Treatment of cervical pregnancy with ultrasound-guided local methotrexate injection

OBJECTIVES

Cervical pregnancy (CP) is a rare type of ectopic pregnancy. While methotrexate (MTX) is generally the first-line method of choice for clinically stable women, there is still no consensus on the most appropriate treatment for this abnormal pregnancy. The aim of this study was to investigate the efficacy of a single local MTX injection under transvaginal ultrasound guidance for the initial treatment of CP and to assess post-treatment fertility.

METHODS

We reviewed retrospectively 15 patients with CP treated with local MTX injection under transvaginal ultrasound guidance. In all patients, the serum human chorionic gonadotropin (hCG) levels were monitored and the gestational sac was evaluated using ultrasonography after treatment. Magnetic resonance imaging (MRI) was performed as necessary. We evaluated the patients' clinical characteristics and clinical course after treatment, the efficacy of the treatment and the post-treatment fertility in patients desiring subsequent pregnancy.

RESULTS

The median estimated gestational age at the time of MTX injection was 6 + 2 (range, 5 + 2 to 11 + 0) weeks. All 15 patients were treated successfully, without the need for blood transfusion or surgical procedures; however, three patients required an additional local MTX injection due to a poor decline in serum hCG level following the initial injection, while one patient required uterine artery embolization due to persistent vaginal bleeding and an enlarging gestational sac with blood vessels visible on contrast-enhanced MRI. The mean time following initial MTX injection for hCG normalization was 43.8 (95% CI, 33.3-54.3) days and for resumption of menses was 68.4 (95% CI, 51.9-84.9) days. Seven of the 10 women desiring subsequent pregnancy following treatment had uneventful pregnancy, one became pregnant but miscarried spontaneously at 8 weeks of gestation, one was treated by laparoscopic surgery after diagnosis of a tubal pregnancy and one did not conceive.

CONCLUSIONS

A single, ultrasound-guided, local MTX injection is apparently effective for the treatment of CP without the need for concomitant procedures or surgical intervention. Furthermore, this conservative technique both preserves fertility and allows for the possibility of subsequent uneventful pregnancy. Copyright © 2016 ISUOG. Published by John Wiley & Sons Ltd.

Twisted ovarian tumor causing progressive hemothorax: a case report of porous diaphragm syndrome

BACKGROUND

Porous diaphragm syndrome is caused by a defect in the diaphragm. The defect may induce pleural effusion in a patient with an ovarian tumor.

CASE REPORT

A 59-year-old Japanese woman with an ovarian tumor and right hemothorax underwent thoracotomy and presented with a fenestra in the right diaphragm through which bloody fluids were flowing from the peritoneal cavity into the pleural space. Following suturing of the fenestra, laparotomy revealed intraabdominal bleeding due to torsion of an ovarian tumor.

CONCLUSION

This is the first report in which the diaphragmatic defect was identified in a patient with an ovarian tumor and hemothorax. Porous diaphragm syndrome may be involved in the pathophysiology of right pleural effusion observed in other medical conditions such as Meigs' syndrome, ovarian hyperstimulated syndrome, and ovarian cancer.

Characterization of 17beta-hydroxysteroid dehydrogenase type 4 in human ovarian surface epithelial cells

The human ovarian surface epithelium (hOSE) is a single layer of mesothelial-type primitive epithelial cells that are potential estrogen targets. It has been reported that hOSE cells can produce estrogen. However, the mechanisms that regulate estrogen level(s) in hOSE cells are not yet known. To elucidate the enzymes involved in these reactions, we examined gene expression of 17beta-hydroxysteroid dehydrogenases (17beta-HSDs) in primary hOSE (POSE) and OSE2a cells using RT-PCR. We found that POSE cells and cells of the immortalized hOSE line, OSE2a, bidirectionally converted estrone (E1) and 17beta-estradiol (E2). Both cell types expressed mRNA for 17beta-HSD type 1 (17beta-HSD1), suggesting that the enzyme is involved in the E1 to E2 conversion. Interestingly, both cells expressed 17beta-HSD4 mRNA but not 17beta-HSD2 mRNA. We prepared an antibody against the carboxyl terminal of 17beta-HSD4 (anti-17beta-HSD4 antibody), which recognized the 80 and 48 kDa proteins in POSE and OSE2a cells based on immunoblot analysis. Furthermore, immunohistochemical study revealed the presence of 17beta-HSD4 in hOSE cells in the human ovary. These results suggest that 17beta-HSD4 is involved in estrogen inactivation and may protect against an excessive accumulation of E2 in hOSE cells.

Establishment of an immortalised human ovarian surface epithelial cell line without chromosomal instability

Epithelial ovarian carcinoma is thought to derive from ovarian surface epithelium (OSE). The black box of the early molecular changes in ovarian carcinogenesis is being interpreted by the development of experimental systems employing immortalised human OSE cells. However, the existing cell lines of the OSE cells have limited utility due to chromosomal instability. Our goal was to establish new immortalised human OSE cells that retain the original characteristics of the primary cells without chromosomal alterations. Using primary human OSE cells obtained from a postmenopausal patient with endometrial cancer, five cell lines (‘HOSE1’ lines) were newly established by infection with retroviral expression vectors containing type 16 human papillomavirus (HPV-16) E6, E7, a variant E6 (E6Δ151), and Bmi1 polycomb gene, in combination with telomerase reverse transcriptase (hTERT). Consequently, five HOSE1s cell lines, HOSE1s-E6/hTERT, -E7/hTERT, -E6/E7/hTERT, -E6Δ151/E7/hTERT, and -E6Δ151/Bmi1/hTERT, grew beyond the population doubling number of 200. These cell lines, except for HOSE1-E6/hTERT, essentially showed the original features of the primary human OSE cells. Of them, HOSE1-E7/hTERT preserved diploidy in a kariotype analysis, and did not show transformed phenotypes in anchorage-independent growth and tumour formation. Thus, HOSE1-E7/hTERT may provide a novel model system with which to investigate the mechanisms of early molecular changes.

Expression of variant luteinizing hormone/chorionic gonadotropin receptors and degradation of chorionic gonadotropin in human chorionic villous macrophages

Human gonads and non-gonadal organs/tissues express luteinizing hormone/chorionic gonadotropin (LH/CG) receptors. This study aimed to identify the LH/CG receptors and to clarify their function in human placental chorionic villous macrophages. Macrophages as well as syncytiotrophoblasts of human chorionic villous tissues were immunohistochemically positive for LH/CG receptor throughout gestation. By reverse transcription-nested polymerase chain reaction methods, villous macrophages were shown to express a variant type of LH/CG receptor, the sequencing of which revealed a deletion of exon 9. For experiments in vitro, a monocyte-macrophage cell line, THP-1, was transfected with vector alone, wild-type LH/CG receptor, and exon 9-deleted LH/CG receptor after phorbol 12-myristate 13-acetate (PMA) treatment. Non-PMA-treated THP-1 cells transfected with vector alone were also examined. THP-1 cells expressed exon 9-deleted LH/CG receptor after treatment with PMA. After the cells of the four groups were cultured in medium containing intact human CG (hCG), the concentrations of hCG and its beta-core fragment (beta-CF) were measured in the supernatant of the culture medium and in the cell cytosol. Time-dependent hCG uptake was observed in both non-PMA-treated and PMA-treated THP-1 cells, suggesting that the variant receptor is not directly involved in the ingestion of hCG. The degradation of hCG and excretion of beta-CF were progressed in PMA-treated cells but not in the un-treated cells. In the cell cytosol, the ratio of beta-CF and hCG concentrations (beta-CF/hCG) was significantly higher in the PMA-treated cells than in non-PMA-treated cells; however, it did not differ between the PMA-treated cells transfected with exon 9-deleted receptor and those transfected with vector alone. Macrophages may express the variant receptor in order to recognize the intracytoplasmic hCG and transport it to the lysosome. Among the two PMA-treated cells, the ratio was lower in those transfected with wild-type receptor. The expression of the variant receptor may modulate the degradation of hCG but be reduced by expression of the wild-type receptor in its lacking macrophages. Our data suggest a potentially important role for exon 9-deleted LH/CG receptors expressed in human placental villous macrophages in the local metabolism of hCG.

Randomized Comparison of Intra-Arterial Chemotherapy Versus Intra-Arterial Chemotherapy and Gelfoam Embolization for Treatment of Advanced Cervical Carcinoma

PURPOSE

We evaluated the effects of intra-arterial infusion therapy by comparing the results obtained with a combination of intra-arterial anticancer drugs with and without transcatheter arterial embolization (TAE) in patients with cervical cancer.

METHODS

Between April 1999 and March 2003, intra-arterial therapy was administered to 45 patients (mean age 49 years) with cervical cancer. Of these, 18 had stage IIb , 4 had stage IIIa, 19 had stage IIIb, and 4 had stage IVb cancer; the histopathologic types were squamous cell carcinoma (n = 35), adenocarcinoma (n = 8), and adenosquamous carcinoma (n = 2). A total of 45 patients gave their informed consent and were randomized on a continuous basis into one of three groups according to the therapeutic protocols: group A consisted of 15 patients who received cisplatin, group B consisted of 17 patients who received cisplatin, mitomycin, doxorubicin hydrochloride, and 5-fluorouracil, and group C consisted of 13 patients who received cisplatin and TAE. Each protocol was administered twice with a 3 week interval between treatments. The efficacy of treatment was evaluated on the basis of the tumor reduction ratio (%) using MR imaging and the side effects were analyzed.

RESULTS

In groups A, B, and C, the tumor reduction ratio was 54%, 84%, and 86%, respectively; it was significantly greater in groups B and C than in group A (p < 0.01). The difference between groups B and C was not statistically significant. Although all group C patients developed severe pain after TAE, the pain was controlled with analgesics. Thrombocytopenia occurred in 6 of 17 (35%) group B patients.

CONCLUSION

Group B and C patients had better tumor reduction than those in group A. Fewer hematologic complications occurred in group C patients compared with group B.

A case of metastatic malignant hemangiopericytoma of the ovary: recurrence after a period of 17 years from intracranial tumor

Hemangiopericytoma is an uncommon vascular tumor. Primary or metastatic hemangiopericytoma of the ovary is extremely rare. A 48-year-old Japanese woman had a tumor in the neck. Simultaneously, a solid ovarian tumor was detected. She had received treatment for intracranial hemangiopericytoma 17 years previously. For the ovarian tumor, she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The left ovarian tumor weighed 1510 g and its cut surface was solid without areas of hemorrhage or necrosis. It was microscopically composed of tightly packed tumor cells outside of many vascular vessels. One or two mitotic figures were counted per 10 high power fields. Immunohistochemically, vimentin was expressed but factor-VIII-related antigen, CD 31, and CD 34 were not expressed in the tumor cells. Electron microscopy showed that the tumor cells were grown outside of the endothelium-lined vascular spaces. A discontinuous external basal lamina was also observed. We present a case of metastatic malignant hemangiopericytoma of the ovary from a primary intracranial hemangiopericytoma with a long interval of 17 years.

A case of metastatic malignant hemangiopericytoma of the ovary: Recurrence after a period of 17 years from intracranial tumor

Hemangiopericytoma is an uncommon vascular tumor. Primary or metastatic hemangiopericytoma of the ovary is extremely rare. A 48-year-old Japanese woman had a tumor in the neck. Simultaneously, a solid ovarian tumor was detected. She had received treatment for intracranial hemangiopericytoma 17 years previously. For the ovarian tumor, she underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy. The left ovarian tumor weighed 1510 g and its cut surface was solid without areas of hemorrhage or necrosis. It was microscopically composed of tightly packed tumor cells outside of many vascular vessels. One or two mitotic figures were counted per 10 high power fields. Immunohistochemically, vimentin was expressed but factor-VIII-related antigen, CD 31, and CD 34 were not expressed in the tumor cells. Electron microscopy showed that the tumor cells were grown outside of the endothelium-lined vascular spaces. A discontinuous external basal lamina was also observed. We present a case of metastatic malignant hemangiopericytoma of the ovary from a primary intracranial hemangiopericytoma with a long interval of 17 years.

An immunohistochemical and ultrastructural study of a follicle-stimulating hormone-secreting gonadotroph adenoma occurring in a 10-year-old girl

Female gonadotroph adenomas with endocrinological symptoms are uncommon. Six cases of such adenomas have been reported in the literature: two were girls who presented with precocious puberty and four were premenopausal women with accompanying multiple ovarian cysts. We describe here a 10-year-old Japanese girl with a gonadotroph macroadenoma and present detailed morphological findings of the tumor. The patient's chief complaints were nausea, abdominal distention, and abdominal pain. Abdominopelvic ultrasonography and magnetic resonance imaging (MRI) revealed bilateral multiple ovarian cysts. Endocrinological assays showed elevated serum follicle-stimulating hormone (FSH) (33.7 mIU/ml) and estradiol (3840 pg/ml). MRI of the head showed a large pituitary tumor. Two transsphenoidal operations and subsequent radiation therapy were performed. Immunohistochemically, more than half the tumor cells were positive for anti-FSH-beta monoclonal antibody. Ultrastructurally, the tumor cells exhibited a fairly uniform picture of rounded cells. Their nuclei were slightly irregular and contained heterochromatin, and their cytoplasm contained many round, dense core granules, measuring 140-260 nm in diameter, together with well-developed organelles. An in vitro study showed that the tumor cells in primary culture produced FSH (1089.0 mIU/ml). To our knowledge, this is the first immunohistochemical and ultrastructural study of an FSH-secreting gonadotroph adenoma occurring in childhood.

Detailed morphology of human ovarian surface epithelium focusing on its metaplastic and neoplastic capability

Ovarian epithelial tumors are thought to derive from the surface epithelium of the ovary, which differentiates after invagination of the coelomic mesothelium over the gonadal ridges during early embryonic development. On the putative mullerian potential of this epithelium, endometriosis, including ovarian endometriosis, can be explained by a metaplastic process from the peritoneum. In the present study, we assessed specific changes in the architecture and in the cytological characteristics of human ovarian epithelial cells on the surface and within the inclusion cyst. Grossly normal ovaries were retrieved from 215 patients undergoing incidental oophorectomy and 33 patients with contralateral ovarian tumor. In addition, 75 patients diagnosed with epithelial ovarian cancer and 26 ovarian endometriosis patients undergoing oophorectomy were selected. The incidence of cortical invagination, epithelial papillomatosis and pseudostratification was not different in normal ovaries between pre- and post-menopausal women, whereas inclusion cysts were more frequently observed in post-menopausal women (p<0.05). The occurrence rates of invagination and inclusion cysts were significantly higher in normal ovaries examined after incidental oophorectomy (p<0.05) and in those with contralateral ovarian tumor (p<0.05), respectively. Although serous metaplastic change with cilia was most common and it did not differ before and after menopause, the frequency of mucinous, endometrioid and transitional cell changes was low in the two groups of pre- and post-menopausal women. Mucinous metaplasia was more frequently observed in patients with contralateral ovarian tumor than those without ovarian tumor (12.1% vs. 1.9%; p<0.05). Four (5.3%) of 75 ovarian cancer patients revealed malignant transformed cells from a single layer of normal epithelium covering the ovarian surface or inclusion cyst. Ovarian or extraovarian endometriosis was identified in 16 (21.3%) of 75 epithelial ovarian cancer patients analyzed. An in situ carcinogenesis in the endometriotic cyst was seen in three epithelial ovarian cancers (4.0%). In seven (26.9%) of 26 ovarian endometriosis cases, epithelial cells on the ovarian surface or within the inclusion cyst were histologically changed to endometriotic gland cells. Careful and extensive observations of surgical specimens with ovarian carcinoma and ovarian endometriosis showed that they originated from the ovarian epithelium lining the surface and cortical small cysts.

Clear cell sarcoma arising in the retroperitoneum

Abstract.

Katabuchi H, Honda R, Tajima T, Ohtake H, Kageshita T, Ono T, Okamura H. Clear cell sarcoma arising in the retroperitoneum.

Clear cell sarcoma is a rare soft-tissue neoplasm, arising most commonly in the tendons and aponeuroses of young adults. We report here the first female case of clear cell sarcoma arising in the retroperitoneum with clinical features similar to those of malignant ovarian tumors. Aspects of clinical presentation, histopathologic evaluation, and treatment are described.

Clear cell sarcoma arising in the retroperitoneum

Clear cell sarcoma is a rare soft-tissue neoplasm, arising most commonly in the tendons and aponeuroses of young adults. We report here the first female case of clear cell sarcoma arising in the retroperitoneum with clinical features similar to those of malignant ovarian tumors. Aspects of clinical presentation, histopathologic evaluation, and treatment are described.

Clinical value of thymidine kinase in patients with cervical carcinoma

OBJECTIVE

Our purpose was to determine the clinical value of thymidine kinase (TK), which is an important pyrimidine pathway enzyme involved in salvage DNA synthesis, in patients with cervical carcinoma.

METHODS

We examined TK mRNA expression by reverse transcription polymerase chain reaction in 19 tissue specimens of invasive cervical carcinoma and 9 normal cervices and related it to thymidylate synthase (TS) and thymidine phosphorylase (TP) mRNA expressions. Serum TK level was determined by radioenzymatic assay in 79 patients with invasive cervical carcinoma, 7 patients with microinvasive carcinoma, 21 patients with carcinoma in situ and 32 normal women.

RESULTS

TK mRNA expression was upregulated in invasive cervical carcinoma compared with the normal cervix (p < 0.05) and significantly correlated with TS mRNA expression (p < 0.0001) but not with TP mRNA expression. The serum TK level was significantly higher in patients with invasive carcinoma than in normal women and patients with carcinoma in situ (p < 0.01 and p < 0.05). In patients with invasive cervical carcinoma, the serum TK level significantly correlated with TK mRNA expression (p < 0.05), but not with any conventional clinicopathologic factors. High serum TK levels significantly correlated with a poorer survival (p < 0.05), and multivariate analysis showed serum TK level to be an independent prognostic factor (p < 0.05).

CONCLUSION

TK may play an important role in influencing the malignant behavior of cervical carcinoma, and measurement of the serum TK level may be useful in predicting survival in patients with cervical carcinoma.

Glial implants in gliomatosis peritonei arise from normal tissue, not from the associated teratoma

Metaplasia of subcoelomic mesenchyme has been implicated, but not proven, in the pathogenesis of common gynecological diseases such as endometriosis and rarer entities such as leiomyomatosis peritonealis disseminata and gliomatosis peritonei (GP). GP is associated with ovarian teratomas and is characterized by numerous peritoneal and omental implants composed of glial tissue. Two theories to explain the origin of GP have been proposed. In one, glial implants arise from the teratoma, whereas in the other, pluripotent Müllerian stem cells in the peritoneum or subjacent mesenchyme undergo glial metaplasia. To address the origin of GP, we exploited a unique characteristic of many ovarian teratomas: they often contain a duplicated set of maternal chromosomes and are thus homozygous at polymorphic microsatellite (MS) loci. In contrast, DNA from matched normal or metaplastic tissue (containing genetic material of both maternal and paternal origin) is expected to show heterozygosity at many of these same MS loci. DNA samples extracted from paraffin-embedded normal tissue, ovarian teratoma and three individual laser-dissected glial implants were studied in two cases of GP. In one case, all three implants and normal tissue showed heterozygosity at each of three MS loci on different chromosomes, whereas the teratoma showed homozygosity at the same MS loci. Similar results were observed in the second case. Our findings indicate that glial implants in GP often arise from cells within the peritoneum, presumably pluripotent Müllerian stem cells, and not from the associated ovarian teratoma. This finding has important implications for more common gynecological entities with debatable pathogenesis, such as endometriosis, by definitively demonstrating the metaplastic potential of stem cells within the peritoneal cavity.

Characterization and tumorigenicity of human ovarian surface epithelial cells immortalized by SV40 large T antigen

OBJECTIVES

Epithelial ovarian cancers are considered to arise from neoplastic transformation of the ovarian surface epithelium (OSE). However, the earliest events in ovarian carcinogenesis have not been clearly defined because patients are often diagnosed in the advanced stages and useful in vivo and in vitro experimental systems using human OSE cells are lacking. We aimed to improve the availability of experimental models for the study of human ovarian carcinogenesis.

METHODS

Subcultured human OSE cells were transfected with SV40 large T antigen. Resulting OSE cell lines were characterized using immunocytochemistry and tested tumorigenicity.

RESULTS

Six immortalized OSE cell lines were obtained. All cell lines essentially retained the original morphological features of normal OSE cells and showed higher proliferation rates and saturation density. Although they were all nontumorigenic in athymic mice, OSE2b-2 sv cells, which were selected in soft agar from colonies of an SV40 large T antigen-expressing transfectant, OSE2b sv, produced tumors on the peritoneal surface, mesothelium, and diaphragm and induced ascites after being injected intraperitoneally. Solid tumors also grew when mice were inoculated subcutaneously. The tumor cells were formed in a solid sheet arrangement and no evidence of glandular or squamous differentiation was present. They were weakly immunostained with an antibody against cytokeratin, and intercellular junctions resembling attachment devices were ultrastructurally present between cells. The tumors were histologically diagnosed as undifferentiated carcinomas.

CONCLUSIONS

The established cell lines may provide a model system to investigate the mechanisms of cytogenic and molecular changes from normal OSE cells through the various steps of transformation.

Expression of monocyte chemoattractant protein-1 in peritoneal endometriotic cells

It is well known that the number of peritoneal macrophages is increased in patients with pelvic endometriosis. We measured the concentration of monocyte chemoattractant protein-1 (MCP-1) using an enzyme-linked immunosorbent assay (ELISA) in the peritoneal fluid of women with and without endometriosis. The expression of MCP-1 in pelvic endometriotic lesions obtained from the peritoneum was also examined using immunohistochemistry and nonradioactive in situ hybridization. The mean concentration of MCP-1 in the peritoneal fluid was significantly higher in the patients with endometriosis (P<0.05). The most significant elevation, compared with non-endometriosis patients, was found in stage I of the disease (P<0.05). However, no statistically significant difference was found among endometriosis stages I, II, III, and IV. Immunohistochemical staining revealed that MCP-1-positive cells were localized in the glandular epithelium of the endometriotic lesions and in the stromal macrophages distributed in those lesions, but normal peritoneal cells were negative. The in situ hybridization method demonstrated expression of MCP-1 mRNA on the endometriotic glandular epithelium and stromal macrophages. These findings suggest that MCP-1 may be involved in the histogenesis and early development of peritoneal endometriosis.

Distribution and cytological properties of macrophages in human Fallopian tubes

The macrophages in human Fallopian tubes of women in the reproductive and postmenopausal periods were examined with a focus on their morphological properties by immunohistochemical staining and transmission electron microscopy. The fine structure of the smooth muscle cells in the Fallopian tubes was also investigated during the reproductive period. For immunohistochemical staining, we used two monoclonal antibodies that were specific for human macrophages, namely PM-1K and PM-2K. PM-1K recognizes human monocytes/ macrophages corresponding to CD68, and PM-2K recognizes tissue macrophages. PM-1K-positive cells were always present and their numbers increased significantly during the menstrual and early to mid-secretory phases. In contrast, relative numbers of PM-2K-positive cells were small throughout the menstrual cycle. In the postmenopausal period, few PM-1K-positive cells were detected, but PM-2K-positive cells remained. The macrophages during the secretory phase in the endosalpingeal stroma had well-developed intracytoplasmic organelles, but relatively few cytoplasmic vacuoles and granules. In the same phase, many cells of the monocyte/macrophage lineage appeared in the vascular lumen of the endosalpingeal stroma. The macrophages during the menstrual phase had well-developed intracellular organelles, with cytoplasmic vacuoles and granules of various sizes and configurations. During the late secretory phase, just prior to menstruation, the smooth muscle cells contained few cytoplasmic filaments but electron-lucent or electron-dense lysosome-like bodies were seen. These findings suggested the presence of macrophages in human Fallopian tubes. It is possible that such macrophages might be involved in the physiological functions of the tubes during the reproductive period and moreover that they might participate in the reconstruction of the muscle layer of the tubes.

Coelomic metaplasia theory of endometriosis: evidence from in vivo studies and an in vitro experimental model

Ultrastructure studies of pelvic peritoneal tissue from women undergoing laparotomy suggest that before endometriosis has become established in the peritoneum, there might be a metaplastic change by peritoneal mesothelial cells into endometrial glandular cells. A new in vitro experimental model of endometriosis using human ovarian surface epithelium cells has shown evidence that endometriotic lesions can arise by a process of metaplasia from the ovarian surface epithelium. In this model, when both ovarian surface epithelium and ovarian stromal cells were cocultured with 17beta estradiol in a three-dimensional collagen gel lattice, the ovarian surface epithelium cells formed a lumen structure, surrounded by endometrial stromal cells with an epithelial mesenchymal structure. Immunoreactivity for epithelial membrane antigen and cytokeratin was shown in the glandular cells and cilia, as well as in the microvilli. Electron microscopy showed evidence of tight junctions on cell surfaces. These findings suggest that endometriosis may manifest as a serial change from the adjacent mesothelial cells.

Human villous macrophage-conditioned media enhance human trophoblast growth and differentiation in vitro

In human chorionic villi, numerous macrophages, so-called Hofbauer cells, are located adjacent to trophoblasts. To determine the role of the macrophages in the proliferation and differentiation of trophoblasts, cytotrophoblast cells were cultured in serum-free culture-conditioned media of villous macrophages (VMCM), peritoneal macrophages (PMCM), and villous fibroblasts (VFCM). In VMCM, proliferation of cytotrophoblast cells was detected at 24 h by immunocytochemistry with Ki-67-antibody. A large number (P < 0.001) of multinucleated syncytia was formed in VMCM. In VMCM, cytotrophoblast cell fusion was completed by 96 h, which coincided with the peak of hCG secretion and initiation of human placental lactogen (hPL) release. Levels of hCG (P < 0.001) and hPL (P < 0. 001) secretion from syncytial cells were significantly higher in VMCM than in PMCM or in VFCM. Concentrations of macrophage colony-stimulating factor (M-CSF) and vascular endothelial growth factor (VEGF) analyzed by ELISA were greater in VMCM than in PMCM or in VFCM, whereas monocyte chemoattractant protein-1 (MCP-1) concentration was high in PMCM. The expression patterns of M-CSF, VEGF, and MCP-1 in villous macrophages and peritoneal macrophages by reverse transcriptase-polymerase chain reaction were similar to their secretion patterns. Thus, villous macrophages have a greater ability to stimulate hCG and hPL secretion than do peritoneal macrophages. This study suggests that macrophages within the villous stroma may stimulate the growth and differentiation of trophoblasts through their secreted substances.

Somatic mutations in the STK11/LKB1 gene are uncommon in rare gynecological tumor types associated with Peutz-Jegher's syndrome

Peutz-Jegher's syndrome (PJS) is a rare autosomal dominant disorder characterized by mucocutaneous pigmentation, hamartomatous polyposis, and predisposition to benign and malignant tumors of the gastrointestinal tract, breast, ovary, uterine cervix, and testis. Germline-inactivating mutations in one allele of the STK11/LKB1 gene at chromosome 19p13.3 have been found in most PJS patients. Although ovarian sex cord tumors with annular tubules (SCTATs) and minimal deviation adenocarcinomas (MDAs) of the uterine cervix are very rare in the general population, both tumor types occur with increased frequency in women with PJS. An earlier report indicated that the 19p13.3 region containing the STK11 gene was affected by loss of heterozygosity (LOH) in nearly 50% of MDAs of the uterine cervix. We investigated the role of STK11 mutations and LOH of the 19p13.3 region in two PJS-associated SCTATs and in five SCTATs and eight MDAs of the uterine cervix, which occurred in patients lacking features of PJS (referred to here as "sporadic" cases). Germline mutations in the STK11 gene, accompanied by LOH of markers near the wild-type STK11 allele, were found in the two PJS-associated SCTATs. Somatic mutations in the coding region of STK11 were not found in any of the sporadic SCTATs or MDAs studied, although LOH of the 19p13.3 region was seen in three of eight MDAs. Our findings indicate that STK11, like other tumor suppressor genes, is affected by biallelic inactivation in gynecological tumors of PJS patients. In addition, although LOH of the 19p13.3 region was seen in sporadic MDAs, somatic STK11 mutations are rare. A yet-to-be-defined tumor suppressor gene in the 19p13.3 region may be the specific target of inactivation in these tumors.

The molar vesicle fluid contains the beta-core fragment of human chorionic gonadotropin

The human chorionic gonadotropin (hCG) beta-core fragment (beta-CF) is a major molecular form of hCG beta subunit (hCGbeta) immunoreactivity in the urine of pregnant women and patients with trophoblastic disease. The majority of evidence supports the fact that the beta-CF is a degradative product of intact hCG and free hCGbeta in the kidneys. We found a beta-CF-like substance in the fluid of molar vesicles from a patient with complete hydatidiform mole. The molar fluid beta-CF (mbeta-CF) was indistinguishable from the beta-CF in the patient's urine (ubeta-CF) by immunoreactivity and by elution profile on gel chromatography. The binding study to lectins, however, showed that mbeta-CF contains a carbohydrate moiety that differs from that of ubeta-CF. Immunohistochemistry with anti-beta-CF antibody demonstrated a strong immunoreactivity in a large number of macrophages in the molar villous stroma. In vitro incubation of intact hCG with peritoneal macrophages showed a slow increase of intact hCG in the cell cytosol with the appearance of beta-CF-like substance in the cell supernatant. In conclusion, the source of beta-CF in molar fluid is likely to be macrophages existing in the villous stroma. Thus macrophages may ingest intact hCG and act as a local regulator of gonadotropic hormones.

Predicting the effect of gonadotropin-releasing hormone (GnRH) analogue treatment on uterine leiomyomas based on MR imaging

PURPOSE

To test the hypothesis that the simple assessment of signal intensity on T2-weighted MR images is predictive of the effect of hormonal treatment with gonadotropin-releasing hormone (GnRH) analogue.

MATERIAL AND METHODS

The correlation between T2-weighted MR imaging of uterine leiomyomas and histologic findings was evaluated using 85 leiomyomas from 62 females who underwent myomectomy or hysterectomy. We also correlated the pretreatment MR images features obtained in 110 women with 143 leiomyomas with the effect of GnRH analogue treatment. The size (length x width x depth) of the leiomyoma was evaluated before and at 6 months after treatment by ultrasound.

RESULTS

The proportion of leiomyoma cell fascicles and that of extracellular matrix affected signal intensities of uterine leiomyomas on T2-weighted MR images. The amount of extracellular matrix was predominant in hypointense leiomyomas on T2-weighted images, while diffuse intermediate signal leiomyomas were predominantly composed of leiomyoma cell fascicles. Marked degenerative changes were noted in leiomyomas with heterogenous hyperintensity. The homogeneously intermediate signal intensity leiomyomas showed significant size reduction after treatment (size ratio; posttreatment volume/pretreatment volume 0.29+/-0.11). The size ratio for the hypointense tumors was 0.82+/-0.14, and 0.82+/-0.18 for the heterogeneously hyperintense tumors. There was a significant difference in the response to treatment between the homogeneously intermediate signal intensity leiomyomas and the hypointense or heterogeneously hyperintense leiomyomas (both p<0.01).

CONCLUSION

Signal intensity on T2-weighted MR images depends on the amount of leiomyoma cell fascicles and extracellular matrix. Simple assessment of the MR signal intensity is useful in predicting the effect of GnRH analogue on uterine leiomyomas.

A follicle-stimulating hormone-secreting gonadotroph adenoma with ovarian enlargement in a 10-year-old girl

OBJECTIVE

To report a rare case of gonadotroph adenoma accompanied by ovarian enlargement in a child.

DESIGN

Case report.

SETTING

A university hospital.

PATIENT(S)

A 10-year-old Japanese girl with multiple cysts of both ovaries.

INTERVENTION(S)

Endocrinologic assays, immunohistochemical staining, ultrastructural observations, and in vitro analysis.

MAIN OUTCOME MEASURE(S)

The endocrinologic assays showed an elevated serum FSH level. The tumor cells excised from the gonadotroph adenoma were immunohistochemically positive for antihuman FSH monoclonal antibody. When cultured in vitro, the tumor cells secreted FSH in the primary culture.

RESULT(S)

The gonadotroph adenoma produced FSH. After transsphenoidal surgery, both ovaries decreased in size.

CONCLUSION(S)

The ovarian enlargement was induced by endogenous FSH from the gonadotroph adenoma. To our knowledge, this is the first reported case of gonadotroph adenoma accompanied by ovarian enlargement in childhood or adolescence.

Expression of the thymidine phosphorylase gene in epithelial ovarian cancer

Thymidine phosphorylase (TP) is associated with angiogenesis and the progression of solid tumours. High intracellular levels of this enzyme indicate increased chemosensitivity to pyrimidine antimetabolites. TP gene expression in 56 cases of epithelial ovarian cancer (27 of serous, 10 mucinous, 12 endometrioid, five clear cell and two undifferentiated) were analysed by polymerase chain reaction of RNA after reverse transcription. These included eight of low malignant potential. Twenty were stage I, four stage II, 27 stage III and five stage IV. The level of TP gene expression was presented by the relative yield of the TP gene to the beta2-microglobulin gene. TP gene expression ranged from 0.19 to 5.38 (median 0.93). The value of TP gene expression in stage III-IV was significantly higher than that of TP gene expression in stage I-II (P = 0.0005). Histological grade significantly associated with TP gene expression (P = 0.008), but histological subtype did not (P = 0.166). A follow-up study of 34 cases after complete resection of the primary tumours by surgical operation was performed. TP gene expression of the cases with recurrence showed significantly higher levels compared to cases without recurrence (P = 0.049). Survival data were available for 47 of the 56 patients. The prognosis of the patients with high TP gene expression (equal to, or greater than, median) was to be significantly worse than patients with low TP gene expression (less than median) (P = 0.021). The TP gene expression level may play one of the key roles in the biology of ovarian epithelial cancer and define a more aggressive tumour phenotype. A new therapeutic intervention mediated by TP protein activity is anticipated.

Increased serum levels of 5-S-cysteinyldopa and intercellular adhesion molecule-1 in a patient with a uterine amelanotic metastasis from a primary vaginal malignant melanoma

A 75-year-old Japanese woman, who had an enlarged uterus and two nodules on the anterior vaginal wall, underwent wide excision of the anterior vaginal wall, bilateral inguinal lymphadenectomy, modified radical hysterectomy, and pelvic lymph node dissection. Her serum level of 5-S-cysteinyldopa (5-S-CD) was elevated, but her serum intercellular adhesion molecule-1 (ICAM-1) level was within normal limits. Histologic examination of the vaginal wall revealed atypical melanocytes at the dermoepidermal junction and numerous melanin-containing granules in the cytoplasm of the tumor cells. The tumor in the uterus consisted of sheets of anaplastic cells with evidence of diminished melanization. Five months after her initial presentation, she developed a recurrence and expired. The serum level of ICAM-1 was beyond the normal limit at the time of recurrence. Both the serum 5-S-CD and the ICAM-1 levels became elevated after recurrence and appeared to be correlated with disease progression.

A novel in vitro experimental model for ovarian endometriosis: the three-dimensional culture of human ovarian surface epithelial cells in collagen gels

OBJECTIVE

To develop an in vitro experimental model of ovarian endometriosis using human cells and to investigate the pathogenesis of endometriosis.

DESIGN

Controlled in vitro coculture study.

SETTING

A department of obstetrics and gynecology at a university hospital.

PATIENT(S)

Ovaries and endometrium were obtained from patients who underwent a hysterectomy because of gynecologic disease.

INTERVENTION(S)

Human ovarian surface epithelial (OSE) cells were cultured alone and OSE cells and endometrial stromal (ES) cells were cultured together in a three-dimensional collagen gel culture system with or without the addition of E2.

MAIN OUTCOME MEASURE(S)

The aggregated collagen gels containing the cultured cells were examined morphologically.

RESULT(S)

The OSE cells in single culture with E2 formed circular arrangements. These cells were immunohistochemically positive for cytokeratin but negative for epithelial membrane antigen. In the cocultures of OSE and ES cells with E2, the OSE cells formed a lumen structure surrounded by ES cells. Immunoreactivity for cytokeratin and epithelial membrane antigen was detected in the glandular cells and cilia were identified on the cell surface by electron microscopy. Without the addition of E2, no structures were detected.

CONCLUSION(S)

A new in vitro experimental model was established with the aid of human OSE cells. Endometriotic lesions can arise through a process of metaplasia from OSE cells in the presence of E2 and ES cells.

Establishment of a new cell line, OKT1, from small cell carcinoma secreting ectopic ACTH of the uterine cervix

OBJECTIVE

Small cell carcinoma of the uterine cervix is rare and represents a unique entity among gynecological tumors. It sometimes demonstrates neuroendocrine differentiation, including adrenocorticotropin (ACTH) secretion. In this study, we established a new cell line, OKT1, from a case of carcinoma secreting ectopic ACTH without Cushing's syndrome and determined the character of the cell line.

METHODS

OKT1 was established from OKT tumor cells, derived from a biopsy specimen of small cell cervical carcinoma, and serially heterotransplanted into nude mice. To characterize OKT1, the cell morphology, growth properties, immunohistochemical properties, hormone- and tumor-associated antigen secretion, tumorigenic potential, DNA profile, and chromosomal alteration were studied.

RESULTS

The population doubling time of OKT1 was approximately 27 h. The cytological properties of OKT1, including DNA ploidy pattern, were similar to those of the primary tumor. Neuroendocrine differentiation was shown in the OKT1 cells by the positive immunocytochemical staining of neuron-specific enolase (NSE) and the presence of NSE and ACTH in the culture media. The xenograft of 1 x 10(8) OKT1 cells into nude mice yielded tumor mass. Furthermore, OKT1 demonstrated HPV type 18 and absence of a p53 gene mutation from exons 5 through 8.

CONCLUSION

To our knowledge, OKT1 is the first cell line established from small cell cervical carcinoma with ACTH secretion.

Spatio-temporal changes of prolyl 4-hydroxylase in granulosa cells during ovulation in eCG-hCG-treated immature rat ovaries

The immunolocalization of prolyl 4-hydroxylase (PHase), a key enzyme of collagen synthesis, and the effects of anti-progesterone RU486 on PHase during the ovulatory process in eCG-hCG-treated immature rat ovaries were studied to investigate the mechanisms of tissue repair in follicle walls after follicular rupture. Immunolocalization of PHase was studied using an anti-rat PHase subunit monoclonal antibody, and the amount of immunoreactive PHase was measured by enzymeimmunoassay. No obvious immunolocalization of PHase was observed in theca cells throughout the ovulatory process except just after follicular rupture. In contrast, in granulosa cells, PHase was first observed at 9 h after the hCG injection, and the staining intensity apparently increased from 9 to 15 h, especially around the apex of preovulatory follicles and the orifice of ruptured follicles. Consistent with these observations, PHase concentration in granulosa cells isolated from the ovaries significantly increased by 9 h (0.45 +/- 0.03 pg per cell), and reached a peak at 15 h (0.66 +/- 0.06 pg per cell) after the hCG injection. This peak was inhibited when 20 mg RU486 kg-1 was administered at 8 h (0.46 +/- 0.05 pg per cell), and the RU486-inhibited PHase concentration was recovered by the concomitant administration of 10 mg progesterone kg-1 (0.65 +/- 0.02 pg per cell). The results suggest that PHase expressed in granulosa cells may play an important role in the repair of ruptured follicle walls, via progesterone-dependent PHase production.

Carcinoma of the uterine cervix. High-resolution turbo spin-echo MR imaging with contrast-enhanced dynamic scanning and T2-weighting

PURPOSE

To compare high-resolution contrast-enhanced (Gd-DTPA) dynamic MR imaging with T2-weighted turbo spin-echo (TSE) imaging in the evaluation of uterine cervical carcinoma.

MATERIAL AND METHODS

Thirty-two patients with cervical carcinoma underwent MR imaging on a 1.5 T superconductive unit to have the extension of the disease assessed before treatment. A phased-array coil was used in all patients. In 25 patients, surgical confirmation of the diagnosis was obtained after imaging. Radiation therapy was selected for the remaining 7 patients with advanced carcinoma. Qualitative and quantitative image analyses were also performed.

RESULTS

The cervical carcinomas showed maximum contrast in the cervical stroma and myometrium in the early dynamic phase. The tumor/cervical-stroma contrast in the early dynamic phase obtained with the T1-weighted TSE technique (contrast-to-noise ratio 22.6) was significantly higher than that obtained in T2-weighted TSE imaging (contrast-to-noise ratio 4.3). In the evaluation of parametrial invasion, the accuracy of T2-weighted imaging was 71.8% and contrast-enhanced dynamic imaging 81.2%.

CONCLUSION

High-resolution contrast-enhanced (Gd-DTPA) dynamic MR imaging in cervical cancer offers improved tumor/cervical-stroma contrast and provides useful information on parametrial invasion.

Micropapillary serous carcinoma of the ovary: an immunohistochemical and mutational analysis of p53

Micropapillary serous carcinoma (MPSC) has recently been described as a distinct ovarian neoplasm that shares histologic features with both serous borderline tumors (SBTs) and typical serous carcinomas of the ovary. To further define the relationship of MPSC to these two neoplasms, we evaluated all three tumor types for expression of the p53 protein and p53 gene mutations. The majority of MPSCs demonstrated positive, but only moderately intense, p53 immunostaining in >50% of the cells, whereas SBTs showed very weak staining in a small number of cells. In contrast, the majority of serous carcinomas displayed diffuse, very intense staining and those that did not stain completely lacked any staining for p53. This pattern of p53 immunostaining in MPSCs can be distinguished from the pattern observed in SBTs and in serous carcinomas. Both the MPSCs and the SBTs lacked p53 mutations in the cases analyzed, whereas all immunopositive serous carcinomas were found to have mutations in p53. In addition, one of the immunonegative cases of serous carcinoma had a frameshift mutation resulting in a truncated protein, providing a likely explanation for the lack of detectable p53 protein. These findings provide support for classifying MPSC as a distinct neoplasm of the ovary and suggest that increased expression of wild-type p53 may play a role in its pathogenesis.

Distribution and fine structure of macrophages in the human ovary during the menstrual cycle, pregnancy and menopause

We evaluated the distribution and ultrastructural characteristics of macrophages in the ovaries of women of reproductive ages, during pregnancy, and after menopause, by immunohistochemistry and transmission electron microscopy. Macrophages appeared around the ovarian follicle with its development. Their organelles were poorly developed, and no vacuoles or granules were observed in the cytoplasm. Macrophages were also present in the cavity of the atretic follicle, being larger in size than those in the developing follicle and characterized by cytoplasmic vacuoles and granules of a lysosomal nature. With the luteinization of the follicle, macrophages were seen to be distributed inside and outside the corpus luteum, but constituted only a minor population as compared with other kinds of leukocytes. The intracellular organelles were well-developed, including the lysosomal granules. In early pregnancy, the number of macrophages was noticeably increased in the corpus luteum. They were observed mainly outside the corpus luteum, and stained strongly with hCG immunohistochemically. Macrophages were present in the regressing corpus luteum and in the corpus albicans. Numerous lipid droplets and elongated cholesterol crystals were seen in the cytoplasm. Macrophages therefore appeared to be present throughout the ovarian cycle and may be involved in the development and atresia of the follicles and the progression and the regression of luteal tissues.

Adenoma malignum: MR imaging and pathologic study

PURPOSE

To evaluate the clinical, pathologic, and magnetic resonance (MR) imaging findings in adenoma malignum, a rare variant of uterine cervical adenocarcinoma.

MATERIALS AND METHODS

Medical records of all patients (n = 7) with adenoma malignum of the uterine cervix diagnosed pathologically between 1988 and 1996 were retrospectively reviewed. Unenhanced T1-weighted and T2-weighted images and gadolinium-enhanced T1-weighted MR images were evaluated, and findings were correlated with gross pathologic and microscopic features.

RESULTS

In five of seven patients, enlargement of the cervix was seen. All lesions were detected as multiple cystic lesions that extended from the endocervical gland to the deep stroma of the cervix. They appeared isointense (n = 5) or slightly hyperintense (n = 2) relative to the uterus on T1-weighted images and markedly hyperintense relative to the uterus on T2-weighted images. Solid portions of variable size were seen between cystic lesions, and both the multiple cystic component and the solid portion were most apparent on the gadolinium-enhanced T1-weighted images. Microscopic parametrial invasion was seen in two patients but was not detected at MR imaging.

CONCLUSION

Adenoma malignum was depicted on MR images as a multicystic mass with solid portions located in the deep cervical stroma. Gadolinium enhancement helped identify the solid portion of the tumor.

Follicular development and ovulation in macrophage colony-stimulating factor-deficient mice homozygous for the osteopetrosis (op) mutation

To clarify the role of macrophages and macrophage colony-stimulating factor (M-CSF) in follicular development and ovulation, the processes of folliculogenesis and ovulation, numerical changes in macrophages, and proliferative capacity of granulosa cells were examined in op/op mice before or after daily M-CSF administration. The natural estrous cycle was determined daily by means of vaginal smears. The number of ovulated ova in both fallopian tubes was significantly smaller in op/op mice than in normal littermates. Such ova markedly increased in number after daily M-CSF administration. The numbers of both antral and mature follicles in the proestrous ovary were markedly lower in op/op mice than in the controls and increased after daily M-CSF administration. Flash-labeling with [3H]thymidine showed that the proliferative capacity of granulosa cells in antral follicles was reduced in op/op mice but elevated after daily M-CSF administration. Numbers of granulosa cells and macrophages in the antral follicles were significantly decreased in op/op mice but were increased after M-CSF treatment. All these data provide evidence that macrophages are implicated in the process of folliculogenesis and ovulation.

Role of macrophages in ovarian follicular development

The effects of macrophages on granulosa cell proliferation were examined using gonadotropin-primed immature female rats and osteopetrotic (op/op) mice, a model defective in monocyte-macrophage lineage cells. Macrophages were found in the follicles at various developmental stages in rats and mice. The labeling index with [3H]thymidine of cultured rat granulosa cells was maximal when they were cultured with peritoneal macrophages at a macrophages:granulosa cell ratio of 0.01. This ratio was similar to those in rat preantral and antral follicles in vivo. In op/op mice, the number of developing follicles was markedly reduced, but increased after daily macrophage-colony-stimulating factor (M-CSF) administration. In the antral follicles of op/op mice, both granulosa cells and macrophages were significantly decreased in number but were increased after M-CSF treatment. Double immunohistochemical staining revealed that epidermal growth factor (EGF)-positive cells were macrophages in the developing rat follicles. These findings suggest that macrophages are located in the developing follicles and participate in promoting granulosa cell growth through a paracrine mechanism by secreting EGF and other cytokines.

Mutations in DNA mismatch repair genes are not responsible for microsatellite instability in most sporadic endometrial carcinomas

Endometrial carcinoma is the second most common tumor type in women with hereditary nonpolyposis colorectal carcinoma. Microsatellite instability (MI) has been observed in the inherited (hereditary nonpolyposis colorectal carcinoma-associated) form of endometrial carcinoma as well as in approximately 20% of presumably sporadic cases. Recent studies suggest that MI in many cell lines or xenografts derived from sporadic colorectal carcinomas is not attributable to mutations in four known human DNA mismatch repair (MMR) genes (hMSH2, hMLH1, hPMS1, and hPMS2). Mutational analyses of these four MMR genes in endometrial carcinomas have not been previously reported. We analyzed nine sporadic MI-positive primary endometrial carcinomas for mutations in the above four MMR genes. Mutations were detected in two tumors (in hMSH2), and both of the mutations were acquired somatically. Immunohistochemical staining revealed a lack of expression of hMSH2 protein in the two tumors containing hMSH2 mutations. Our data suggest that mutations in these four known DNA MMR genes are not responsible for MI in the majority of sporadic endometrial carcinomas displaying this phenotype.

Activated (HLA-DR+) T-lymphocyte subsets in early epithelial ovarian cancer and malignant ovarian germ cell tumors

We examined peripheral blood T-lymphocyte subsets before initiation of therapy in 79 healthy controls, 3 patients with endometriosis, 95 patients with common epithelial tumors of the ovary, 15 patients with ovarian germ cell tumors, and 3 patients with ovarian sex cord-stromal tumors. In stage Ia/Ib patients with epithelial ovarian cancer, the percentages of activated CD4+ (CD4+HLA-DR+) T cells and activated CD4+ T cells in the CD4+ T-cell subsets were significantly higher than those of healthy controls and patients with benign or borderline epithelial tumors of the ovary. These immunologic parameters were subsequently decreased in patients in stage Ic and more advanced stages. In malignant ovarian germ cell tumors, a similar increase in the CD4+ T-cell subsets was observed. Moreover, the percentage of activated CD8+ T cells in the CD8+ T-cell subsets in stage Ia/Ib patients increased significantly compared with those in healthy controls and patients with benign tumors. Our findings indicate that activated T lymphocytes may play some roles in oncogenesis and progression of both epithelial ovarian cancer and malignant ovarian germ cell tumors.

Immunohistochemical localization of epidermal growth factor and its effect on granulosa cell proliferation in rat ovary

The localization of epidermal growth factor (EGF) in the ovary and its effect on proliferation of granulosa cells were investigated in gonadotrophin-primed immature female rats. Immunoreactions with anti-rat EGF monoclonal antibody were observed sparsely in the granulosa layer and antrum of follicles, but not in the theca layer or stromal tissue. The EGF-positive cells were round or oval shaped and often larger than granulosa cells. The localization and morphological appearances of these cells in the follicles were in good agreement with those of macrophages. Although EGF alone did not promote granulosa cell growth in vitro, the labelling index with [3H]thymidine of granulosa cells cultured with 0.1 ng/ml EGF and 0.1 ng/ml basic fibroblast growth factor was significantly greater than that without the growth factors (18.4% vs. 15.8%, P < 0.01). These results suggest that macrophages in follicles may modulate follicular development through a paracrine mechanism by secreting EGF and other growth factors.

Activated (HLA-DR+) T-lymphocyte subsets in cervical carcinoma and effects of radiotherapy and immunotherapy with sizofiran on cell-mediated immunity and survival

A prospective randomized trial on 312 patients with locally advanced cervical carcinoma (FIGO stages IB-IV) was carried out. The 5-year survival in 90 patients treated with radiotherapy and antitumor polysaccharide sizofiran, an extract from the culture broth of Schizophyllum commune Fries, in combination was significantly (P = 0.045) better than that in 82 patients treated with radiotherapy alone. Treatment with sizofiran and 5-fluorouracil in combination improved (P = 0.003) the 5-year survival in 60 patients treated with radiotherapy. In 244 cervical carcinoma patients, the percentage of activated CD8+ (CD8+HLA-DR+) T cells in the CD8+ T-cell subsets in peripheral lymphocytes increased significantly as the disease progressed. A similar tendency was observed in the percentage of activated CD4+ (CD4+HLA-DR+) T cells in the CD4+ T-cell subsets. These immunologic parameters were significantly increased by radiotherapy, but not by surgery. Sizofiran accelerated a recovery in the activated CD8+ T cells in the CD8+ T-cell subsets compared with that of sizofiran nontreated patients after radiotherapy. Our data show that possible immune impairment in cervical carcinoma may be caused by disturbances in cell-mediated immunity, and that sizofiran is an effective immunotherapeutic agent for cervical carcinoma because it stimulates a rapid recovery of the immunologic parameters impaired by radiotherapy.