X, -4, -8, -11, -13, -15, -17, and -22. Common clonal structural abnormalities (occurring in four or more cases) involved regions 1p36, 1q32, 1q42, 3p13-->p26, 3q26-->q29, 7p22, 9q34, 11p13-p15, 17q21-->q23, 19p13.3, and 19q13.3. Trisomy 12 was noted as the sole anomaly in three of five borderline and grade 1 tumors. Two grade 2 tumors contained i(1q), -14, -15 and -22. The results suggest that the pathogenesis of borderline and low-grade tumors may differ from that of higher grade tumors. Two high-grade tumors had an apparent translocation between 17q21 and 19p13.3, two chromosome regions believed to be critical to ovarian carcinogenesis.