1H NMR-based metabonomic analysis of urine from young spontaneously hypertensive rats

Spontaneously hypertensive rats (SHR) and their substrains are a useful model for studying essential hypertension which is a complex, polygenic, and multifactorial disorder. Their genetic and metabolic features are of great interest because they may provide insights into the mechanism of blood pressure regulation. We have compared urinary metabolic profiles of young SHR with those of their age-matched normotensive controls, Wistar Kyoto rats, using (1)H NMR-based metabonomics. Principal components analysis was applied to the NMR spectral data after data-reduced and normalized by the total integral or the creatinine integral. Consequently, a clear separation of urine samples between the two strains was observed in the principal components scores plot. The loadings plot from the data normalized by the creatinine integral showed that many metabolites such as citrate, alpha-ketoglutarate, and hippurate contributed to the separation, and the urinary levels of most metabolites used in this study, including these three, were lower in SHR than in Wistar Kyoto rats. These metabolic changes may be concerned with blood pressure regulation in SHR, although a relation to other strain differences cannot be ruled out. The present study suggests the usefulness of a (1)H NMR-based metabonomic approach using SHR in the field of hypertension research.

Himeic acid A: a new ubiquitin-activating enzyme inhibitor isolated from a marine-derived fungus, Aspergillus sp

A new ubiquitin-activating enzyme (E1) inhibitor, himeic acid A, was isolated from a culture of marine-derived fungus, Aspergillus sp. The structure was determined by spectroscopic analysis. The formation of an E1-ubiquitin (Ub) intermediate was 65% inhibited by himeic acid A at the concentration of 50 microM, while two new related compounds, himeic acids B and C, showed little inhibitory activity even at 100 microM.

Investigations into Biochemical Changes of Genetic Hypertensive Rats Using 1H Nuclear Magnetic Resonance-Based Metabonomics

Genetically hypertensive rats provide a simple and accessible model for studying essential hypertension, which is a polygenic, heterogenous and multifactorial disease. Their genetic and metabolic features are of great interest because they may provide insight into the pathophysiological processes underlying essential hypertension. We have investigated the genetic influence on metabolic balance and metabolite excretion patterns in stroke-prone spontaneously hypertensive rats (SHRSP) with established hypertension using 1H NMR-based metabonomics. Urinary metabolite profiles for SHRSP and their age-matched normotensive controls, Wistar Kyoto rats, were acquired using 1H NMR spectroscopy. Principal components analysis was applied to these complex NMR data to facilitate differentiation and determine metabolic differences between urine samples collected from the hypertensive and normotensive rats. Consequently, it was possible to distinguish urine samples between the two strains in the principal components scores plot. The loadings plot showed that taurine, creatine and some unidentified metabolites resonating at around delta 2.48, 3.10 and 3.58 predominantly contributed to the separation. In SHRSP, the urinary levels of taurine and creatine were found to be higher and the intensities of the unknown signals much lower than those in the Wistar Kyoto rats. Although the pathophysiological significance of these components remains to be elucidated, this study suggests that 1H NMR-based metabonomics is a promising approach to provide new information on metabolic changes related to the pathophysiological processes of the genetically hypertensive rats.

Tetrapetalone A, a novel lipoxygenase inhibitor from Streptomyces sp

A simple new assay was designed for lipoxygenase inhibitors. This assay was used to find the novel lipoxygenase inhibitor, tetrapetalone A (1). Tetrapetalone A (1), C26H33NO7, was isolated from Streptomyces sp. USF-4727 strain. Its planar structure was determined by spectroscopic evidence and by methylating with diazomethane to show the presence of a novel tetracyclic skeleton and a beta-D-rhodinosyl moiety. The stereochemistry of 1 was investigated by the coupling constant in the 1H-NMR spectrum, NOE correlations, modified Mosher's method and derivation. We have reported the structural elucidation of 1 in our previous paper. However, further investigation gave another structure for 1, which is described in this paper. Tetrapetalone A showed similar inhibitory activity against soybean lipoxygenase to the two well-known lipoxygenase inhibitors, kojic acid and NDGA, while methylated tetrapetalone A (2) showed little inhibitory activity, even at a concentration of 1 mM.

Direct nuclear magnetic resonance spectroscopic analysis of (13)C-labeled antipyrine metabolites in human urine

Antipyrine is a useful probe to evaluate variation of in vivo activities of oxidative hepatic drug-metabolizing enzymes. Here we describe an approach using (13)C labeling and NMR spectroscopy for the direct and simultaneous analysis of major metabolites of antipyrine in human urine. [C-Methyl-(13)C]antipyrine (500 mg) was dosed orally to human volunteers, and the post-dose urine was analyzed by 100-MHz (13)C NMR spectroscopy under the conditions of distortionless enhancement by polarization transfer (DEPT) without any pretreatments such as deconjugation, chromatographic separation, or solvent extraction. Consequently, all the major metabolites in urine were successfully detected with favorable signal-to-noise ratios in the limited acquisition time (30 min). The reproducibility of the NMR detection was sufficient for the quantitative evaluation of the metabolic profile. A quantitative method is proposed using a combination of inverse gated decoupling and DEPT experiments with [2-(13)C]sodium acetate as an internal standard. The present approach is useful and practical to evaluate variation of in vivo activities of the conjugation enzymes as well as oxidative enzymes responsible for the formation of antipyrine metabolites in humans. This direct approach would enhance the value of the antipyrine test because of its simplicity and convenience.

Stereoselective internal acyl migration of 1beta-O-acyl glucuronides of enantiomeric 2-phenylpropionic acids

Internal acyl migration reactions of 1beta-O-acyl glucuronides of 2-arylpropionic acids (profens) are of interest because of their possible role in covalent binding to serum proteins and consequent allergic reactions. The stereoselective degradation of 1beta-O-acyl glucuronides of enantiomeric 2-phenylpropionic acids (PAs), the basic structures of profens, in phosphate buffer (pH 7.4) at 37 degrees C, has been investigated using HPLC. Apparent first-order degradation of 1beta-O-acyl glucuronide and the sequential appearance of 2-, 3- and 4-O-acyl isomers were observed for each enantiomer. Acyl migration was observed to predominate over hydrolysis as in the other profen glucuronides. All the positional isomers and anomers were characterized using NMR and HPLC-NMR. The overall degradation half-life of (R)- and (S)-PA glucuronides was 1.8 and 3.3 h, respectively. These results suggest that (R)-PA glucuronide could be more susceptible to covalent binding to proteins via acyl migration than the corresponding antipode. The lability of the (R)-diastereomer over the antipode is consistent with previous reports on other profen glucuronides. Thus, the diastereomeric PA glucuronides are considered to be the best model compounds for the computation of structural physicochemical parameters to control the stereoselective internal acyl migration of profen glucuronides because PA has the simplest chemical structure of all the profens.

Use of nuclear magnetic resonance spectroscopy and selective C-labeling for pharmacokinetic research in man: detection of benzoic acid conversion to hippuric acid

This paper demonstrates that the stable isotope tracer technique using NMR spectroscopy and the selective 13C labeling of protonated carbons can provide a relatively sensitive method to investigate pharmacokinetic problems in man. The urinary excreted [1,3,5-13C3]hippuric acid ([13C]HA) formed from orally administered [1,3,5-13C3] benzoic acid ([13C]BA) as a model substrate was successfully quantitated without any separation procedures by proton-decoupled 13C-NMR spectroscopy of 10-fold concentrated urine in a 10 min accumulation time. In spite of the low dosage (10mg BA), the C3,5 resonances of [13C]HA were detected with favorable signal-to-noise ratios to quantitate [13C]HA concentration. The administered [13C]BA was found to be quantitatively biotransformed to HA and excreted in urine within 4h. The lower limit of detection was estimated to be 50 nmol in an NMR tube, which was improved about one order of magnitude over that of BA labeled in the quaternary carbon (C7). The potential of an inverse detection experiment using heteronuclear multiple quantum coherence was also investigated in order to detect [13C]HA in urine, with a higher sensitivity. The inverse experiment improved the sensitivity by a factor of 2--3 over 13C¿1H¿-NMR, although the specificity of detection was relatively poor.

Spontaneous perforation of pyometra presenting as generalized peritonitis in a patient with cervical cancer

Pyometra is a relatively common event. However, it is extremely rare for this condition to perforate spontaneously into the peritoneum, and to date only 14 cases have been reported in English literature. We recently experienced such a case in a patient with cervical cancer. The clinical features, pathologic findings, diagnosis, therapy, and outcome of these 15 cases were reviewed. Only 5 cases were associated with malignant diseases, consisting of 2 cervical cancers, 2 colon cancers, and 1 endometrial cancer. All of the patients developed generalized peritonitis, and 4 patients died of this. Correct preoperative diagnosis was difficult. Therefore, immediate and appropriate therapy is important.

Metastatic adenocarcinoma to the uterine cervix from gastric cancer. A clinicopathologic analysis of 16 cases

BACKGROUND

Metastatic adenocarcinoma to the uterine cervix from gastric cancer is rare, and the clinicopathologic features of this metastasis are unclear.

METHODS

A clinicopathologic review of 16 patients with metastatic adenocarcinoma to the uterine cervix from gastric cancer was performed.

RESULTS

The ages of the patients ranged from 29 to 57 years, and 81.3% of the patients were premenopausal. Nine of the patients had undergone gastrectomy previously. In 11 patients the histologic type of the gastric cancer was poorly differentiated adenocarcinoma and, in 5 patients, signet ring cell carcinoma. The cervical metastasis was diagnosed 11-121 months (mean, 57.5 months) after the diagnosis of the gastric cancer in 10 of the patients. In six patients, the cervical metastasis was discovered synchronously or before the diagnosis of the gastric cancer. The colposcopic findings were normal in 57.1%, but 56.3% had abnormal cervical smears. In all patients, tumor cells were present in the dilated lymphatics of the cervix. Metastases to the uterine body and bilateral ovaries were common, and half of the patients had metastases to the paraaortic lymph nodes. Extirpation of the cervix was performed in six patients. The prognosis was poor, regardless of the treatment method.

CONCLUSIONS

The route of metastasis to the cervix is surmised to be retrograde lymphatic, and this extension is often slow. Periodic gynecologic examinations should be performed indefinitely for premenopausal female patients with advanced gastric cancer.

Endometrial carcinoma in women aged 40 years or younger: a Japanese experience

We report on the clinical and pathologic findings in 17 cases of endometrial carcinoma in Japanese women aged 40 years or younger. Age of the patients ranged from 16 to 40 years, with a median of 35 years. Nine of 17 tumors (52.9%) were stage I or II (FIGO 1988) but 8 (47.1%) were stage III. Four of the 8 patients with stage III disease had pelvic lymph node metastases and one also had para-aortic lymph node metastasis. One patient had metastasis to the ovary and peritoneal cytology was positive in 4 patients. Histologically, 13 of these 17 patients had endometrioid adenocarcinoma, 3 had adenoacanthoma and 1 had an undifferentiated carcinoma. Ten were well differentiated tumors (G1), 3 were moderately differentiated tumors (G2), and 4 were poorly differentiated tumors (G3). Nine of 17 (52.9%) showed deep myometrial invasion (more than a half of the myometrium) and 5 of 17 (29.4%) demonstrated lymphatic/vascular space invasion. Pelvic and para-aortic lymph node metastases were seen in 4 of 15 (26.7%) and 1 of 15 (6.7%), respectively. Two of these 17 patients died of disease in a relatively short follow-up period. In our experience there is no difference in the survival rates between patients aged 40 years or younger and those over 40 years.

Skin metastasis from carcinoma of the uterine cervix

Of 1190 patients with carcinoma of the uterine cervix, 15 (1.3%) developed skin metastases. The incidence of skin metastasis was 0.8% in stage I, 1.2% in stage II, 1.2% in stage III, and 4.8% in stage IV. The incidence of skin metastasis seemed to be higher in patients with adenocarcinoma and undifferentiated carcinoma than in patients with squamous cell carcinoma. The interval between the diagnoses of cervical cancer and skin metastasis ranged from 0 to 69 months, with a mean of 16.9 months. The most common sites of skin lesions were the abdominal wall and vulva, followed by the anterior chest wall. Skin lesions presented as nodules in 86.7% (13/15), and 66.7% of the patients had multiple lesions. Skin metastasis was detected as the initial metastatic lesion in 9 patients. However, only 4 patients had neither local recurrence nor other distant metastasis at the time of diagnosis of skin metastasis. The prognosis was grave, but 3 patients survived more than 12 months after the diagnosis of skin metastasis. The main treatment for these patients was extirpation of the skin lesion followed by radiotherapy.

Malignant mixed Müllerian tumor of the fallopian tube: report of two cases and review of literature

Malignant mixed Müllerian tumors are usually found in the endometrium, vagina, cervix, and ovary. It is extremely rare for this tumor to arise in the fallopian tube, and to date only 37 tubal cases have been reported. We recently experienced 2 such cases. The clinical features, pathologic findings, diagnosis, therapy, and outcome of these 39 cases were reviewed. The clinical features and diagnosis were similar to those of primary carcinoma of the fallopian tube. Correct preoperative diagnosis was difficult. Histologically, 18 patients had homologous elements and 21 had heterologous elements in the sarcomatous components. The most common type of heterologous element was cartilage, followed by striated muscle and bone. The clinical stage (FIGO staging of ovarian carcinoma) was stage I in 15 cases, stage II in 11 cases, stage III in 8 cases, stage IV in 3 cases, and unknown in 2 cases. In all the patients except 1, the tumor was surgically removed. Postoperatively, radiotherapy was given to 9 patients, chemotherapy to 9 patients, and both to 2 patients. Sixteen patients died of the disease, after a mean period of 16.1 months. Of the 15 stage I patients, 10 survived more than 12 months. The most important prognostic factor was spread of the tumor at diagnosis.

Fine-needle aspiration cytology in patients with gynecologic malignancies

Four hundred five fine-needle aspiration (FNA) cytologies were obtained from 352 sites in 287 patients with gynecologic malignancies. The majority of specimens were aspirated for recurrent or metastatic disease. The most common clinical diagnosis was cervical carcinoma (128 cases) followed by ovarian carcinoma (80 cases) and others (79 cases). The sites of FNA were lymph node (134 cases), retroperitoneal lymphocyst (57 cases), pelvic mass (52 cases), subcutaneous mass (34 cases), and others (75 cases). Of 335 sites excluding inadequate specimens, 162 (48.4%) revealed malignant cells. There was no difference in the accuracy of FNA between diseases in the superficial sites and those in the deep sites. However, the sensitivity for local recurrent diseases was lower than that for primary or metastatic diseases (86.4% vs 100.0%). The overall accuracy of FNA cytology was 95.2%, and it was satisfactory for the diagnosis of gynecologic malignant diseases. FNA should be repeated if the initial FNA specimen is inadequate for diagnosis. When distinct malignant cells are observed in FNA cytology, a biopsy may be omitted.

Cytologic diagnosis of primary adenocarcinoma of Bartholin's gland. A case report

The cytologic and histologic findings in an extremely rare case of adenocarcinoma of Bartholin's gland are described. The tumor cells in scraping and fine needle aspiration smears were in clusters. The nuclei were oval to oblong, and some cells had a peripherally displaced nucleus. The chromatinic material was slightly increased, and some nuclei had prominent nucleoli. The cytoplasm was basophilic and abundant. Microcalcifications and psammoma bodies were numerous. The tentative diagnosis was primary adenocarcinoma of Bartholin's gland, based on the cytologic findings and location of the tumor. Similar findings were noted in the biopsy and surgical specimens.

Alveolar rhabdomyosarcoma of the vulva. Report of two cases

The cytologic and histologic findings in two cases of the extremely rare alveolar rhabdomyosarcoma of the vulva are reported. The tumor cells in fine needle aspiration smears from one case and tumor imprints from both cases were isolated or were in sheets or reticular patterns. The nuclei were round to oval; only a few cells were multinucleated. The chromatinic material was increased in amount and finely granular. Many mitotic figures were observed. The cytoplasm was scanty in general, but some cells had abundant cytoplasm; cross striations were not recognized. The tumor cells were positive with immunocytochemical stains for desmin, vimentin and myoglobin. Similar findings were observed in biopsy and surgical specimens.

Clear cell carcinoma of the ovary: a clinicopathologic analysis of 34 cases

The clinical and pathologic aspects of 34 cases of pure clear cell carcinoma of the ovary are discussed. These tumors represented 12.1% (34/280) of all ovarian cancers. The ages of the patients ranged from 34 to 78 years (mean 51.6 years) and 59% were postmenopausal. The clinical stages (FIGO) of these patients were as follows; I 22, II 5, III 6, and IV 1. Thirty-nine percent of the patients were nulligravidas. The diameters of the tumor varied from 6 to 31 cm (mean 16 cm), and 47% of the patients had endometriosis. Thirteen tumors were directly connected with endometriosis and this suggests that some ovarian clear cell carcinoma arose from the epithelium of an endometriotic cyst. Three architectural patterns (solid, papillary, and tubulocystic) were recognized. Forty-seven percent of the tumors were predominantly papillary and 24% contained mixtures of these three patterns. Four cell types such as clear, hobnail, eosinophilic, and flattened were also seen. Thirty-eight percent of the tumors had psammoma bodies. Histological patterns and cell types were not prognostic factors, and the stage at presentation was the most important prognostic factor. The 5-year survival rate was 54% (7/13) which was better than that in patients with serous adenocarcinoma of the ovary. The estimated survivals in patients with clear cell carcinoma however, were worse than those in patients with serous adenocarcinoma when compared stage for stage.

Malignant hemangiopericytoma of the omentum presenting as an ovarian tumor

Malignant hemangiopericytomas are usually found in the musculature of the extremities, the retroperitoneum, and the pelvis. Malignant hemangiopericytoma arising in the omentum is extremely rare. We recently experienced such a case, in which a malignant ovarian tumor was suspected preoperatively on the basis of the sonogram, CT scan, magnetic resonance image, and increased CA-125 value. Microscopically, the tumor showed many mitoses, increased cellularity, and cytologic atypia. The patient was treated with CAP combination therapy following resection of the tumor; however, an intraperitoneal recurrence probably due to implantation was recognized 11 months later.

Squamous cell carcinoma arising in a cystic teratoma presenting as a vulvar mass

A case of squamous cell carcinoma arising in a cystic teratoma presenting as a vulvar mass is reported. This appears to be the first report of such a case.

[Pseudomyxoma peritonei with myxoglobulosis--a case report and the pathogenesis of the myxoglobules]

A case of pseudomyxoma peritonei with myxoglobulosis is described. The myxoglobulosis was characterized by globules consisting of firm opaque whitish-gray nodule that measured up to 1.0 cm in diameter. Many globules in the abdominal cavity were filled with mucinous material. Electron microscopically, these globules were found to be covered by mesothelial cells with microvilli and contained mucous material, fibrous tissue, and a few myofibroblasts.

Pulmonary metastasis from carcinoma of the uterine cervix

Of 817 patients with carcinoma of the uterine cervix that were treated and followed-up, 50 (6.1%) developed pulmonary metastases. The incidence of pulmonary metastasis was 3.2% in stage I, 5.0% in stage II, 9.4% in stage III, and 20.9% in stage IV disease. The incidence of pulmonary metastasis in patients with adenocarcinoma and undifferentiated carcinoma was higher. Of the patients in whom lung metastases were detected, 41.7% had no symptoms; 96% was diagnosed within 2 years from the initiation of treatment. All patients had abnormal shadows in chest X rays. We recommend that chest X rays be obtained every 2 months within the 8 months after treatment and every 6 months thereafter. Eighty-one percent of the patients had local recurrence or other distant metastatic lesions. The main treatment for these patients was chemotherapy, and CAP was effective for the patients with adenocarcinoma. Surgical resection of the pulmonary lesion may be an effective treatment for the patients who have no lesions in other sites.

[An evaluation of scalene lymph node metastasis in patients with gynecologic malignancies]

From 1981, through 1985, 90 patients with primary or recurrent gynecologic malignancies underwent a scalene lymph nodes (SLN) biopsy. Pelvic lymph nodes (PN) and paraaortic lymph nodes (PAN) also were examined for metastasis with CT, lymphography, and palpation or were biopsied after a laparotomy. Twenty-three of these 90 patients (25.6%) were found to have positive SLN. In 5 of these 23 (21.7%), their SLN had not been palpable on physical examination. All signs of PN, PAN and SLN were examined in 42 patients. Twenty-one of these 42 (50%) had positive PN, 14 (66.7%) had positive PAN, and 4 (28.6%) had positive SLN. Seven patients with negative PAN had no SLN metastasis. Of twenty-one patients with negative PN, 2 had positive PAN and none had an SLN metastasis. Thus, it has been concluded that an evaluation of SLN is important for the management of a gynecologic malignancy in patients with positive PAN.

Bone metastasis from cervix cancer

Among 713 patients followed after treatment for cancer of the uterine cervix, 48 (6.6%) had a metastasis to the bone. The rates of metastasis in each of the four clinical stages were 11/273 (4.0%) in stage I, 16/243 (6.6%) in stage II, 13/162 (8.0%) in stage III, and 8/35 (22.9%) in stage IV, respectively. The most frequent site of metastasis was the vertebral column, particularly the lumbar spine (23 cases, 48%) followed by the pelvic bones. Pulmonary metastasis also frequently occurred. For 32 (67%), lesions of the bone were detected within 1 year after completion of the initial treatment, and 36 (75%) died within 1 year after detection of the metastasis. Those patients who survived over 2 years were those for whom the lesions of the bone had been treated by radiotherapy followed by chemotherapy.

Peritoneal cytology in patients with endometrial carcinoma

Peritoneal cytology was obtained in 61 patients with carcinoma of the endometrium at the time of laparotomy. The incidence of positive peritoneal cytology was 23.0%. It increased as the clinical stage advanced. The incidence of positive peritoneal cytology in patients with well-differentiated carcinoma or superficial myometrial invasion was low. The rate of paraaortic lymph node metastasis was higher in patients with positive peritoneal cytology than in patients with negative peritoneal cytology. However, this trend was not recognized in pelvic lymph node metastasis. In the positive peritoneal cytology group, 64.3% had disease outside of the uterus, while in the negative group only 12.8%. The 2-year survival rate in patients with positive peritoneal cytology was 57.1% and it was 86.4% in patients with negative peritoneal cytology. It is concluded that the findings of positive peritoneal cytology is an important prognostic factor and routine peritoneal cytology should be obtained at the time of laparotomy in patients with carcinoma of the endometrium.

[Superior vena cava syndrome associated with carcinoma of the uterine cervix--report of two cases]

Superior vena cava syndrome (SVCS) is a very rare complication in patients with a gynecologic malignancy. Only 4 cases have been reported in the English literature thus far and, to our knowledge, no such case has been reported in the Japanese literature. We have encountered two cases of SVCS in patients with cervical cancer. In case 1, the SVCS developed secondarily to a metastasis of the cervical cancer to the lungs and mediastinum. In case 2, the cause of the SVCS had been presumed to be due to metastatic cervical cancer, however on autopsy, it turned out to be due to a coexistent malignant lymphoma.

Peritoneal cytology in patients with carcinoma of the uterine cervix

Peritoneal cytology was obtained in 125 patients with carcinoma of the uterine cervix at the time of laparotomy. The incidence of positive peritoneal cytology was 11.2%. Positive peritoneal cytology was found four times more frequently in adenocarcinoma than in squamous cell carcinoma. The incidence of pelvic lymph node and paraaortic lymph node metastasis was higher in patients with positive peritoneal cytology than in patients with negative peritoneal cytology. The 2-year survival rate in patients with positive peritoneal cytology was 30.0% and it was 82.7% in patients with negative peritoneal cytology. Some patients (28.6%) with positive peritoneal cytology developed peritonitis carcinomatosa. It was concluded that it is very important to obtain peritoneal cytology routinely at the time of laparotomy in patients with carcinoma of the cervix.

[Gliomatosis peritonei]

Gliomatosis peritonei, the miliary implants of mature glial tissues on the peritoneum or omentum, is a rare complication of solid ovarian teratoma. Our case is reported and 38 previously reported cases are reviewed. The grade of the primary tumors varied from grade 0 to grade 3. Only five cases were composed entirely of mature tissues. Five of the 39 patients died. Despite of varied therapy, the rest of the patients were alive from 3 months to 38 years later. Inspite of intraperitoneal implants, the prognosis in patients with these tumors is good, irrespective of the mode of therapy. On the basis of this study, we recommended a conservative therapy for the primary tumor and therapy for the implants is not required.

[Treatment of epithelial ovarian carcinoma with cisplatin and adriamycin: analysis of factors influencing prognosis in advanced cases]

Thirty previously untreated patients with epithelial ovarian carcinoma were treated with cisplatin and adriamycin (PA). Of eight evaluable patients, six were responders (two CRs and four PRs). The three-year survival rates were 83% for stage I, 67% for stage II, 50% for stage III, and none for stage IV. Toxicities included moderate myelo-suppression, mild nephrotoxicity, alopecia, and severe vomiting in almost all patients. Patients with residual lesions smaller than 2 cm had excellent prognosis when PA was given for more than five courses. Patients with residual lesions larger than 2 cm, however, had poor prognosis irrespective of the number of courses. No specific relation between histological grade and prognosis could be found. From the present data, aggressive cytoreductive surgery followed by PA therapy repeated more than five times is recommended for achieving a good outcome in the treatment of epithelial ovarian carcinoma.

Modified VAB-3 combination chemotherapy of advanced and recurrent endodermal sinus tumors of the ovary

Three patients with advanced and recurrent endodermal sinus tumor (EST) of the ovary were treated with modified vinblastine, actinomycin-D, and bleomycin (VAB-3) regimen. Serum alpha-fetoprotein (AFP) levels were monitored for all patients during and after therapy. In all patients a clinical response was achieved. In one stage IV patient with huge multiple liver metastases complete response was attained and she is free of disease following secondlook larparotomy. In other two patients, one stage IV and another recurrent, with large liver metastases, partial responses were achieved with normalization of serum AFP. Serum AFP monitoring is valuable for the management of EST, but a negative AFP titer does not eliminate the possibility of persistent or recurrent disease. The VAB-3 combination, previously found effective in metastatic nonseminomatous testicular cancer, is also effective in advanced and recurrent EST of the ovary.

Endolymphatic stromal myosis: a case with positive estrogen and progesterone receptors and good response to progestins

This report describes a case of recurrent and metastatic endolymphatic stromal myosis (ESM), which showed good response to progestin therapy. Metastatic lung nodules regressed after medroxyprogesterone acetate (MPA) treatment, recurred while MPA was stopped, and disappeared again when MPA was restarted. The levels of estrogen and progesterone receptors measured in the resected tumor amounted to 79.5 and 310 fmole/mg protein, respectively. Sex steroid hormone dependency of ESM was reviewed in the literature.

[Modified VAB-3 combination chemotherapy of stage IV endodermal sinus tumor of the ovary]

A case of pure endodermal sinus tumor (EST) of the ovary with huge multiple liver metastases was treated with modified VAB-3 protocol. Serum alpha-fetoprotein (AFP) before treatment was 137,775 ng/ml. A complete clinical response was achieved with rapid shrinkage of liver metastases and normalization of serum AFP. Second-look laparotomy preformed 17 months after the start of chemotherapy revealed no evidence of disease. VAB-3 combination chemotherapy, which was proved to be very effective in the treatment of metastatic testicular cancer, also seems to be effective in the treatment of advanced EST of the ovary. This is believed to be the first detailed report of the successful management of advanced EST of the ovary.

Cyclophosphamide-induced interstitial pneumonitis in a patient with ovarian carcinoma

A 40-year-old female with ovarian cancer being treated with daily oral cyclophosphamide developed fatal interstitial pneumonitis. Autopsy did not show any evidence of ovarian cancer. The review of the literature revealed eight reported cases of cyclophosphamide-induced interstitial pneumonitis and fibrosis. The case is reported to alert gynecologists to this rare but lethal complication of cyclophosphamide.