Distribution of CA 125 in Placental Tissues

The presence of the tumor marker CA 125 was studied in different compartments of the human placenta. Levels of CA 125 in the cytosol of chorionic villi ranged from 27 - 17100 U/g (median 560 U/g). In the placental amnion and chorion concentrations ranged from 175-29000 U/g, median 1060 U/g and were not statistically different. In the umbilical cord values were significantly lower (range 44 - 7600 U/g; median 180 U/g).

Maternal serum probes were above the upper limit of normal in all cases (range 48 - 500 U/ml; median 131 U/ml). Immunohistochemistry detected CA 125 exclusively within the amniotic cells of the placenta and the umbilical cord. This might be because CA 125 fixes more to insoluble structures in the amnion or because of contamination of chorionic villi with the underlying decidua.

Peritoneum and tissues of the female reproductive tract as physiological sources of CA-125

The origin of physiological CA-125 serum levels, which in normally menstruating women were shown to depend on their actual menstrual cycle phase, has not yet been completely elucidated. It is furthermore conceivable that physiological CA-125 sources may contribute to serum elevations in the various pathologies associated with increased circulating CA-125. The present review deals with menstrual cycle-dependent expression of CA-125 in normal tissues of the female reproductive tract in relation to the actual circulating CA-125 levels together with in vivo data concerning the inductive effect of medroxyprogesterone acetate on circulating CA-125 studied in 24 postmenopausal women. Furthermore, in vitro results on constitutive, steroid hormone- and cytokine-modulated CA-125 shedding from human peritoneal mesothelial and ovarian surface epithelial cells are summarized.

Increased neopterin concentrations in patients with cancer: indicator of oxidative stress?

In vitro, large amounts of neopterin are produced by human monocytes/macrophages upon stimulation with interferon-gamma. In vivo increased neopterin concentrations in human serum and urine indicate activation of cell-mediated (Th1-type) immune response, e.g., during virus infections, autoimmune diseases, allograft rejection and in certain types of malignancy. In various groups of patients with malignant diseases neopterin concentrations correlate to the stage of disease, and higher neopterin concentrations in serum, urine or ascitic fluid were shown to significantly predict worse prognosis regarding relapse and survival. The amounts of neopterin produced by activated monocytes/macrophages correlate with their capacity to release reactive oxygen species (ROS). With this background, neopterin concentrations in body fluids can be regarded as an indirect estimate of the degree of oxidative stress emerging during cell-mediated immune response. Moreover, recently neopterin was found itself to be capable of enhancing toxic effects induced by ROS. In vitro, neopterin derivatives were able to interfere with intracellular signal transduction pathways involved in, e.g., programmed cell death and the induction of proto-oncogene c-fos or nuclear factor-chi B. The data support the view that increased production of ROS--indicated by increased neopterin concentrations--could modulate the development, the proliferation and the survival of malignant cells.

[Endometriosis in tamoxifen therapy]

Tamoxifen is widely used in anti-oestrogen treatment of breast cancer. Recent reports show that, due to oestrogen-agonistic effects, tamoxifen is associated with endometrial carcinoma. We report on the case of a patient who developed endometriosis during tamoxifen treatment.

Neopterin, a marker of cell-mediated immune activation in human pregnancy

High neopterin excretion is closely associated with activation of cell-mediated immunity. We studied urine and serum neopterin concentrations and serum interferon-gamma concentrations in normal pregnant women. In our study population, neopterin concentrations exceeded the normal range in 663 of 840 samples (79%). Neopterin levels increased with the time of pregnancy. Serum samples drawn from women in the third trimester of pregnancy also showed high neopterin concentrations in almost all cases; however, no circulating interferon-gamma was detected. Whereas neopterin is able to penetrate into the blood stream because of its small size (M = 253 D), diffusion of interferon-gamma is limited. Raised neopterin levels provide evidence for activated cell-mediated immunity during pregnancy.

Neopterin as a marker for activated cell-mediated immunity: application in malignant disease

A review is presented on studies concerning neopterin determination in patients with malignant neoplastic diseases. Neopterin is produced chiefly by human macrophages through their activation by T-cell-derived interferon gamma. In vivo, determinationof neopterin in various body fluids provides a convenient way to monitor early events that are involved in cell-mediated immune responses. In malignant neoplasia, elevation of neopterin concentrations in body fluids depends on tumor type. Within a given type of tumor, more advanced stages are generally associated with higher levels than early disease. In a variety of different tumor types and sites, a significantly poorer prognosis was associated with high pretherapeutic neopterin concentrations. This predictive value is independent of several possible confounders such as stage or therapy. During follow-up malignant disease, neopterin elevations may predict deterioration of the clinical status of the patients and thereby provide a valuable additional marker for monitoring such patients. Possible immunobiological implications of the results are discussed.

[Prognostically relevant factors in malignant mixed Müllerian tumor]

In a retrospective analysis of 429 endometrial carcinoma and 29 malignant mixed Müllerian tumour (MMMT) patients, the prognostic factors were evaluated. More than 80% of endometrial carcinomata were staged as I or II, whereas about 30% of MMMT's already in stage III or IV (p less than 0.05). MMMT patients were 10 years older than the carcinoma group (73a vs 63a; p less than 0.001). The risk factors parity, adipositas, and diabetes were equally distributed in the two groups, the survival was worse in MMMT (p less than 0.0001). Applying univariate analysis stage, grading, myometrial invasion and type of therapy significantly affected the survival of endometrial carcinoma patients. After a Cox regression, only stage and grading remained significantly associated with the prognosis. For MMMT's, the survival was also influenced by stage, myometrial invasion, and kind of therapy. Moreover, the parity was found to affect markedly the course of disease. Cox regression of our data excluded all but stage and parity. The beneficial influence of parity on the prognosis of MMMTs, despite a latency of more than 20 years from the last birth to tumour appearance, is unique in oncology.

Urinary neopterin excretion in patients with uterine sarcomas

Neopterin, a pyrazinopyrimidine compound, is a marker of activation of cell-mediated immunity. Urinary neopterin concentrations were measured in a total of 44 patients with uterine sarcomas. Pretherapeutic neopterin excretions were elevated in 78% (14/18). The mean neopterin concentration of patients with sarcomas was significantly higher (P less than 0.0001) than that obtained in women with benign myomas and healthy controls. Furthermore, a significant correlation of normal or raised neopterin concentrations with the clinical course of disease was found. These data suggest that urinary neopterin measurement might be a useful immunologic marker for women with uterine sarcomas.

[Modulation of hCG synthesis by alpha tumor necrosis factor in JAR choriocarcinoma cells]

The tumour necrosis factor (TNF) stimulates in cultured JAR choriocarcinoma cells the biosynthesis of hCG, including the free alpha and beta chain and the holo-hCG. Although elevated serum TNF levels have been shown by Balkwill et al. (1987) in about 50% of tumour patients, we were unable to confirm these data in the 10 examined patients, who had a choriocarcinoma. Despite its excellent in-vitro action, INF could not be confirmed to exercise an influence on the regulation of hCG in choriocarcinoma patients.

Rapid development of resistance to tumor necrosis factor alpha on Ishikawa human endometrial carcinoma cells

The human endometrial adenocarcinoma cells IK were found to be highly susceptible for TNF but rapidly developed a resistance to this cytokine. Inhibitors of RNA transcription or protein biosynthesis could not overcome this resistance. Moreover TNF resistance was not associated with increased resistance to hydrogen peroxide. The resistant phenotype remained stable and was not communicated to neighbouring cells in a paracrine manner. The TNF treatment did not induce a multidrug resistance on IK cells. Nude mice bearing xenotransplanted endometrial carcinoma cells did not benefit from TNF treatment.

Modulation of ovarian carcinoma tumor marker CA-125 by gamma-interferon

Interferons are known to modulate several cellular functions by the induction of different proteins. In our study a gamma-interferon-mediated presentation of one of the most important ovarian tumor markers (CA-125) on the cell surface was demonstrated using two ovarian carcinoma cell lines in vitro (HTB-77 and SKOV-3). This induction was found to be dependent on an intact protein biosynthesis. The gamma-interferon effect reached a maximum on the third day of treatment. Under such conditions the CA-125 concentration was increased intracellularly, on the cell surface, and in the supernatant culture medium. The surface antigen was shed rapidly with a half-life of 1 day. The addition of dexamethasone to gamma-interferon treated HTB-77 cells improved CA-125 expression synergistically. HLA-DR and CA-125 expression was found to be regulated by interferons in different ways. The demonstration of CA-125 expression provides an important insight into the potential regulatory mechanism governing this tumor marker. Since interferons are naturally occurring substances as well as therapeutically administered agents, it seems necessary to pay attention to possible tumor marker modulation.

[Tumor markers in gynecology]

The employment of tumour markers in gynaecology has gained increasing importance in recent times. Beta HCG for chorionic carcinoma and alpha 1 fetoprotein for germ cell tumours are an essential part of postoperative surveillance. Initial analyses of the amylase isoenzymes are available. CEA, TPA, and CA 125 are recognized as established tumour markers. Very promising results have been obtained using SCC in patients with cervical carcinoma. Neopterin, a marker for cell-mediated immunity, provides good prognostic information.

Effects of interferon-alpha on macrophage activation in patients with ovarian carcinoma and cervical dysplasia

Patients with progressive ovarian carcinoma and patients with dysplasia of the uterine cervix were studied in order to compare clinical efficacy, hematological toxicity and effects on macrophage activation of administered interferon-alpha for both patient groups. One of three patients with ovarian carcinoma showed a minor response. Four of six patients with cervical dysplasia had slight improvements of PAP-smears. Moderate hematological toxicity was observed in the former patient group while side effects were much more pronounced in the latter patients group. However, changes of hematological parameters were not statistically different. Interestingly, the administered interferon-alpha caused the same activation of macrophages in both patients groups as indicated by raised neopterin levels. This activation does not result in clinical improvement but appears to play a role for the hematological toxicity observed during therapy of patients with ovarian carcinoma. It has been suggested that suppression of hematopoiesis is mediated by interferon-gamma. The present neopterin data propose that this lymphokine is continuously produced through influence of the tumor and enhanced by interferon-alpha.

[Severe bacterial infections in gynecology and obstetrics]

Within a 3-years period the presence of nosocomial bacteriaemias was analyzed retrospectively among 13.878 hospitalized patients. The incidence was 0.050%. Antibiotic prophylaxis and the operative technique play an important role in achieving a low incidence of morbidity due to infection. The management of a severe infection includes antibiotic therapy according to culture sensitivity and intensive care.

Effects of biological response modifiers on ovarian carcinoma cell lines

Interferons have a mechanism of action different from chemotherapeutic agents. They modulate many physiologically important cellular functions and are a major building block in the network constructed by the biological response modifiers. Moreover, interferons are known to interact also with anticancer drugs to increase their therapeutic benefit. The aim of the present study was to evaluate the effects of interferon-gamma on cultured ovarian carcinoma cell lines. The growth of 3 out of 4 carcinoma cell lines (OVCAR-3, HTB-77, 2780 vs CRL-1572) was inhibited by interferon-gamma. The same cell lines which were growth inhibited also showed an induction of HLA-DR on their surface. CA-125 was found to be increased in 2 of them (OVCAR-3 and HTB-77) by interferon-gamma, whereas CEA was not detectable even after treatment. For HMFG-I, a shightly increased surface expression was induced on OVCAR-3 cells. HMFG-II expression was not significantly affected by interferon-gamma. The combined treatment with interferon-gamma and cisplatin, retinoic acid, or tumor necrosis factor alpha was studied on the ovarian carcinoma cells. For the combination with cisplatin we observed an additive or synergistic amplification of the antiproliferative activity, whereas tumor necrosis factor alpha resulted in a marked synergism in each case. In contrast to breast cancer cells retinoic acid and interferon-gamma acted synergistically only in one ovarian carcinoma cell line.

CA 125 in human milk and serum

CA 125 serum concentrations drawn immediately following delivery exceeded 35 U/ml in all cases (median 276 U/ml). One week post partum elevations of CA 125 were still found, but the median level decreased to 45 U/ml. Six weeks after parturition no positivity was detected in the serum (median 12 U/ml). Considerable CA 125 levels were present in the human milk 1 week after delivery (median 208 U/ml). CA 125 was still found in the milk after 6 weeks (median 153 U/ml). We conclude that positive CA 125 concentrations in the serum after parturition derive from an antigen transfer to the maternal circulation during the placental separation. Furthermore, CA 125 seems to be synthesized by the lactating breast.

[Multiple cancers in gynecologic oncology]

An analysis of 97 patients with multiple primary gynaecological neoplasms (90 double-, 6 triple- and 1 quadruple carcinomas) was done at the Gynaecological Department of the University of Innsbruck. Two thirds of the tumour combinations were located in the female genital tract including the breast. Concerning the early detection of simultaneous or subsequent malignancies of the cervix or corpus uteri, one should pay attention to the mamma being involved in the treatment or aftercare of such cancers. In the same way the inner female genital tract has to be observed in breast cancer patients. Regular colposcopic and cytological examinations of the cervical portio as well as a systematic prevention of endometrial cancer (pistolet in local anaesthesia) is highly recommended. The prognosis of the "highly malignant" tumour does not worsen as a result of a second malignant cancer.

Preactivated T cells in cancer patients with poor prognosis

We investigated the outcome of disease in correlation with pretherapeutic urinary neopterin levels in 161 patients suffering from cervical carcinoma and 51 patients suffering from ovarian cancer. Neopterin is produced by human macrophages upon stimulation with interferon gamma and is therefore a measure for activated T cells. In both types of cancer, neopterin levels before therapy were of predictive significance. Patients with pretherapeutically high neopterin levels were more likely to die earlier. Even 12-18 months after the start of therapy this effect was significant. The data indicate that primary events in the immune surveillance are intact in those patients but effector mechanisms might be diminished. Persistent activation of cell-mediated immunity appears to be unfavorable in cancer patients.

Correlation between steroid hormone receptors, histological and clinical parameters in ovarian carcinoma

Estrogen (ER) and progesterone (PR) receptors in ovarian tumors of 62 patients (51 carcinomas, 11 benign tumors) were estimated by the dextran-coated charcoal method using Scatchard plot analyses. 63% of carcinomas were ER-positive (greater than 10 fmol/mg cytosol), 38% were PR-positive (greater than 25 fmol/mg cytosol), whereas in benign tumors only 45% were ER-positive and 36% were PR-positive. We found no statistically significant correlation between receptor content and stage of disease, menopausal status or age of the patient. The highest concentration of ER and PR was observed in patients between 61 and 70 years of age. Life table analysis for patients with advanced ovarian carcinomas showed no significant difference in survival time in the group with higher ER and PR content. This study also reports the results obtained in a group of patients with receptor-positive ovarian carcinomas treated with a combination of chemotherapy and antiestrogen therapy. In comparison to treatment with cytotoxic chemotherapy alone, no significant difference in the time of survival or duration of remission could be found.

Combination chemotherapy with epirubicin and cisplatin in ovarian carcinoma

Combination chemotherapy with epirubicin-cisplatin was employed after surgical treatment in 67 women with ovarian carcinoma. 50 mg/m2 of epirubicin and cisplatin each were administered at monthly intervals. The response rate was correlated with the clinical stage and the residual disease. Tumor regression (CR + PR) was observed in 63.6% of patients with stage III disease, and in 50% of those with stage IV disease. Furthermore, complete or partial responses were obtained in 86.4% of patients with a residual deposit of 2-5 cm, and in 33.3% of women with a residual deposit exceeding 5 cm in diameter. Anemia occurred in 47.8%, leukopenia in 43.3%, and thrombocytopenia in 4.5% of the patients. No cardiotoxicity was recorded.

Safe use of propofol in a patient with acute intermittent porphyria

On two occasions a patient suffering from acute intermittent porphyria (AIP) was anaesthetized with propofol as the sole agent. The concentrations of urinary porphobilinogen, porphyrins and porphyrin precursors did not exceed preoperative values, and no exacerbation of the disease was noted.

Squamous cell carcinoma antigen in patients with cancer of the uterine cervix

The serum concentrations of the tumor-associated antigen SCC were determined in 62 patients with invasive carcinoma of the uterine cervix. Antigen values above 2.0 ng/ml were considered as slightly positive, and those above 4.0 ng/ml as highly positive. Pretherapeutic levels were elevated (greater than 2.0 ng/ml) in 68% of the patients with cervical carcinoma. In 49 patients with carcinoma in situ, 18% of the SCC values were above the normal range. The greatest incidence of positive SCC titers (84%) was observed in women with recurrent cervical carcinoma. Only 6.7% of women in remission had elevated titers. Five of 24 cases (21%) with invasive endometrial carcinoma had SCC values exceeding 2.0 ng/ml. Slightly positive levels of tumor antigen were seen in 1.8% (1/56) of the control subjects. Serial SCC determinations revealed a correlation with the clinical course of disease in 84%. The determination of SCC is useful for the surveillance of patients with cervical squamous cell carcinoma.

Clinical significance of neopterin for prognosis and follow-up in ovarian cancer

Neopterin, a pyrazinopyrimidine compound, is a marker of activation of cell-mediated immunity. The prognostic value of pretherapeutically and of serially measured urinary neopterin levels in patients with ovarian cancer was assessed, in a blinded manner, by analysis of 658 urine specimens from 74 women. The specimens were collected during a 5-year period (January 1981 to January 1986). Thirty-one deaths due to cancer were observed during the study period. By statistical analysis, a significant predictive value of pretherapeutic neopterin levels was found and compared with that of other possible prognostic clinical and laboratory findings. Multivariate analysis, using stratification by tumor stage, demonstrated that this predictive information was independent of other variables. A significant association was found between serial neopterin measurements and the current risk of death during follow-up (P less than 0.0001). In addition, current death risk was correlated with neopterin levels measured 6 months previously (P = 0.026). The histological outcome at surgical reexamination was correlated with the current neopterin levels (P = 0.016). Further, normal neopterin levels in women with evidence of tumor at surgical reexamination were shown to be a sign of better prognosis than elevated levels. Measurement of urinary neopterin levels during follow-up of women with ovarian cancer appears to be a valuable adjunct to conventional techniques, particularly in patients refusing explorative surgery.