Sexual and Psychosexual Consequences of Treatment for Gynaecological Cancers

Modern multimodality cancer treatment has led to a rise in cancer survivors, and by 2030 the survival rate is estimated to increase by 31.4%. This is an impressive survival statistic on which clinicians and services continue to build. One of the less well-acknowledged consequences of survivorship among health professionals and patients alike is female sexual dysfunction, despite it occurring in more than 60% of women diagnosed with cancer. The systematic assessment and management of late effects from cancer lack integration within current models of oncology follow-up. Although highly prevalent, issues linked to sexual health are often not addressed among survivors. This overview aims to focus on the sexual impact of gynaecological cancer treatment. Clinicians should raise the topic of the sexual consequences of cancer treatment as a legitimate aspect of survivorship and service provision. Increased focus on the sexual consequences of treatment and cancer survivorship may in time lead to greater clinical recognition, service development and, most importantly, increase research focused on the effective management of what remains a neglected aspect of cancer care.

Vaginal epithelioid angiosarcoma: A literature review of a rare entity in an unusual site

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Often asymptomatic, hidden location and present late.

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Radiation is a well-recognised cause of any angiosarcoma irrespective of the anatomic site.

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Management can only be generalised from reported angiosarcomas of the uterus, cervix, and ovary.

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Treatment includes external radiation and intracavitary brachytherapy after surgical excision.

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Follow-up is required to assess efficacy as the prognosis remains poor even with early intervention.

We describe an extremely rare case of a 66-year-old woman with a vaginal epithelioid angiosarcoma. She presented with constitutional symptoms, pelvic pain, vaginal bleeding, and a violaceous vaginal lesion. A thorough gynaecological examination, tissue biopsy and imaging were crucial to establish an accurate diagnosis. With only 3 other cases reported in the literature, epithelioid angiosarcoma of the vagina seem to present late due to their nonspecific presentation and secluded location. Once diagnosed, optimal treatment is difficult to determine and together with the overly aggressive behaviour of these tumours, they are associated with a poor prognosis. To our knowledge, our case study and systematic literature review is the first to compare the management outcomes of epithelioid subtype angiosarcomas of the vagina. The rarity of this pathology contributes to diagnostic difficulties and lack of consensus regarding treatment of angiosarcomas of the vagina.

The value of local registry data for describing cervical cancer management and outcomes over three decades in Australia

Registry data on invasive cervical cancers (n = 1,274) from four major hospitals (1984-2012) were analysed to determine their value for informing local service delivery in Australia. The methodology comprised disease-specific survival analyses using Kaplan-Meier product-limit estimates and Cox proportional hazards models and treatment analyses using logistic regression. Five- and 10-year survivals were 72% and 68%, respectively, equating with relative survival estimates for Australia and the USA. Most common treatments were surgery and radiotherapy. Systemic therapies increased in recent years, generally with radiotherapy, but were less common for residents from less accessible areas. Surgery was more common for younger women and early-stage disease, and radiotherapy for older women and regional and more advanced disease. The proportion of glandular cancers increased in-step with national trends. Little evidence of variation in risk-adjusted survival presented over time or by Local Health District. The study illustrates the value of local registry data for describing local treatment and outcomes. They show the lower use of systemic therapies among residents of less accessible areas which warrants further investigation. Risk-adjusted treatment and outcomes did not vary by socio-economic status, suggesting equity in service delivery. These data are important for local evaluation and were not available from other sources.

WOMEN IN CANCER THEMATIC REVIEW: Ovarian cancer-peritoneal cell interactions promote extracellular matrix processing

Ovarian cancer has a distinct tendency for metastasising via shedding of cancerous cells into the peritoneal cavity and implanting onto the peritoneum that lines the pelvic organs. Once ovarian cancer cells adhere to the peritoneal cells, they migrate through the peritoneal layer and invade the local organs. Alterations in the extracellular environment are critical for tumour initiation, progression and intra-peritoneal dissemination. To increase our understanding of the molecular mechanisms involved in ovarian cancer metastasis and to identify novel therapeutic targets, we recently studied the interaction of ovarian cancer and peritoneal cells using a proteomic approach. We identified several extracellular matrix (ECM) proteins including, fibronectin, TGFBI, periostin, annexin A2 and PAI-1 that were processed as a result of the ovarian cancer-peritoneal cell interaction. This review focuses on the functional role of these proteins in ovarian cancer metastasis. Our findings together with published literature support the notion that ECM processing via the plasminogen-plasmin pathway promotes the colonisation and attachment of ovarian cancer cells to the peritoneum and actively contributes to the early steps of ovarian cancer metastasis.

The role of ABC transporters in ovarian cancer progression and chemoresistance

Over 80% of ovarian cancer patients develop chemoresistance which results in a lethal course of the disease. A well-established cause of chemoresistance involves the family of ATP-binding cassette transporters, or ABC transporters that transport a wide range of substrates including metabolic products, nutrients, lipids, and drugs across extra- and intra-cellular membranes. Expressions of various ABC transporters, shown to reduce the intracellular accumulation of chemotherapy drugs, are increased following chemotherapy and impact on ovarian cancer survival. Although clinical trials to date using ABC transporter inhibitors have been disappointing, ABC transporter inhibition remains an attractive potential adjuvant to chemotherapy. A greater understanding of their physiological functions and role in ovarian cancer chemoresistance will be important for the development of more effective targeted therapies. This article will review the role of the ABC transporter family in ovarian cancer progression and chemoresistance as well as the clinical attempts used to date to reverse chemoresistance.

Antibody-based immunotherapy for ovarian cancer: where are we at?

Cytoreductive surgery and chemotherapy continue to be the mainstay of ovarian cancer treatment. However, as mortality from advanced ovarian cancer remains very high, novel therapies are required to be integrated into existing treatment regimens. Immunotherapy represents an alternative and rational therapeutic approach for ovarian cancer based on a body of evidence supporting a protective role of the immune system against these cancers, and on the clinical success of immunotherapy in other malignancies. Whether or not immunotherapy will have a role in the future management of ovarian cancer is too early to tell, but research in this field is active. This review will discuss recent clinical developments of selected immunotherapies for ovarian cancer which fulfil the following criteria: (i) they are antibody-based, (ii) target a distinct immunological pathway, and (iii) have reached the clinical trial stage. Specifically, the focus is on Catumaxomab (anti-EpCAM×anti-CD3), Abagovomab, Oregovomab (anti-CA125), Daclizumab (anti-CD25), Ipilimumab (anti-CTLA-4), and MXD-1105 (anti-PD-L1). Catumaxomab has reached phase III clinical trials and exhibits promise with reports, showing that it can cause a significant and sustained reduction in ascites. Phase I-III clinical trials continue to be conducted on the other antibodies, some of which have had encouraging reports. We will also provide our perspective on the future of immunotherapy for ovarian cancer, and how it may be best employed in treatment regimens.

Does retention of the ovaries improve long-term survival after hysterectomy? A gynecological oncological perspective

Ovarian cancer is, in most cases, a lethal disease as it is virtually impossible to diagnose at an early stage and almost impossible to treat successfully when detected at an advanced stage. In postmenopausal women, there is no prevention for ovarian cancer but oophorectomy. Therefore, from the gynecological oncological perspective, where benign gynecological pathology requires surgery in postmenopausal women, oophorectomy should be the preferred option.

510. TRANSFORMING GROWTH FACTOR INDUCED PROTEIN TGFβI PROMOTES OVARIAN CANCER CELL MOTILITY AND ADHESION TO PERITONEAL CELLS

Ovarian cancer is characterized by metastases to the peritoneal surface lining the abdominal cavity. It remains unclear which factors promote the implantation of ovarian cancer cells onto the peritoneal lining. We have recently investigated interactions between ovarian cancer cells (OVCAR-5, OVCAR-3, and SKOV-3) and mesothelial cells isolated from omental tissues (LP-9). We conducted a proteomic screen of the conditioned medium of co-cultures of ovarian cancer and mesothelial cells. One of the molecules identified to be modulated is the extracellular matrix adhesion protein, transforming growth factor-beta-induced protein (TGFβI, also known as b ig-H3 or keratoepithelin) which is induced by transforming growth factor-beta in many cell types which has been shown to promote adhesion and migration of hepatoma and astrocytoma cells and enhance colon cancer cell extravasation. In this study we investigated the expression of TGFβI in ovarian cancer tissues and the effects of recombinant TGFβI on ovarian cancer motility and adhesion to peritoneal mesothelial cells. In functional assays, treatment with recombinant TGFβI significantly increased adhesion of all three ovarian cancer cell lines to LP-9 mesothelial cells by up to 25% (P<0.01) and increased motility in OVCAR-5 cells by 62% (P<0.001). Furthermore, addition of a neutralising TGFβI antibody reduced OVCAR-5 adhesion to LP-9 to 79% of control level (P<0.001). TGFβI produced by LP-9 cells was processed to smaller forms when co-cultured with ovarian cancer cell lines by western blotting. MALDI-TOF/TOF mass spectrometry identified TGFβI processing at both the N and C terminal domains. The addition of broad spectrum protease inhibitors blocked the TGFβI processing and reduced OVCAR-5 adhesion to LP-9 cells to 60% of control level (P<0.001). We conclude that although some ovarian cancer cells produce low levels of TGFβI, TGFβI abundantly expressed by peritoneal mesothelial cells can promote ovarian cancer cell adhesion and motility.

Proteins' promise--progress and challenges in ovarian cancer proteomics

Ovarian cancer is the leading cause of gynaecological cancer death. The mortality rate of ovarian cancer could be greatly decreased if there were a screening test which was able to detect the disease at an early stage, resulting in an increased probability of cure. The most promising prospect for the early detection of ovarian cancer comes from the rapidly advancing field of clinical proteomics. An increasing number of reports on the potential clinical application of proteomics research for early detection as well as risk assessment and management of ovarian cancer are being published. Although the research is very promising, major technical challenges are still preventing new discoveries in ovarian cancer proteomics from being translated into clinical practice.

Tissue and plasma expression of the angiogenic peptide adrenomedullin in breast cancer

Adrenomedullin (ADM) is an angiogenic factor that has also been shown to be a mitogen and a hypoxia survival factor for tumour cells. These properties point to ADM as a potential promoter of human malignancies, but little data are available concerning the expression of ADM in human breast cancer. In the present work, we have examined ADM peptide expression in a series of malignant breast tumours by immunohistochemistry using a newly developed anti-ADM monoclonal antibody. In addition, ADM plasma concentrations in breast cancer patients and healthy controls were determined by radioimmunoassay. Of the examined breast cancer samples, 27/33 (82%) showed a moderate to strong staining intensity. ADM-peptide expression in breast tumours was significantly correlated with axillary lymph node metastasis (P=0.030). Analysis of ADM plasma concentrations showed no significant difference between the circulating ADM levels of breast cancer patients and healthy controls. However, a significant positive correlation was found between tumour size and plasma ADM levels (r=0.641, P=0.017). Moreover, ADM levels in breast cancer patients correlated with the presence of lymph node metastasis (P=0.002). In conclusion, we have shown for the first time that ADM peptide is widely expressed in breast cancer and that the degree of expression is associated with lymph node metastasis. ADM peptide in plasma of breast cancer patients reflects the size of the primary tumour, but is unlikely to be a useful tumour marker for the detection of breast cancer. Plasma ADM might represent an independent predictor of lymph node metastasis. The clinical implications of these findings remain to be evaluated.

Protease activated receptor-1 is down regulated by levonorgestrel in endometrial stromal cells

Progestogens are used clinically for contraception, to control excessive menstrual bleeding and to oppose oestrogen in hormone replacement therapy. The use of intrauterine levonorgestrel (LNG) is however, associated with endometrial atrophy and decidualisation of the stroma. In this study, we aimed to identify genes whose expression is modulated by LNG either alone or in combination with progesterone. Thus endometrial stromal cells were stimulated with progesterone, LNG or LNG and progesterone. Poly-A RNA was isolated and used to probe expression arrays. The expression of a number of genes was altered on exposure to LNG or LNG and progesterone. Alteration of expression patterns was confirmed using semi-quantitative RT-PCR and western blot analysis. In particular, the protease activated receptor-1 (PAR-1) gene that encodes a receptor for thrombin was down regulated. This is the first demonstration that PAR-1 is down regulated by the progestogen LNG in human endometrium. Alteration in the expression levels of this receptor may affect both growth and haemostatic activity within the endometrium and may account for the observed morphological effects seen in users of intrauterine LNG delivery devices.

Menorrhagia: an update

Menorrhagia is defined as a 'complaint of heavy cyclical menstrual bleeding occurring over several consecutive cycles'. Objectively it is a total menstrual blood loss equal to or greater than 80 ml per menstruation. It is estimated that approximately 30% of women complain of menorrhagia. Excessive bleeding is the main presenting complaint in women referred to gynecologists and it accounts for two-thirds of all hysterectomies, and most of endoscopic endometrial destructive surgery. Thus, menorrhagia is an important healthcare problem. Its etiology, investigation, medical and surgical management are described. In approximately 50% of cases of menorrhagia no pathology is found at hysterectomy. Abnormal levels of prostaglandins or the fibrinolytic system in the endometrium have been implicated. Effective medical treatments suitable for long-term use include intrauterine progestogens, antifibrinolytic agents (tranexamic acid) and nonsteroidal anti-inflammatory agents (mefenamic acid). Over the past decade there has been increasing use of endometrial destructive techniques as an alternative to hysterectomy. Their further refinement and the advent of fibroid embolization has increased the options available to women.

Wnt-7a is upregulated by norethisterone in human endometrial epithelial cells: a possible mechanism by which progestogens reduce the risk of estrogen-induced endometrial neoplasia

Progestogens are added to oestrogen in hormone replacement therapy regimens to reduce the risk of endometrial cancer. We have performed in vitro studies analysing gene expression of isolated normal endometrial epithelia cells (NEE) treated with estradiol and the progestogen norethisterone acetate (NETA). We report here for the first time upregulation of the Wnt-7a gene by NETA in estrogen treated NEE. Wnt genes are a large family of developmental genes associated with cellular responses such as oncogenesis. We therefore suggest that upregulation of Wnt-7a may be associated with the antineoplastic effects of progestogens on the endometrium.

Tamoxifen induction of angiogenic factor expression in endometrium

Tamoxifen is the current therapy of choice for patients with oestrogen receptor positive breast cancer, and it is currently under evaluation as a prophylactic for women at high risk of developing the disease. However, tamoxifen is also known to induce proliferative changes in the endometrium increasing the risk of developing endometrial hyperplasia, polyps and carcinoma. Angiogenesis is an intimate part of this process. For this reason, we have examined the expression of several well characterized angiogenic factors, namely, acidic and basic fibroblast growth factor, thymidine phosphorylase, vascular endothelial growth factor and adrenomedullin in both normal and tamoxifen exposed pre- and postmenopausal endometrium. Vascular density and endothelial proliferation index were also quantified. We found increased expression of acidic and basic fibroblast growth factor and adrenomedullin after treatment with tamoxifen mainly in premenopausal tissue. Vascular density was significantly increased in pre- but not post-menopausal endometrium (P=0.0018) following tamoxifen treatment. These results support the notion that angiogenesis is integral to the response to tamoxifen exposure, and is a potential target with which to block these side effects of tamoxifen.

Adrenomedullin inhibits hypoxic cell death by upregulation of Bcl-2 in endometrial cancer cells: a possible promotion mechanism for tumour growth

Regions of hypoxia are a common feature of solid tumours. When tumour cells are exposed to hypoxic stress, transcription of a battery of genes is initiated. The angiogenic factor adrenomedullin (ADM) is a hypoxia regulated gene. ADM is thought to act through the G protein-coupled receptor calcitonin receptor-like receptor (CRLR), with specificity being conferred by the receptor associated modifying protein 2 (RAMP2). Here we report for the first time that ADM treated or stably transfected Ishikawa cells overexpressing ADM show increased resistance to hypoxia induced apoptosis. These cells also show an upregulation of the oncoprotein Bcl-2, which is protective against hypoxic cell death when transiently transfected into Ishikawa cells. Since Ishikawa cells express the putative ADM-receptor CRLR-RAMP2 the production and secretion of ADM with the consecutive upregulation of Bcl-2 could establish an autocrine/paracrine mechanism rescuing malignant cells from hypoxic cell death. These results, taken together with our previous findings that ADM is an angiogenic factor which is upregulated by the nonsteroidal antiestrogen tamoxifen (TAM) in endometrial cells, implicate this peptide as a promoter of tumour growth and a possible target for anticancer strategies.

Prognostic relevance of serum vascular endothelial growth factor in ovarian cancer

BACKGROUND

The vascular endothelial growth factor (VEGF) is the angiogenic growth factor most strongly implicated in tumor angiogenesis. Its special role in the pathophysiology of ovarian cancer emerges from its dual functional capability as an endothelial cell mitogen and a potent stimulator of vascular permeability, leading to the characteristic ascites accumulation in this disease. The aim of our study was to analyze the prognostic value of serum VEGF (sVEGF) as a tumor marker in ovarian cancer.

PATIENTS AND METHODS

41 patients with ovarian carcinomas were included in the study. Venous blood was taken from all patients preoperatively. From 15 patients an additional postoperative blood sample was drawn. sVEGF was measured in duplicate using a commercially available ELISA-kit.

RESULTS

The mean sVEGF level for the ovarian cancer patients was 522 +/- 321 pg/ml (SD) (median: 440; range: 55-1263 pg/ml) No statistically significant correlation could be found between sVEGF concentration and age, histologic type or FIGO-stage. sVEGF values four weeks after surgery were significantly lower than those before treatment (p = 0.002). In patients after radical surgery sVEGF values dropped or stayed stable below the cut-off more often than in patients with residual disease. In the univariate analysis, improved overall survival (OS) was found for ovarian cancer patients with a sVEGF below the cut-off value of 440 pg/ml (p = 0.017). sVEGF was also tested in a multivariate analysis together with residual disease and FIGO-stage using the Cox's proportional hazard model. In the final model only residual disease had an independent influence on OS (p = 0.018).

CONCLUSION

sVEGF levels decrease significantly after cytoreductive therapy and might indicate treatment efficiency. According to our study, sVEGF is not an independent prognosticator of survival for ovarian cancer.

Expression of the hypoxically regulated angiogenic factor adrenomedullin correlates with uterine leiomyoma vascular density

Uterine leiomyomas are the most prevalent benign tumor type in women of reproductive age and are one of the most common indications for hysterectomy. The expression of five angiogenic factors, adrenomedullin (ADM), vascular endothelial growth factor (VEGF), acidic fibroblast growth factor, basic fibroblast growth factor, and platelet-derived endothelial cell growth factor/thymidine phosphorylase, were examined in 91 uteri collected throughout the menstrual cycle; 52 of which contained leiomyomata, and the remainder were normal controls. The microvascular density and endothelial proliferative indices were then determined for each of the uterine sections. ADM and VEGF were the most widely expressed angiogenic factors in the leiomyomas. Furthermore, the expression of ADM and VEGF in the endometrium and myometrium was up-regulated in leiomyoma-bearing uteri compared with controls. Although acidic fibroblast growth factor and basic fibroblast growth factor were expressed in leiomyomas and endometrium in all of the uterine samples examined, they were only expressed in the myometrium of leiomyomata-bearing uteri. Endothelial proliferation in leiomyomas was statistically greater than that of the myometrium and endometrium, both within and between uteri (P < 0.05). The vascular density in the myometrium but not the endometrium was significantly increased in leiomyoma-containing uteri (P < 0.05). Expression of ADM alone correlated directly with vascular density and endothelial cell proliferation index in leiomyomas and myometrium and may account for the high vascularity found in leiomyomas and the myometrium of leiomyoma-bearing uteri. As such, ADM is identified as a novel target for antiangiogenic therapy of these benign, clinically problematic uterine tumors.

Steroids and the endometrium

Steroids are commonly employed in current clinical practice. The benefits of steroids in hormone replacement therapy, contraception and prevention or treatment of breast cancer are limited by their side effects arising from disorders in endometrial function. These side effects are complex and enclose bleeding problems and endometrial proliferation during hormone replacement therapy and antioestrogen treatment or menstrual disturbances during oral contraception. Numerous reports have identified gene targets influenced by steroids and have implicated these products as contributors to endometrial physiology or pathology. The expression of estrogen and progesterone receptors is regulated by steroids. The new estrogen receptor (ER) subtype ERbeta with different functional characteristics from ERalpha was recently described in endometrium. In addition, there is now increasing evidence that the functionally distinct progesterone receptor (PR) isoforms A and B are differentially expressed in this tissue. The relative proportions of these steroid receptors and their interaction determine the expression of specific genes upon steroidal stimulation. Steroids induce endometrial expression of various growth and angiogenic factors. Dysregulations of this steroid modulated expression is believed to be involved in the pathogenesis of many endometrial diseases. Irregular bleeding induced by steroidal contraception, for example, is thought to involve aberrant endometrial vascular development and expression of angiogenic growth factors. The antioestrogen tamoxifen induces growth factors like vascular endothelial growth factor and adrenomedullin which may be key mediators of endometrial neoplastic effects. This review describes recent advances regarding the mechanism of action of steroids on endometrium. The expression of oestrogen and progesterone receptors as well as steroid hormone dependent growth factors and angiogenic modulators are going to be discussed.

Androgen receptor gene mutations do not occur in ovarian cancer

Genetic alterations have been frequently found in ovarian cancer. There is some indirect evidence indicating that mutation of the steroid receptor genes may play a role in the carcinogenesis of ovarian cancer. Human androgen receptor (hAR) gene mutations have been found in up to 50% of hormone-relapsed prostate cancer. The role of hAR mutation and its association with decreased expression in ovarian cancer has never been elucidated. In this study mutations of hAR gene in 38 human ovarian cancer cell lines with different AR expression pattern were studied using SSCP. No mutation of the hAR gene was found. Mutation of hAR gene is an infrequent event and therefore unlikely to be involved in the development of ovarian cancer. The decreased expression of hAR in advanced ovarian tumor is not due to genetic aberration of hAR. Mutation screening of hAR may not provide any information for risk assessment of developing ovarian cancer.

Risk factors associated with early-onset sepsis in premature infants

OBJECTIVE

To define perinatal factors associated with early-onset neonatal sepsis.

STUDY DESIGN

Maternal and neonatal variables were analysed retrospectively in 343 infants born before 35 weeks using univariate and multivariate statistical analysis.

RESULTS

Logistic regression analysis identified risk factors for probable neonatal sepsis: gestational age at delivery (odds ratio 0.9, 95% confidence interval (CI) 0.91-0.96), premature rupture of the membranes (odds ratio 2.9, 95% CI 1.004-8.56), Apgar score after 1 min (odds ratio 0.7, 95% CI 0.53-0.96), and histological chorioamnionitis and/or funisitis (odds ratio 4.1, 95% CI 1.36-12.12). There was a strong association between probable sepsis and intracranial haemorrhage of the infant (odds ratio 4.3, 95% CI 1.07-17.40). Funisitis had a high specificity (91%) and positive predictive value (82%) for the detection of neonatal sepsis < or =32 weeks.

CONCLUSIONS

Independent obstetrical risk factors for early-onset neonatal sepsis in premature infants may help to identify newborns who benefit from maternal antibiotic prophylaxis before birth. The histological examination of the umbilical cord can be used as an additional diagnostic test to detect newborns at risk of infection.

CASA and Ca 125 in diagnosis and follow-up of advanced ovarian cancer

BACKGROUND

CA 125 is the most important tumor marker in ovarian cancer. Due to its low specificity and the fact that some ovarian malignancies do not produce considerable amounts of CA 125 a combination with the Cancer Associated Serum Antigen (CASA) may reflect more accurately the clinical situation.

MATERIALS AND METHODS

CA 125 and CASA determination was performed in sera of 78 patients with advanced ovarian cancer pre- and postoperatively, monthly during chemotherapy and during follow-up care. The cut-off values for CASA were 4 U/ml, for CA 125 35 U/ml and 65 U/ml, respectively.

RESULTS

In the detection of advanced ovarian cancer a combination of both tumor markers was superior to the use of either CASA or CA 125 alone. In the follow-up situation CA 125 with the 35 U/ml cut-off showed the highest sensitivity. Both markers had similar prognostic relevance when marker levels three months after surgery were used.

CONCLUSION

CA 125 and CASA have similar characteristics in preoperative diagnosis and postoperative follow-up. In clinical situations with inconclusive or negative CA 125 serum values CASA is helpful to improve management of patients with advanced ovarian cancer.

Diagnostic value of serum VEGF in women with ovarian tumors

BACKGROUND

Angiogenesis is necessary for growth and invasiveness of malignant tumors. Vascular endothelial growth factor (VEGF) is considered to play a key role in tumor angiogenesis. Few data are available with regard to serum levels of VEGF in patients with ovarian tumors. We investigated the diagnostic value of serum VEGF in patients with ovarian neoplasms.

MATERIALS AND METHODS

61 patients with ovarian neoplasms (41 ovarian carcinomas, 20 cystadenomas) and 20 healthy women were included into the study. VEGF serum concentrations were determined by a commercially available ELISA.

RESULTS

Statistical analysis revealed significant differences in VEGF serum values of ovarian cancer patients vs. healthy controls or patients with cystadenomas. No difference could be seen between serum levels of healthy controls and women with benign ovarian tumors. For ovarian cancer patients vs. normal controls a sensitivity of 71% and a specificity of 65% resulted. The sensitivity and specificity of cancer patients vs. patients with benign neoplasms were 71% and 65%, respectively.

CONCLUSION

Our results suggest that VEGF has potential as a serum marker with diagnostic relevance in ovarian neoplasms.

Prognostic relevance of the endothelial marker CD 34 in ovarian cancer

BACKGROUND

Tumour angiogenesis and microvessel density are of prognostic significance in several human neoplasia. To investigate how tumour vascularity correlates with disease-free survival microvessel density was assessed in 38 patients with ovarian cancer using the highly specific endothelial marker CD 34.

METHODS

Representative specimens were obtained and stained using monoclonal CD 34 antibodies. The microvessels were quantified at 200x and 400x magnification in the most active areas of neovascularisation. Degree of angiogenesis was correlated with histologic tumour type, grading, and tumour stage. Furthermore, survival was calculated using Kaplan-Meier analysis and results again correlated with the microvessel count.

RESULTS

No correlation was found between microvessel density, histologic type, grading, and FIGO stage. Patients with a vessel count more than 40 (200x magnification) had a statistically significant lower overall survival (p = 0.022).

CONCLUSION

Our results indicate that CD 34 is a useful marker in determining tumour neovascularisation which might be of prognostic relevance in patients with ovarian cancer.

Doppler ultrasonographic evidence of intrapartum brain-sparing effect in fetuses with low oxygen saturation according to pulse oximetry

OBJECTIVE

This study was undertaken to verify by means of Doppler ultrasonography and simultaneous fetal pulse oximetry the redistribution of fetal blood flow in favor of the brain during intrapartum hypoxemia.

STUDY DESIGN

During labor 11 term fetuses with abnormal heart rate patterns and arterial oxygen saturation <30% and 14 control term fetuses with normal oxygen saturation were simultaneously monitored by pulse oximetry and Doppler ultrasonography. The results were compared with the Student t test.

RESULTS

The blood flow velocity in the middle cerebral artery was significantly higher in the presence of reduced oxygen saturation, implying lower pulsatility and resistance indices (P <.001). The reduction of blood flow in the umbilical artery was not significant (P =.61).

CONCLUSION

Simultaneous intrapartum pulse oximetry and Doppler ultrasonography proved that reduced arterial oxygen saturation (<30%) is associated with profound changes in fetal hemodynamics and could be tolerated for only a limited period, which should be the subject of further studies.

Regulation of endometrial angiogenesis

Bleeding problems are the most common reason for discontinuation of hormone replacement therapy. Human endometrium undergoes the unique process of benign angiogenesis under the control of ovarian steroids during reproductive life and it is presumed that similar processes occur when women take hormone replacement therapy. The key players in endometrial growth and angiogenesis are vascular endothelial growth factor, thymidine phosphorylase and adrenomedullin. Regulation of these angiogenic factors is described.

Comparison of long-term survival of cytomegalovirus promotre versus Rous Sarcoma virus promoter-driven thymidine kinase gene therapy in nude mice bearing human ovarian cancer

The cytomegalovirus (CMV) promoter is considered one of the strongest positive regulators leading to expression of higher levels of the thymidine kinase (TK) enzyme than the Rous Sarcoma virus (RSV) promoter in vitro and in vivo. Cell killing efficacy of adenovirus-mediated CMV promoter-driven herpes simplex virus (HSV) TK gene therapy has been found to be 2 to 10 times more effective than RSV driven HSV-TK gene therapy in vitro. In this study the impact of CMV- versus RSV-driven HSV-TK gene therapy on long-term survival of nude mice bearing human ovarian cancer has been evaluated using a prospective randomized experimental design. The experiment was designed to show significance of survival differences from a 50% increase of survived days at a p-value of 0.05 with a power of 80%. All treatment groups showed an increase in median survival compared with control groups. Treatment benefit was ADV/CMV-TK vector dose dependent. At a given viral dose, no significant prolongation of survival was observed comparing CMV- and RSV-driven ADV-TK indicating that simply increasing cell killing efficacy in vitro above a minimal threshold level using a stronger promoter may not lead to prolongation of survival in the HSV-TK/GCV system.

Risk factors associated with preterm (<37+0 weeks) and early preterm birth (<32+0 weeks): univariate and multivariate analysis of 106 345 singleton births from the 1994 statewide perinatal survey of Bavaria

OBJECTIVE

The study was conducted to identify medical, obstetrical and social risk factors associated with early preterm births (<32+0 gestational weeks).

STUDY DESIGN

The Statewide Perinatal Survey of Bavaria is a collection of perinatal data from all Bavarian maternity units using a uniform numbered questionnaire. Data on 106345 singleton births from the 1994 Survey were analysed using univariate and multivariate logistic regression analysis.

RESULTS

In the multivariate analysis, early preterm birth was associated with premature rupture of the membranes (odds ratio (OR) 1.6, 95% confidence interval (CI) 1.37-1.86), treatment for infertility (OR 1.7, 95% CI 1.19-2.34), previous induced abortion (OR 1.8, 95% CI 1.57-2.13), maternal age >35 years (OR 1.8, 95% CI 1.47-2.16), premature cervical dilatation (OR 2.3, 95% CI 1.86-2.94), a history of stillbirth (OR 3.2, 95% CI 2.13-4.83), a history of preterm birth (OR 3.3, 95% CI 2.45-4.48), maternal age <18 years (OR 3.4, 95% CI 2.03-5.61), malpresentation (OR 3.9, 95% CI 3.10-4.93), preeclampsia (OR 4.0, 95% CI 3.20-4.94), uterine bleeding (OR 5.0, 95% CI 4.08-6.02), preterm labour (OR 7.0, 95% CI 5.94-8.22), and chorioamnionitis (OR 22.3, 95% CI 17.40-28.66).

CONCLUSION

These data identify a subgroup of women at an increased risk for early preterm birth and may benefit from an intensified prenatal care. Risk factors related to the obstetrical history, genital infections, preeclampsia and maternal age are the most relevant for early preterm birth.

The efficacy of adenovirus-mediated gene therapy of ovarian cancer is enhanced by using the cytomegalovirus promoter

The cytomegalovirus(CMV) promoter is considered one of the strongest positive regulators. In this study toxicity, cell killing efficacy and bystander effect of Rous Sarcoma Virus(RSV) driven herpes simplex thymidine kinase(TK) gene therapy was compared with CMV driven TK gene therapy in three ovarian cancer cell lines with different growth patterns using a 3-(4,5-dimethylthiazol)-2,5-diphenyl tetra-zolium bromide (MTT) based assay. ADV/CMV-TK was shown to be 2 to 10 times more effective in tumor cell killing than ADV/RSV-TK. The difference in cell killing efficacy between ADV/CMV-TK and ADV/RSV-TK was dependent on the individual cell line. A CMV promoter dependent eight to ten fold improvement in cell killing efficacy was observed in the relatively slow growing SKOV3 cell line which is not easily transducible, while only a 2 to 4 fold difference was observed in the easily transducible OV-CA-2774 and OV-CA-1225 cell lines. ADV/CMV-TK also showed a stronger bystander effect than ADV/RSV-TK in all three ovarian cancer cell lines. Our data demonstrated that the efficacy of adenovirus-mediated gene therapy of ovarian cancer can be enhanced by using the CMV promoter without increasing toxicity.

Improvement of gene therapy for ovarian cancer by using acyclovir instead of ganciclovir in adenovirus mediated thymidine kinase gene therapy

Adenovirus(ADV) mediated thymidine kinase(TK) gene therapy followed by ganciclovir(GCV) administration is widely used in different types of cancer. ACV shares the same mechanism of selective cell killing in ADV/TK positive cells as GCV and can be used at 4.5 times higher doses in patients without significant side effects. An increased dose of TK substrate is associated with improved bystander effect and more efficient cell killing. Toxicity and cell killing efficacy were assessed using a 3-(4,5-dimethylthiazol)-2,5-diphenyl tetrazolium bromide(MTT) based assay in three ovarian cancer cell lines with different proliferation patterns. At the same concentration, equal or higher cell killing efficacy and bystander effect were observed using ACV rather than GCV. 2.5 and 5 times (25 micrograms/ml and 50 micrograms/ml) higher concentrations of ACV always resulted in more effective cell killing than GCV (10 micrograms/ml, P < 0.01). Our data indicate that replacing GCV with ACV in the ADV-TK gene therapy may increase the treatment effect without increasing toxicity.

The endothelial marker CD 34 in the assessment of tumour vascularisation in ovarian cancer

OBJECTIVE

Tumour angiogenesis as well as the density of newly formed vessels are of potential prognostic relevance in the assessment of malignant neoplasia. Among other monoclonal antibodies the endothelial marker CD 34 is being increasingly investigated in the assessment of tumour vascularisation, especially in vascular tumours. The aim of this study was to determine the value of CD 34 as an immunohistochemical method to quantify tumour vascularisation in ovarian cancers.

METHODS

In a preliminary study 30 solid ovarian cancers were investigated with regard to their CD 34 expression. Paraffine embedded specimens were processed immunohistochemically using the PAP-method, in a dilution of the primary antibody CD 34 of 1:50. Morphological aspects, such as tumour homogenicity and vessel distribution, as well as vessel density were analysed.

RESULTS

The primary antibody CD 34 reacted positively with the endothelium of arteries, veins and capillaries, noting a more marked expression in small vessels. Furthermore, enhanced staining of those tumour sections with connective tissue was observed, very likely due to the increased vascular pattern of connective tissue. Non-homogenous distribution (e.g. "hot spots") was also seen. Overall, an excellent marking and therefore quantification of tumour vessels was achieved using CD 34.

SUMMARY

In this pilot study we were able to demonstrate the ability of CD 34 to mark tumour vessels in solid cancers of the ovary. Whether this marker will be of any prognostic relevance in the future is under investigation in a larger patient cohort at present.

Correlation of the EGF-receptor with cell kinetic and classical prognostic factors in breast cancer

SPECIFIC OBJECTIVE

The Epidermal Growth Factor Receptor (EGFR) is a specific cell membrane receptor that shows homology to the product of the oncogene c-erbB2 in human breast cancer. Growth factors bound to the EGFR are able to stimulate the growth of tumor cells in an autocrine or paracrine manner. Our objective was to examine whether there is a relationship between EGFR, cell kinetic prognostic factors (ploidy, proliferation-antigen Ki67) and classical prognostic factors (hormone receptors, menopausal status, nodal status) in breast cancer.

METHODS

EGFR was assayed in tumor tissue of 55 patients with breast cancer using an ELISA, the ploidy-status was evaluated by image analysis and Ki67 was determined by immune histochemistry. Estrogen- (ER) and Progesterone-Receptor (PR)-concentrations were quantified using a radioligand assay.

RESULTS

There was a significant positive correlation between the EGFR and the cell kinetic prognostic factors: EGFR positive tumors were significantly-more often aneuploid and Ki67-positive. In addition there was an inverse association between EGFR- and ER-concentration, but no association between EGFR and PR. The EGFR did not correlate with the nodal and the menopausal status.

CONCLUSIONS

Our study revealed associations between EGFR, ER, Ki67 and ploidy. Whether these correlations can help to predict the course of disease, providing further information in addition to the conventional factors (nodal status, steroid hormone receptors etc.) has to be investigated by several years of clinical follow up.

Clinical value of CYFRA 8/18 and TPS in the diagnosis and follow up of invasive breast cancer

In a prospective study, we evaluated the diagnostic accuracy of CYFRA 8/18, TPS, CEA and CA 15-3 among 415 patients in various clinical situations of invasive breast cancer and 244 women with benign breast diseases. In comparison to TPS, the sensitivity of CYFRA 8/18 was slightly lower as well in local malignancy (25% vs. 30%) as in metastatic cancer (54% vs. 57%), but in follow up care the rate of false positive results of TPA (> or = 25%) seems to be higher than that of CYFRA 8/18 (> or = 17%). In conclusion, the clinical value of CYFRA 8/18 and TPA appears to be similar.