Teleoncology for gynecologic cancers

Teleoncology describes cancer care provided remotely to improve access to care in rural or underserved areas. In the United States, 14.8 million women live more than 50 miles away from the closest gynecologic oncologist; 4.3 million women live more than 100 miles distant. Teleoncology may therefore partially relieve the geographic barriers to high-quality gynecologic cancer care these women experience. Little has been published on the feasibility of remote provision of high-quality care for gynecologic cancers, perhaps owing to the particular difficulties inherent in remote management of patients who may require both medical and surgical intervention. In this article, we review the data supporting the use of telemedicine in the treatment of cancer patients with a specific focus on applicability to management of gynecologic malignancies. We further add our group's experience with the treatment of rural, underserved gynecologic cancer patients. We believe that development of teleoncologic systems is critical to ensure that all women have access to high-quality gynecologic cancer care, regardless of where they reside.

Society of Gynecologic Oncology recommendations for the prevention of ovarian cancer

Mortality from ovarian cancer may be dramatically reduced with the implementation of attainable prevention strategies. The new understanding of the cells of origin and the molecular etiology of ovarian cancer warrants a strong recommendation to the public and health care providers. This document discusses potential prevention strategies, which include 1) oral contraceptive use, 2) tubal sterilization, 3) risk-reducing salpingo-oophorectomy in women at high hereditary risk of breast and ovarian cancer, 4) genetic counseling and testing for women with ovarian cancer and other high-risk families, and 5) salpingectomy after childbearing is complete (at the time of elective pelvic surgeries, at the time of hysterectomy, and as an alternative to tubal ligation). The Society of Gynecologic Oncology has determined that recent scientific breakthroughs warrant a new summary of the progress toward the prevention of ovarian cancer. This review is intended to emphasize the importance of the fallopian tubes as a potential source of high-grade serous cancer in women with and without known genetic mutations in addition to the use of oral contraceptive pills to reduce the risk of ovarian cancer.

Use of diphenylamine in the detection of apoptosis

The diphenylamine assay is a very useful tool in measuring apoptosis by determining the percentage of fragmentation of known amounts of DNA into oligosomal-sized fragments. Another advantage of the diphenylamine assay is that apoptotic DNA fragmentation can be analyzed in both adherent and shed cells following treatment or experimentation. Data obtained from the experiment are expressed as a percentage relative to uninduced or untreated controls. This assay was first described by Dische (1,2) in the 1930s and later modified by Burton (3) in the mid-1950s. These modifications have resulted in an enhanced sensitivity of up to five times by adding sulfuric acid and acetaldehyde, and by allowing the colorimetric reaction to develop overnight at room temperature. These changes have also resulted in a reduction of the interference from other substances that were an initial drawback with the originally described method, further enhancing the sensitivity of the assay. The diphenylamine reaction takes advantage of the bonds between purines and deoxyribose, which are very labile. Once these bonds are broken, inorganic phosphates are liberated from the DNA and provide the substrate, which is measured by the reaction. The overall preparation time is approximately 3 h for 30 samples with incubation occurring overnight for 12 to 16 h. Reading of the results takes approximately 1 min per sample. This assay has been used to detect apoptotic fragmentation by others, and more recently by our group to evaluate cisplatin and Taxol induced fragmentation in ovarian carcinoma cell lines (4).

Ovarian cancer patient surveillance after curative-intent initial treatment

OBJECTIVE

Patient surveillance after potentially curative treatment of ovarian carcinoma has important clinical and financial implications for patients and society. The optimal intensity of surveillance for these patients is unknown. We aimed to document the current follow-up practice patterns of gynecologic oncologists.

METHODS

We created four idealized vignettes describing patients with stages I-III ovarian cancer. We mailed a custom-designed survey instrument based on the vignettes to the members of the Society of Gynecologic Oncologists (SGO). SGO members were asked, via this instrument, how often they requested 11 discrete follow-up evaluations for their patients for the first 10 postoperative years after treatment with curative intent.

RESULTS

We received 283 evaluable responses (30%) from the 943 SGO members and candidate members. The most frequently performed items for each year were office visit, pelvic examination, and serum CA-125 level. Imaging studies such as chest X-ray, abdominal-pelvic CT, chest CT, abdominal-pelvic MRI, and transvaginal ultrasound were rarely recommended. There was marked variation in the frequency of use of most tests. There was a decrease in the frequency of testing over time for all modalities.

CONCLUSION

This dataset provides detailed documentation of the self-reported surveillance practices of highly credentialed experts who manage patients with ovarian cancer in the 21st century. The optimal follow-up strategy remains unknown and controversial. Our survey showed marked variation in surveillance intensity. Identifying the sources of this variation warrants further research.

The impact of liquid-based cytology in decreasing the incidence of cervical cancer

Major advances in screening have lowered the death rate from cervical cancer in the United States. One of the first major advances in cervical cancer screening was the Papanicolaou (Pap) test. The second major advance was liquid-based cytology (LBC). This review presents a wide range of data, discusses the strengths and weaknesses of the available information regarding Pap technologies, and reviews the meta-analyses, which have examined the differences in clinical performance. The review concludes with information on new and future developments to further decrease cervical cancer deaths.

ATR mutation in endometrioid endometrial cancer is associated with poor clinical outcomes

PURPOSE Mutations in the DNA damage response gene ATR (exon 10 A10 mononucleotide repeat) have been previously described in endometrial and other cancers with defective DNA mismatch repair. In vitro studies showed that endometrial cancer cell lines with A10 repeat tract truncating mutations have a failure in the ATR-dependent DNA damage response. Cell lines carrying A10 mutations fail to trigger Chk1 activation in response to ionizing radiation and topoisomerase inhibitors. We sought to determine the frequency and clinicopathologic significance of ATR mutations in patients with endometrioid endometrial cancer. PATIENTS AND METHODS The ATR exon 10 A10 repeat was analyzed by direct sequencing in 141 tumors with microsatellite instability (MSI-positive) and 107 microsatellite stable (MSI-negative) tumors. The relationships between mutations and clinicopathologic variables, including overall and disease-free survival, were assessed using contingency table tests and Cox proportional hazard models. Results ATR mutations were identified in 12 cases (4.8%; three cases with insertions and nine cases with deletions). Mutations occurred exclusively in MSI-positive tumors (P = .02), with an overall mutation rate of 8.5%. Mutation was not associated with age, race, surgical stage, International Federation of Gynecology and Obstetrics grade, or adjuvant treatment. Multivariate analyses revealed a significant association with reduced overall survival (hazard ratio [HR] = 3.88; 95% CI, 1.64 to 9.18; P = .002) and disease-free survival (HR = 4.29; 95% CI, 1.48 to 12.45; P = .007). CONCLUSION Truncating ATR mutations in endometrial cancers are associated with biologic aggressiveness as evidenced by reduced disease-free and overall survival. Knowledge of ATR mutation status may hold promise for individualized treatment and targeted therapies in patients with endometrial cancer.

Phase II evaluation of topotecan and navelbine in patients with recurrent ovarian, fallopian tube or primary peritoneal cancer

OBJECTIVE

To assess the efficacy and toxicity profile in patients with recurrent ovarian or primary peritoneal cancer treated with topotecan at 2.5 mg/m(2) days 1 and 8 plus vinorelbine at 25 mg/m(2) days 1 and 8 every 3 weeks.

MATERIALS AND METHODS

Eligibility criteria included patients with recurrent primary peritoneal or epithelial ovarian cancer with either platinum-resistant or platinum-sensitive disease. Patients were required to have a performance status of <or=2 and normal hepatic and renal function. Response to therapy and toxicity were assessed using standard criteria. Chi square and Student's t-tests were used as appropriate. Survival was assessed with Kaplan-Meier method.

RESULTS

All 40 patients enrolled were assessable for response. The median age of the patients was 58 years (range 30-82). Median treatment-free interval was 4.0 months. A total of 216 cycles of chemotherapy were administered with a median of 5.0 cycles per patient. Overall median TTP with this treatment regimen was 19 weeks (range 2-136 weeks). The response rate was 30% overall, and the response for platinum-sensitive and platinum-resistant patients was 44% (95% CI:22-69%) and 18% (95% CI:5-40%) respectively. Median progression-free survival was 3.0 months (range 1-9 months). Median overall survival was 16.4 months (range 1.5-51.7 months). Assessment of toxicity by patient showed 58% demonstrating grade 3/4 neutropenia with the vast majority being uncomplicated. No severe non-hematological toxicity was observed.

CONCLUSION

Administration of topotecan and navelbine is feasible with demonstrable activity and tolerable toxicity. This regimen may be considered especially in platinum-sensitive patients if a non-platinum based doublet is desired.

A multi-institutional evaluation of factors predictive of toxicity and efficacy of bevacizumab for recurrent ovarian cancer

While bevacizumab has shown activity in recurrent ovarian cancer, a higher than expected incidence of bowel perforations has been reported in recent trials. We sought to determine factors associated with toxicity and tumor response in patients with relapsed ovarian cancer treated with bevacizumab. A retrospective review of patients with recurrent ovarian cancer treated with bevacizumab was undertaken. Response was determined radiographically and through CA125 measurements. Statistical analysis to determine factors associated with toxicity and response was performed. Sixty-two eligible patients were identified. The cohort had received a median of 5 prior chemotherapy regimens. Single-agent bevacizumab was administered to 12 (19%), while 50 (81%) received the drug in combination with a cytotoxic agent. Grade 3–5 toxicities occurred in 15 (24%) patients, including grade 3–4 hypertension in 4 (7%), gastrointestinal perforations in 7%, and chylous ascites in 5%. Development of chylous ascites and gastrointestinal perforations appeared to correlate with tumor response. The overall response rate was 36% (4 complete response, 17 partial response), with stable disease in 40%. A higher objective response rate was seen in the bevacizumab combination group compared to single-agent treatment (43% vs 10%) (P = 0.07). However, 29 grade 3–5 toxic episodes were seen in the combination group vs only 1 in the single-agent bevacizumab cohort (P = 0.071). We conclude that bevacizumab demonstrates promising activity in recurrent ovarian cancer. The addition of a cytotoxic agent to bevacizumab improved response rates at the cost of increased toxicity. Gastrointestinal perforations occurred in 7%. The perforations occurred in heavily pretreated patients who were responding to therapy

Prognostic factors associated with response in platinum retreatment of platinum-resistant ovarian cancer

The goal of this study was to determine the factors associated with response to platinum retreatment in patients with platinum-resistant ovarian cancer. A review of patients with epithelial ovarian cancer retreated with cisplatin or carboplatin between 2002 and 2004 was performed. The platinum-free interval (PFI) and treatment-free interval (TFI) were determined for each patient. Response was based on serial CA125 levels using a modification of the Rustin criteria. Patients with clinical benefit ([CB] those who attained at least stable disease) were compared to patients with disease progression (PD). An analysis was performed to determine factors associated with CB in platinum-resistant patients retreated with platinum. Of 48 patients identified, 37 were evaluable included in this analysis. CB was observed in 27 (73%) while disease progression was noted in 10 (27%) women. The PFI was longer in those women who achieved CB (12.3 vs 6.9 months; P = 0.02). The TFI was 7.1 months for patients benefited from platinum retreatment vs 3.5 months for those with disease progression (P = 0.06). There was no statistically significant difference in the number of cytotoxic agents between the time of platinum retreatment and the prior platinum regimen (2 vs 1.5 months; P = 0.61). A prolonged PFI was associated with an improved chance of achieving CB with platinum retreatment. There was no association between the response to platinum retreatment and the number of intervening cytotoxic agents utilized. Further prospective study is warranted to define the optimal timing of platinum retreatment.

CD83 gene polymorphisms increase susceptibility to human invasive cervical cancer

We previously mapped a nonrandom frequent loss of heterozygosity (LOH) region in cervical cancers to 1 Mb of 6p23. Here, we describe the identification of a novel cervical cancer susceptibility gene, CD83. The gene was identified by several complementary approaches, including a family-based association study, comparison of transcript expression in normal and cancerous tissue, and genomic sequencing of candidate. CD83 encodes an inducible glycoprotein in the immunoglobulin superfamily and is a marker for mature dendritic cells. The association study that includes 377 family trios showed that five single nucleotide polymorphisms (SNP) within 8 kb of its 3'-end showed significant allelic association that was strengthened in a subgroup of women with invasive cancers infected by high-risk human papillomavirus type 16 and 18 (rs9296925, P = 0.0193; rs853360, P = 0.0035; rs9230, P = 0.0011; rs9370729, P = 0.0012; rs750749, P = 0.0133). Investigation of CD83 uncovered three alternative transcripts in cervical tissue and cell lines, with variant 3 (lacking exons 3 and 4) being more frequent in cervical cancer than in normal cervical epithelium (P = 0.0181). Genomic sequencing on 36 paired normal and cervical tumors revealed several somatic mutations and novel SNPs in the promoter, exons, and introns of CD83. LOH was confirmed in >90% of cervical cancer specimens. Immunofluorescence colocalized CD83 protein to the Golgi apparatus and cell membrane of cervical cancer cell lines. None of seven nearby genes was differentially expressed in cervical cancer. The importance of CD83 in epithelial versus dendritic cells needs to be determined, as does its role in promoting cervical cancer.

Bevacizumab therapy in patients with recurrent uterine neoplasms

BACKGROUND

Angiogenesis plays an important role in endometrial carcinogenesis. We reviewed our experience with the anti-VEGF monoclonal antibody bevacizumab for the treatment of recurrent uterine neoplasms.

PATIENTS AND METHODS

A retrospective analysis of women with recurrent uterine neoplasms treated with bevacizumab was performed.

RESULTS

A total of 11 patients were identified, 9 with epithelial endometrial carcinomas and 2 with leiomyosarcomas. All patients had multi-site disease and were heavily pretreated with a median of 3 prior chemotherapy regimens. All received bevacizumab combination therapy which was well-tolerated. Two patients had partial responses, 3 had stable disease, while 5 patients progressed. One subject was not assessable for response. The median progression-free interval was 5.4 months for the entire cohort and 8.7 months for those who achieved clinical benefit (PR or SD).

CONCLUSION

Bevacizumab was well-tolerated and displayed promising anti-neoplastic activity in patients with endometrial cancer and uterine leiomyosarcoma.

Novel cytotoxic agents from an unexpected source: bile acids and ovarian tumor apoptosis

OBJECTIVE

Unique biologic activities have been identified for the 4 different bile acids: cholic acid (CA, chenodeoxycholic acid (CDCA), deoxycholic acid (DCA), and ursodeoxycholic acid (UDCA). The aim of this study was to examine and compare the effects of these 4 bile acids on the human ovarian cancer cell lines A2780 and A2780-CP-R(cisplatin-resistant) and to evaluate mechanisms of action.

METHODS

Antiproliferative effects were determined by the cytotoxic MTT assay. Cells undergoing apoptosis were identified by morphologic analysis of cells stained using Diff-Quick and nuclear staining with DAPI and by quantitative nucleosome ELISA assay. Cells were lysed in buffer after 24 h of exposure to three different concentrations of bile acid (50 mM, 200 mM, and 400 mM) and protein concentrations were determined. Cell extracts containing 25 mg of protein were assayed for protein kinase C (PKC) enzyme activity.

RESULTS

None of the bile acids stimulated proliferation of ovarian cancer cells. CA and UDCA had only minimal cytotoxic effect even at maximum concentrations. In contrast, DCA and CDCA administration resulted in statistically significant dose-dependent cytotoxicity in both platinum sensitive and platinum-resistant cell lines (p<0.05). Cells incubated with DCA and CDCA exhibited morphologic features characteristic of apoptosis. The quantitative nucleosome ELISA assay demonstrated over 10 times increased nucleosome levels after cells were treated for 24 h by DCA and CDCA at 200 mM and 400 mM as compared to CA or UDCA treatment and to untreated controls (p<0.01). All 4 bile acids reduced PKC activity at concentrations of 200 and 400 mM (p<0.01).

CONCLUSIONS

CDCA and DCA have significant cytotoxic activity in ovarian cancer cells via induction of apoptosis. The mechanism of apoptosis appears to be mediated by alternative kinases distinct from PKC. CDCA and DCA may have clinical utility in the treatment of ovarian cancer pending in vivo confirmation of activity especially in cisplatin-resistant disease.

Effect of a T0 radical hysterectomy specimen on survival for early stage cervical cancer

OBJECTIVE

: Radical hysterectomy with regional lymphadenectomy is the surgical procedure of choice for stage IA-IIA cervical carcinoma. The goal of this study was to evaluate the outcome of patients with no residual tumor (T0) in their hysterectomy specimens.

METHODS

: An analysis of all women who underwent type II or III hysterectomy for invasive cervical cancer from 1989 to 2005 was performed. The pathologic data and clinical outcome of each patient was documented. T0 subjects were compared to the remainder of the cohort. Survival was evaluated with the Kaplan-Meier method.

RESULTS

: A total of 594 patients were identified. No residual tumor was noted in the hysterectomy specimens of 171 (29%). T0 patients had earlier stage tumors than the controls (IA 32%, IB 68%) (p<0.0001). Lymphadenectomy was performed in 89% of the T0 subjects. No T0 patients had lymphatic or parametrial disease. The median node yield was similar between the T0 group and those with residual tumors (24 vs. 25) (p=0.34). Adjuvant therapy was not administered to any of the T0 subjects. There were no recurrences and no cancer-related deaths in the T0 patients. Kaplan-Meier analysis revealed an improved disease free (p<0.0001) and overall survival (p<0.0001) for the T0 subjects compared to women with residual tumors. The results were similar when the analysis was restricted to stage IB1 patients (p=0.0004 and 0.002).

CONCLUSIONS

: A T0 radical hysterectomy specimen indicates a curative therapy. This subgroup of patients has a favorable prognosis with minimal risk of recurrence. Patients with T0 tumors may be candidates for less intensive, abbreviated follow-up.

Microsatellite Instability and Epigenetic Inactivation of MLH1 and Outcome of Patients With Endometrial Carcinomas of the Endometrioid Type

Purpose

Most studies of microsatellite instability (MSI) and outcomes in endometrial cancer patients have included varied histologic subtypes. Nonetheless, MSI occurs almost exclusively in endometrioid tumors. The impact of MSI on outcomes in patients with endometrial cancer is controversial. We sought to determine whether MSI and MLH1 methylation are associated with clinicopathologic variables and survival outcomes in a large series of patients with endometrial carcinomas of the endometrioid type.

Patients and Methods

Tumor samples, blood, and clinicopathologic data were prospectively collected and analyzed for 446 patients with endometrioid carcinomas. MSI was determined using five National Cancer Institute (NCI) consensus panel markers, and the methylation status of the MLH1 promoter was determined by combined bisulfite restriction analysis (COBRA). Associations with clinicopathologic variables and survival outcomes were evaluated.

Results

MSI was identified in 147 cases (33%). MSI was associated with higher International Federation of Gynecology and Obstetrics (FIGO) grade (P < .0001). MSI+ tumors without MLH1 methylation were associated with younger age (P < .001). MSI was not associated with overall survival (OS; hazard ratio [HR], 1.011; 95% CI, 0.688 to 1.484; P = .96) or disease-free survival (DFS; HR 0.951; 95% CI, 0.554 to 1.635; P = .86). The combined MSI/MLH1 methylation status (treating MSI− as the reference) did not predict OS (MSI+/MLH1-U: HR, 0.62; 95% CI, 0.27 to 1.44; P = .26; MSI+/MLH1-M: HR, 0.95; 95% CI, 0.62 to 1.46; P = .82) or DFS (MSI+/MLH1-U: HR, 0.51; 95% CI, 0.22 to 1.19; P = .12; MSI+/MLH1-M: HR, 0.93; 95% CI, 0.62 to 1.40; P = .72).

Conclusion

MSI is not associated with survival in patients with endometrioid endometrial cancer.

Body mass index: Relationship to clinical, pathologic and features of microsatellite instability in endometrial cancer

OBJECTIVES

There is a well known association between obesity and endometrial cancer. We sought to examine the relationships between body mass index (BMI), as a measure of obesity, and known demographic, clinical, and molecular characteristics of microsatellite instability and MLH1 promoter methylation in a cohort of patients with endometrial cancer.

METHODS

Corpus cancer specimens were prospectively obtained from 473 consecutively enrolled patients between 1992 and 2004. Clinical and pathologic data were extracted from review of the medical record. Microsatellite instability (MSI) was evaluated in all tumors, and methylation of the MLH1 promoter was determined for MSI positive tumors.

RESULTS

The median (SD) age and BMI were 64.8 years (11.9) and 33.5 (9.4), respectively. Histology included 376 endometrioid (79%), 69 serous/clear cell or mixed (15%), and 28 sarcomas (6%). Median BMI was 32.4 for endometrioid, 31.0 for serous/clear cell or mixed, and 27.8 for sarcomas (p=0.14). BMI was negatively associated with age at surgery (p<0.01). The remainder of analyses excluded sarcoma histology. BMI was associated with stage of disease; patients with stage I/II disease had significantly higher BMI than those with stage III/IV disease (32.6 vs. 30.6; p=0.02). In relation to molecular features of endometrial cancer, BMI was significantly different between MSI positive tumors compared to MSI negative tumors (30.3 vs. 32.7; p=0.02). MSI was also significantly different between tumor histology, occurring with a higher frequency in Type I than Type II tumors (p<0.01).

CONCLUSIONS

The majority of endometrial cancer patients are obese. Those with higher BMI are more likely to be younger, present with early stage disease, and have MSI negative tumors.

Comparison of high-dose-rate and low-dose-rate brachytherapy in the treatment of endometrial carcinoma

PURPOSE

To compare the outcomes for endometrial carcinoma patients treated with either high-dose-rate (HDR) or low-dose-rate (LDR) brachytherapy.

METHODS AND MATERIALS

This study included 1,179 patients divided into LDR (1,004) and HDR groups (175). Patients with International Federation of Gynecology and Obstetrics (FIGO) surgical Stages I-III were included. All patients were treated with postoperative irradiation. In the LDR group, the postoperative dose applied to the vaginal cuff was 60-70 Gy surface doses to the vaginal mucosa. The HDR brachytherapy prescription was 6 fractions of 2 Gy each to a depth of 0.5 cm from the surface of the vaginal mucosa. Overall survival, disease-free survival, local control, and complications were endpoints.

RESULTS

For all stages combined, the overall survival, disease-free survival, and local control at 5 years in the LDR group were 70%, 69%, and 81%, respectively. For all stages combined, the overall survival, disease-free survival, and local control at 5 years in the HDR group were 68%, 62%, and 78%, respectively. There were no significant differences in early or late Grade III and IV complications in the HDR or LDR groups.

CONCLUSION

Survival outcomes, pelvic tumor control, and Grade III and IV complications were not significantly different in the LDR brachytherapy group compared with the HDR group.

Utility of parametrectomy for early stage cervical cancer treated with radical hysterectomy

BACKGROUND

Removal of the parametrial soft tissue is recommended for patients with cervical cancer undergoing radical hysterectomy. Parametrectomy results in significant morbidity. The objective of the study was to determine factors predictive of parametrial tumor spread and to define a subset of patients at low risk for parametrial disease.

METHODS

Patients with invasive cervical cancer who underwent radical hysterectomy from 1989-2005 were examined. Analysis was performed to determine factors associated with parametrial tumor spread. Survival estimates were determined using the Kaplan-Meier method.

RESULTS

A total of 594 patients were identified. Parametrial metastases were documented in 64 (10.8%). Factors associated with parametrial disease were: histology, advanced grade, deep cervical invasion, lymphovascular space invasion (LVSI), large tumor size, advanced stage, uterine or vaginal involvement, and pelvic or para-aortic lymph node metastases (P < .0001 for each). Parametrial metastases were associated with increased risk of recurrence and decreased disease-free and overall survivals (P < .0001). A subgroup analysis was performed to identify patients at low risk for parametrial spread. In pelvic node-negative women parametrial disease was noted in 6.0% (30/498) compared with 47.9% (34 of 71) of those with positive pelvic nodes (P < .0001). If further stratified to women with negative nodes, no LVSI, and tumors < 2 cm, the incidence of parametrial disease was only 0.4%.

CONCLUSIONS

Parametrial spread is a strong predictor of recurrence and decreased survival. Parametrial invasion is rare in patients with small tumors, no LVSI, and negative pelvic nodes (no poor prognostic factors). Further study is warranted to determine the feasibility of omitting parametrectomy in these low-risk patients.

Colposcopic accuracy of obstetrics and gynecology residents

OBJECTIVE

The objective of our study was to determine the accuracy of gynecology residents' colposcopic impressions.

METHODS

A retrospective review of colposcopic examinations was performed. Colposcopic impressions were compared to cervical biopsy and the results stratified by level of residency training. kappa Statistics were calculated to determine the strength of correlation between impression and biopsy results.

RESULTS

Agreement within one-step between cervical histology and the colposcopic impression was found in 351 (77%) of the subjects. Histology impression agreement occurred in 92% of the nurse practitioner procedures, 77% of the second year resident (R2) cases, 75% of R3 colposcopies and 73% of the R4 procedures. The association between cervical biopsy and impression was highly significant (P<0.0001). However, the strength of the correlation was only slight (kappa=0.197). The kappa value was highest for the nurse practitioners (0.376, fair correlation) and lowest for the R3 residents (0.110, slight correlation). The positive predictive value for the association of any colposcopically detected abnormality with any histologic abnormality was 64.1%. The overall PPV was highest for the nurse practitioners (79.3%) and lowest for the R2 residents (58.7%).

CONCLUSIONS

While the colposcopic impressions of gynecology residents were accurate, there was little difference in the accuracy of colposcopic assessment based upon the level of resident training.

Outcomes in 24 selected patients with stage IVB cervical cancer and excellent performance status treated with radiotherapy and chemotherapy

PURPOSE

We sought to review outcomes in patients with stage IVB carcinoma of the cervix treated with irradiation in combination with chemotherapy.

MATERIALS AND METHODS

We report outcomes of 24 consecutive patients with good performance status treated from 1998 to 2005. Most of these patients underwent concurrent irradiation with platinum-based chemotherapy. Some patients received subsequent systemic chemotherapy.

RESULTS

All patients underwent external beam radiotherapy; 7 patients (29%) had additional high-dose-rate and 12 (50%) low-dose-rate brachytherapy. Two patients (8%) received an IMRT boost instead of brachytherapy. The mean dose to point A was variable (73.9 +/- 19.2 Gy). Twenty patients (83%) received radio-sensitizing platinum-based chemotherapy, and the remaining had radiotherapy alone. Seven patients (29%) had further combination chemotherapy. Therapy was well tolerated. The overall survival was 44% at 36 months and 22% at 5 years.

CONCLUSION

Patients with stage IVB cervical cancer have mostly been treated with palliative intent. With the advent of concurrent chemoradiation, we have treated many of these cases with aggressive combination therapy. In this series, the use of radiotherapy and multiagent chemotherapy in patients with stage IVB cervical carcinoma and good performance status was well tolerated and resulted in higher survival rates than previously reported.

Bevacizumab combination therapy in heavily pretreated, recurrent cervical cancer

OBJECTIVE

To report the utility of the monoclonal, anti-vascular endothelial growth factor antibody bevacizumab in combination with cytotoxic chemotherapy for women with recurrent cervical cancer.

METHODS

A retrospective analysis of women with recurrent cervical cancer treated with bevacizumab combination therapy was performed.

RESULTS

Six patients were identified. The patients had a median of 3 prior regimens. All of the patients had multisite, metastatic disease. The combination regimen included IV 5-fluorouracil in 5 (83%) patients and capecitabine in one (17%) subject. Treatment was well tolerated. Grade 4 toxicity occurred in one patient who developed neutropenic sepsis. Clinical benefit (CR, PR, or SD) was noted in 67% of the subjects. This included 1 (17%) complete response, 1 (17%) partial response and two (33%) patients with stable disease. The median time to progression for the four women who demonstrated clinical benefit was 4.3 months.

CONCLUSIONS

Combination bevacizumab is well tolerated and displayed encouraging anti-tumor activity in heavily pretreated recurrent cervical cancer.

Increased risk for abnormalities on perioperative colon screening in patients with microsatellite instability–positive endometrial carcinoma

Microsatellite instability (MSI) is a feature of certain hereditary and sporadic endometrial and colon cancers. We set out to determine whether molecular stratification of endometrial cancers based on tumor MSI status could help identify patients at increased risk for abnormalities found on perioperative colon screening. From a prospectively accrued series of 413 patients, medical records were reviewed from 94 patients with MSI positive (MSI+) and 94 patients with MSI negative (MSI−) endometrial cancers, matched by year of diagnosis. We reviewed clinicopathologic data and results of perioperative colon screening. Differences were analyzed using Fisher exact test and logistic regression analysis. There were no significant clinicopathologic differences between the two cohorts. Sixty-five percent of patients in each group underwent perioperative colon screening. However, patients with MSI+ cancers had a twofold increase in the frequency of colonic abnormalities (30% versus 14.8%, P= 0.044) over those with MSI− cancers. Furthermore, the only primary colon cancers (N= 2) were found in women with MSI+ endometrial cancers that were unmethylated at the MLH1 promoter. Our data suggest that patients with MSI+ endometrial cancers are at increased risk for abnormalities on perioperative colon screening. Those with MSI+MLH1 unmethylated cancers appear to be at highest risk.

DNA mismatch repair and TP53 defects are early events in uterine carcinosarcoma tumorigenesis

Growing molecular evidence shows that uterine carcinosarcomas are clonal tumors. The carcinoma component has a dominant effect in the aggressive clinical behavior of these tumors. Defective DNA mismatch repair affects up to 30% of endometrial adenocarcinomas. The frequency and importance of defective DNA mismatch repair in the histiogenesis of uterine carcinosarcomas remains controversial. We studied the pattern and frequency of defective DNA mismatch repair and TP53 alterations in the epithelial and mesenchymal components of 28 uterine carcinosarcomas. We found evidence of defective DNA mismatch repair in six cases (21%) with a concordance rate of 83% for carcinoma-sarcoma pairs (kappa=0.887, P<0.001). Lack of immunostaining for the MLH1 protein was demonstrated in both components in two of these tumors. TP53 defects were evaluated by 17p deletion analysis and p53 immunostaining. Nineteen carcinoma (68%) and 18 sarcoma (64%) components had evidence of either TP53 allelic loss or p53 overexpression. These defects proved clonal in 76% of cases (kappa=0.602, P=0.003). Our results indicate that defective DNA mismatch repair and TP53 defects are common early events in carcinosarcoma tumorigenesis. The high rate of concordance for these molecular defects between the carcinoma and sarcoma components adds to existing molecular evidence that carcinosarcomas are clonal malignancies.

Bevacizumab combination therapy in recurrent, platinum-refractory, epithelial ovarian carcinoma: A retrospective analysis

BACKGROUND

The study was undertaken to determine the safety and efficacy of the monoclonal, antivascular endothelial growth factor antibody bevacizumab in combination with cytotoxic chemotherapy for women with platinum-refractory ovarian cancer.

METHODS

A retrospective analysis of women who received bevacizumab in combination with a cytotoxic agent was performed. Response was determined by measurable disease or assessment of serial cancer antigen (CA) 125 measurements.

RESULTS

Twenty-three patients were identified. The patients were heavily pretreated with a median of 7 prior regimens including a median of 3 prior platinum regimens. The combination regimen included cyclophosphamide in 15 (65%), 5-fluorouracil (5-FU) in 6 (26%), docetaxel in 1 (4%), and gemcitibine/liposomal doxorubicin in 1 (4%). Two (9%) women developed chylous ascites during treatment. CTC Grade 4-5 toxicities occurred in 4 (17%) subjects. Gastrointestinal perforation occurred in 2 (9%) patients. Measurable disease was present in 22. The overall best response rate was 35% and all 8 were partial responses (PRs). Stable disease was found in a further 10 (44%) women, whereas progressive disease was observed in 5 (22%). The median time to progression was 5.6 months in patients with a PR and 2.3 months in subjects with stable disease. Three (13%) women experienced a progression-free interval (PFI) of >6 months. At last follow-up, 8 (35%) subjects had died of disease, whereas 15 (65%) women were alive with disease.

CONCLUSIONS

Combination bevacizumab therapy demonstrated activity in heavily pretreated women with ovarian cancer. Gastrointestinal perforations were identified in 9%. Despite the toxicity of the regimen, prospective studies, particularly in less heavily pretreated patients, are warranted.

MLH3 Mutation in Endometrial Cancer

MLH3 is a recently described member of the DNA mismatch repair gene family. Based on its interaction with the MutL homologue MLH1, it was postulated that MLH3 might play a role in tumorigenesis. Germ line and somatic mutations in MLH3 have been identified in a small fraction of colorectal cancers, but the role of MLH3 in colorectal cancer tumorigenesis remains controversial. We investigated MLH3's role in endometrial tumorigenesis through analysis of tumor and germ line DNA from 57 endometrial cancer patients who were at increased risk for having inherited cancer susceptibility. Patients with known MSH2 or MSH6 mutations were excluded as well as those who had MLH1-methylated tumors. Sixteen different variants were identified by single-strand conformational variant analysis. Of the 12 missense changes identified, three were somatic mutations. One patient had a germ line missense variant and loss of heterozygosity (LOH) in her tumor specimen. There was no evidence of MLH3 promoter methylation based on combined bisulfite restriction analysis. The identification of inherited missense variants, somatic missense mutations (present in 3 of 57 tumors), and LOH in the tumor from a patient with a germ line missense change suggest a role for MLH3 in endometrial tumorigenesis.

Long-term outcome of women who undergo panniculectomy at the time of gynecologic surgery

OBJECTIVE

While panniculectomy has been shown to be a useful technique in obese women undergoing gynecologic surgery, the long-term outcome of these patients has been poorly described. The goal of this study was to determine the long-term outcomes and patient satisfaction of women who underwent panniculectomy at the time of pelvic surgery.

METHODS

A retrospective review of patients who underwent panniculectomy at the time of pelvic surgery between 1996 and 2004 was performed. Postoperative complications and long-term trends in weight were evaluated. Patient satisfaction was assessed by telephone survey.

RESULTS

Forty-two patients were identified. The mean EBL was 522 ml, the mean operating time was just over 4 h. Wound complications were noted in 36% of the subjects. Two weeks after the procedure, 86% of the women had a weight that was lower than their preoperative weight. Weight loss peaked 3 months postoperatively, 97% of the subjects had a net lower weight, with a mean loss of nearly 20 lb. Over the ensuing 2 years, weight loss gradually declined. After 2 years of follow-up, 62% of the women were below their preoperative body weights. The mean weight loss at 24 months was 7 lb. Overall patient satisfaction with the procedure was high. Eighty-six percent of the subjects responded that they would undergo the procedure again given their outcome.

CONCLUSIONS

Panniculectomy is well tolerated and associated with a high rate of patient satisfaction. Panniculectomy is a valuable component of gynecologic surgery in morbidly obese women.

CA-125 response in patients with recurrent ovarian or primary peritoneal cancer treated with pegylated liposomal doxorubicin or topotecan

OBJECTIVE

Recent additions of novel chemotherapeutics, such as pegylated liposomal doxorubicin (PLD) and topotecan (TPT), have provided clinicians with multiple options for treating recurrent ovarian cancer. Evaluating treatment response in patients without radiographic or physically measurable disease is problematic, thereby CA-125 values may be the only available objective criteria. It has been advocated that several cycles of novel agents are required prior to an observed CA-125 response. In this study, we sought to gain insight into response patterns regarding CA-125 in responders vs. non-responders and to determine whether specific "cut-off" values could help predict ultimate clinical response.

METHODS

Patients with recurrent ovarian cancer who received either single agent PLD, TPT, or both were included. CA-125 levels were evaluated prior to initiation of chemotherapy and thereafter for each additional cycle. The Rustin criteria were utilized to evaluate CA-125 response.

RESULTS

Fifty-four of 120 patients were judged to be responders. When comparing responders to non-responders, as expected, the majority of responders demonstrated a decrease after each of the first 4 cycles. However, nearly 50% of responders who received PLD demonstrated an increase in CA-125 after cycle 1. There were no responders who demonstrated two successive rises in CA-125.

CONCLUSION

The majority of patients with recurrent ovarian cancer who will ultimately manifest a CA-125 response to novel agents, such as TPT or PLD, will demonstrate a decrease following each cycle. An initial increase in CA-125 should not mandate discontinuation of current therapy, but a successive rise over two or more cycles reliably predicts that a treatment response ultimately is unlikely.

Human papillomavirus triage for young women with atypical squamous cells of undetermined significance

OBJECTIVE

Human papillomavirus testing is a cost-effective strategy for the management of atypical squamous cells of undetermined significance. Young women have a high prevalence of transient human papillomavirus infections and low incidence high-grade cervical lesions, which may limit the usefulness of human papillomavirus testing in this cohort. We sought to estimate the usefulness of human papillomavirus testing for young women with atypical squamous cells of undetermined significance.

METHODS

A retrospective study of women with atypical squamous cells of undetermined significance was undertaken. Reflex human papillomavirus results and pathologic follow-up were evaluated. Age-stratified rates of human papillomavirus positivity, rates of high-grade dysplasia, and sensitivity and specificity were estimated.

RESULTS

A total of 1,290 women with atypical squamous cells of undetermined significance cytology were identified. The rate of human papillomavirus positivity decreased with age from 55% for those aged 25 years or younger to 12% for women aged older than 50 years (P < .001). The cumulative rate of high-grade lesions increased with age; 12% for patients aged 25 years or younger compared with 24% for women aged older than 50 years (P = .05). A negative human papillomavirus test more effectively excluded high-grade disease in the young women. No high-grade lesions were detected in the human papillomavirus negative women aged 25 years or younger compared with 3.8% of those aged older than 50 years (P = .04). The sensitivity for detection of high-grade disease was higher in women aged younger than 25 years compared with those aged older than 50 years (100% compared with 50%), whereas specificity was lower (14% compared with 44%).

CONCLUSION

Given the high prevalence of human papillomavirus and low occurrence of high-grade lesions in young women with atypical squamous cells of undetermined significance, a human papillomavirus-based triage strategy will result in the referral of a large number of women for colposcopy and may limit its cost-effectiveness.

LEVEL OF EVIDENCE

III.

Defective DNA mismatch repair and XRCC2 mutation in uterine carcinosarcomas

OBJECTIVES

A frameshift mutation in the double-strand breakage repair gene XRCC2 was identified in a mismatch repair (MMR) deficient cell line derived from a uterine carcinosarcoma. The frameshift mutation occurred in a mononucleotide run (poly-T tract), a target for strand-slippage mutation in MMR deficient tumors. We sought to determine if XRCC2 mutation is important to uterine carcinosarcoma tumorigenesis and whether the XRCC2 poly-T tract is a target for mutation in cells lacking MMR.

METHODS

MSI-typing was used to assess the MMR status of 30 primary carcinosarcomas. The entire XRCC2 coding region was sequenced in all tumors. Single strand conformational variant (SSCV) analysis was used to screen for poly-T tract mutation in 50 endometrioid adenocarcinomas with defective MMR.

RESULTS

Seven of 30 (23.3%) primary carcinosarcomas had an MSI-H phenotype. No XRCC2 coding mutations were identified in the 30 carcinosarcomas, and only one of the fifty MSI-H endometrioid adenocarcinomas had an XRCC2 poly-T tract mutation.

CONCLUSIONS

Despite the high frequency of mismatch repair deficiency in carcinosarcomas, no XRCC2 poly-T tract frameshift mutations were identified in these tumors. The fact that only one of 50 additional MSI-H tumors had a frameshift mutation suggests that the XRCC2 poly-T tract is not a frequent target for defective MMR. The absence of coding sequence mutations in primary carcinosarcomas suggests that XRCC2 defects are unlikely to play a significant role in carcinosarcoma tumorigenesis.

Resource utilization for ovarian cancer patients at the end of life: How much is too much?

OBJECTIVE

End-of-life (EOL) medical care consumes 10-12% of national health care expenditures and 27% of Medicare dollars annually. Studies suggest that hospice services decrease EOL expenditures by 25-40%. The goal of this study was to compare the total cost of hospital-based resources utilized in ovarian cancer patients during their last 60 days of life for those enrolled in hospice versus those not on hospice.

METHODS

Study eligibility included patients who expired from ovarian cancer from 1999 to 2003. Medical records were reviewed for demographic data as well as treatment, response and recurrence rates, histologic type, grade and stage. Billing records were analyzed for costs of inpatient and outpatients visits, including radiologic, laboratory and pharmacy charges. Total cost of hospital resources was compared between patients managed on hospice for >10 days (hospice group) versus <10 days (non-hospice group) using the following methods: Mann-Whitney U, Kruskal-Wallis and Student's t tests. Overall survival was compared using Kaplan-Meier statistics.

RESULTS

Of the 84 patients analyzed, 67 (79.8%) were in the non-hospice group and 17 (20.2%) were in the hospice group. Demographic, histologic and staging characteristics as well as platinum sensitivity were similar between the two groups before the last 60 days of life. Mean number of chemotherapy cycles before the study period was also similar (20.4 and 21.0, respectively). However, during the study period, the mean total cost per patient in the non-hospice group was dollar 59,319 versus dollar 15,164 in the hospice group (P = 0.0001). A significant difference in cost was noted for mean inpatient days (dollar 6584 vs. dollar 1629, P = 0.0007), radiology (dollar 6063 vs. dollar 2343, P = 0.003), laboratory (dollar 12,281 vs. dollar 2026, P = 0.0004) and pharmacy charges (dollar 13,650 vs. dollar 4465, P = 0.0017) as well as for treating physician per patient (dollar 112,707 vs. dollar 34,677, P = 0.04). Overall survival for the two groups was the same.

CONCLUSIONS

Our findings demonstrate that there is a significant cost difference with no appreciable improvement in survival between ovarian cancer patients treated aggressively versus those enrolled in hospice at the EOL. These data suggest that earlier hospice enrollment is beneficial. Furthermore, cost variations between physicians and patients imply that education may be an important variable.

Human papillomavirus type and tobacco use as predictors of survival in early stage cervical carcinoma

OBJECTIVE

Molecular and environmental co-factors are known risk factors for cervical cancer. The aim of this study was to define the prognostic significance of HPV 18 and its phylogenetically related viruses and smoking on survival in patients with early stage cervical cancer.

METHODS

HPV typing was performed on stage IB-IIB cervical tumors. Subjects positive for HPV 18 or 45 were compared to the remainder of the cohort and to women with tumors containing HPV 16, 31, or 52. Tobacco use was ascertained by patient questionnaire.

RESULTS

Tumors of 255 women were evaluated. The presence of HPV 18 or 45 was associated with decreased survival. In a multivariable Cox proportional hazards analysis comparing patients with HPV 18 or 45 containing tumors to the rest of the cohort, the hazard ratio for death from cervical cancer was 2.08 (95% CI, 1.07-4.04). The hazard ratio for death from cervical cancer was 2.41 (95% CI, 1.17-4.96) when the HPV 18 and 45 group was compared to women with HPV 16 or its related viruses, 31 and 52. Smoking was associated with a decreased survival for women with HPV 18 or 45, even after adjusting for other known prognostic factors (P = 0.031).

CONCLUSIONS

In addition to pathologic indicators, molecular and environmental co-factors are important determinates of outcome in early stage cervical cancer. The presence of HPV 18 or 45 is associated with a decreased survival. The adverse effect of HPV 18 and 45 on survival is compounded by tobacco use.

Relationship of ovarian neoplasms and body mass index

OBJECTIVE

To describe the distribution of benign and malignant ovarian neoplasms among overweight and obese women.

STUDY DESIGN

A review of patients who presented with a preoperative diagnosis of a pelvic mass between 1996 and 2001 was performed; 1,096 patients were identified. Patients were stratified by body mass index into 3 groups: normal weight, overweight and obese. The pathologic findings in the 3 groups were compared.

RESULTS

Complete follow-up was available on 668 patients. Overall, 248 patients were obese, 176 were overweight, and 244 had a normal body mass index. A significant difference existed in the pathologic findings in the 3 groups (p = 0.049). Women with normal body mass indices were more likely to have malignant ovarian tumors (35.2%) than were the overweight (23.9%) and obese (25.8%) women. Conversely, borderline ovarian tumors were less frequent in women with body mass indices of <25 (5.7%) than in the overweight (13.1%) and obese (10.9%) patients. Benign ovarian neoplasms occurred in 20-25% of the women.

CONCLUSION

Significant differences exist in the distribution of ovarian neoplasms among women with different body mass indices. Obese women are more likely to have ovarian tumors of low malignant potential, while women with normal body mass indices more commonly have invasive ovarian tumors. Body mass index may be an important factor in preoperative counseling and risk assessment.

Cervical sarcomas: an analysis of incidence and outcome

OBJECTIVE

Cervical sarcomas are exceedingly rare neoplasms associated with a poor prognosis. The objective of this study was to examine the treatment and outcome of women with cervical sarcomas.

METHODS

A hospital-based tumor registry was searched to identify all patients with cervical sarcomas treated between 1986 and 2003. The medical records of all patients were reviewed. All pathologic specimens were reviewed by a single pathologist.

RESULTS

Among 1583 with cervical malignancies, 8 cervical sarcomas were identified. All patients presented with vaginal bleeding. The lesions were clinically staged as IB1 (2), IB2 (4), IIIA (1), and IIIB (1). Five of the tumors were carcinosarcomas. Other histologies included sarcoma NOS (12.5%), leiomyosarcoma (12.5%), and endometrial stromal sarcoma (12.5%). Initial treatment included surgery in 5 patients, radiation in 2, and chemoradiation in 1. Six patients were treated with curative intent, 5 received adjuvant therapy. While both patients treated palliatively died from progressive disease, the other 6 patients remain alive after a mean follow-up of 2.5 years. Two patients have recurred. One patient underwent a thoracotomy for an isolated pulmonary metastasis and is alive with no evidence of disease. The second patient developed pulmonary metastases and is alive 8 months after recurrence.

CONCLUSIONS

Cervical sarcomas are rare neoplasms. Most patients present with vaginal bleeding and a palpable cervical mass. While the optimal management of these tumors is uncertain, aggressive primary therapy can result in prolonged survival and cure.

Cervical Dysplasia in Adolescents

BACKGROUND

Although the incidence of cervical dysplasia in adolescents is increasing, a paucity of data exists regarding the outcomes of adolescents with Pap test abnormalities. We determined the natural history and outcome of adolescents with low-grade squamous intraepithelial lesions (LSIL) and high-grade squamous intraepithelial lesions (HSIL).

METHODS

A review of all women aged 18 years or younger with a cytologic diagnosis of LSIL or HSIL between 1997 and 2003 was performed. Follow-up cytologic and histologic samples were evaluated. The most significant abnormality was recorded for each patient. Rates of regression, persistence, and progression were calculated.

RESULTS

A total of 646 adolescents were identified. Follow-up was available for 477 teenagers with LSIL and for 55 with HSIL. Among adolescents with LSIL, 146 (35%) had negative follow-up. Low-grade abnormalities (atypical squamous cells of undetermined significance, LSIL, and cervical intraepithelial neoplasia grade 1) were seen in 199 (47%), whereas high-grade abnormalities were documented in 77 (18%). After 36 months, 62% had regressed, whereas 31% had progressive dysplasia. For the HSIL cohort, negative follow-up was documented in 12 (21.8%) adolescents, and 15 (27.3%) had low-grade abnormalities, whereas more than one half (50.9%) were found to have a high-grade abnormality. At 36 months, 31% of HSIL subjects had progressed to cervical intraepithelial neoplasia 3.

CONCLUSION

Adolescents with LSIL and HSIL cytology are at significant risk for progression to high-grade cervical abnormalities. The rate of development of high-grade cervical abnormalities in adolescents is similar to adults. Adolescents with cytologic abnormalities mandate close follow-up.

LEVEL OF EVIDENCE

II-3.

FDG-PET evaluation of vaginal carcinoma

PURPOSE

To compare the results of CT and positron emission tomography (PET) and F-18 fluorodeoxyglucose (FDG) in the detection of the primary tumor and lymph node metastases in carcinoma of the vagina.

METHODS AND MATERIALS

This was a prospective registry study of 23 consecutive patients with carcinoma of the vagina, in which we respectively compared the results of CT and whole-body FDG-PET. The tumor was clinical Stage II in 16 patients, Stage III in 6, and Stage IVa in 1 patient. The primary tumor ranged in size from 2 to 10 cm (mean 4.9), and 4 patients had palpable groin lymph nodes. All patients were treated with external beam radiotherapy and brachytherapy, 14 received concurrent chemotherapy, and 2 underwent primary tumor excision before the imaging evaluation. The median follow-up was 21 months in those patients alive without disease. Survival was estimated by the Kaplan-Meier method.

RESULTS

Of the 21 patients with an intact primary tumor, CT visualized it in 9 (43%). CT also demonstrated abnormally enlarged groin lymph nodes in 3 patients and both groin and pelvic lymph nodes in 1 patient (4 of 23, 17%). FDG-PET identified abnormal uptake in all 21 intact primary tumors (100%). Abnormal uptake was found in the groin lymph nodes in 4 patients, pelvic lymph nodes in 2, and both groin and pelvic lymph nodes in 2 patients (8 of 23, 35%). The 3-year progression-free and overall survival estimate was 73% and 68%, respectively.

CONCLUSION

The results of this study have demonstrated that FDG-PET detects the primary tumor and abnormal lymph nodes more often than does CT.

Preoperative lymph node staging of early-stage cervical carcinoma by [18F]-fluoro-2-deoxy-D-glucose-positron emission tomography

BACKGROUND

Increasing evidence has documented the value of positron emission tomography (PET) in oncology, but only limited data are available comparing PET findings with the pathologic status of regional lymph nodes in patients with cervical carcinoma. The objective of this study was to determine the sensitivity and specificity of PET in detecting lymph node metastasis in women with early-stage cervical carcinoma.

METHODS

The authors performed a retrospective review of all patients with Stage IA-IIA cervical carcinoma who underwent PET before surgery from 1999 to 2004. The status of the regional lymph nodes was correlated with lymph node pathology.

RESULTS

Fifty-nine patients were identified. Pelvic lymph node metastases were present in 32% of the patients and were detected by PET with a sensitivity of 53%, a specificity of 90%, a positive predictive value (PPV) of 71%, and a negative predictive value (NPV) of 80%. Paraaortic lymph node disease was present in 9% of patients and was detected by PET with a sensitivity of 25%, a specificity 98%, a PPV of 50%, and an NPV of 93%. The mean size of the tumor deposits was larger in the PET-positive pelvic nodes (15.2 mm; range, 2-35 mm) than in the PET-negative lymph nodes (7.3 mm; range, 0.3-20 mm; P = 0.002). Computed tomography (CT) scans were obtained before surgery in 42 patients. The combined sensitivity of PET and CT in these patients was 75%. PET alone detected 9 (36%) of the positive lymph node groups, whereas CT alone detected 3 (12%) of the positive lymph node groups. Neither PET nor CT detected the positive lymph node groups in 8 patients (32%).

CONCLUSIONS

Pathologic validation of PET imaging demonstrated a low sensitivity and a high specificity for PET in patients with early-stage cervical carcinoma.

Panniculectomy: improving lymph node yield in morbidly obese patients with endometrial neoplasms

OBJECTIVE

Panniculectomy has been used to facilitate pelvic surgery in obese women. The goal of this study was to determine the effect of panniculectomy on staging adequacy and lymph node yield in obese women with endometrial carcinoma undergoing staging laparotomy.

METHODS

A retrospective review of patients with endometrial neoplasms who underwent panniculectomy at the time of hysterectomy was performed. For each subject, two control patients were matched by body mass index (BMI).

RESULTS

Twenty-seven endometrial cancer patients who underwent panniculectomy at the time of staging were identified. Panniculectomy was successfully performed in all 27 patients. While the mean number of pelvic nodes was statistically similar between the two groups (16.2 vs. 13.7) (P = 0.199), the paraaortic node count was higher in patients who underwent panniculectomy (4.3 vs. 2.9) (P = 0.032). A paraaortic node dissection was not feasible in 3 (11.1%) of the panniculectomy patients and in 11 (20.4%) of the controls (P = 0.365). There were no differences in intraoperative or postoperative complications or in survival between the two groups.

CONCLUSION

Among obese women with endometrial cancer, panniculectomy is well tolerated, feasible, and associated with acceptable morbidity. While the clinical significance of an increased paraaortic node count is uncertain, our findings suggest that panniculectomy may enhance operative exposure and facilitate endometrial cancer staging.

The role of topotecan for extending the platinum-free interval in recurrent ovarian cancer: an in vitro model

OBJECTIVE

Topotecan, a novel topoisomerase-I inhibitor, is an active agent of second-line chemotherapy for extending the platinum-free interval (PFI) and improving the chances of a response to platinum in recurrent ovarian cancer patients. The aim of this study was to understand the molecular mechanism of topotecan-based second-line chemotherapy through an in vitro cell culture model and to gain clinical insight into sequencing issues for second-line treatment with novel agents versus retreatment with platinum.

STUDY DESIGN

The human ovarian cancer cell line A2780 and the cisplatin resistance cell line A2780-CR were separately seeded in 6-well cell culture plates and then exposed to multiple concentrations of cisplatin plus paclitaxel or topotecan for 7 days. Surviving cells were recovered and cultured in drug-free media for 3 weeks and then replated in a 96-well microtiter plate. The LD(50) for these cells was determined by a cytotoxic MTT assay after exposure to multiple clinically relevant concentrations of cisplatin or topotecan. Surviving cells were cultured in drug-free media for an additional 4 weeks at which time the LD(50) was reassessed for each cell population by a second MTT assay. Using RT-PCR and Northern blot hybridization to measure mRNA expression, the molecular profile of these cells in terms of resistance was evaluated for the multidrug-resistant gene (MDR-1), multidrug-resistant protein (MRP), Topoisomerase-I, and beta-Actin.

RESULTS

The LD(50) to cisplatin was unchanged in A2780-CR cells treated by topotecan. Those A2780-CR cells originally exposed to higher concentrations of cisplatin became more resistant to cisplatin in the MTT assays, while those A2780-CR cell lines treated with a combination of lower cisplatin concentrations and paclitaxel became more sensitive to cisplatin in the MTT assay (P < 0.01). The second MTT assay demonstrated that the LD(50) for cisplatin in every cell line decreased significantly after a 4-week drug-free interval (P < 0.01). There was no difference in the mRNA expression for MRP or topoisomerase-I regardless of cell line, or type or concentration of chemotherapeutic exposure. The mRNA for MDR-1 was uniquely overexpressed in the cisplatin-resistant cell line A2780-CR9 initially treated with low doses of cisplatin and paclitaxel, but was not amplified in A2780 (P < 0.01).

CONCLUSIONS

The acquired resistance to cisplatin in A2780 is potentially due to P-glycoprotein-mediated multidrug resistance. This acquired resistance to cisplatin is an unstable phenotype in that some cell populations become sensitive after a drug-free interval and topotecan treatment. This reversal of resistance, however, does not appear to be simply due to loss of MDR-1 expression. While in vivo confirmation is required, agents with novel mechanisms of action offer a strategy to extend the platinum-free interval and thereby improve survival in patients with recurrent ovarian cancer.

Penetrance and expressivity of MSH6 germline mutations in seven kindreds not ascertained by family history

Hereditary nonpolyposis colorectal cancer (HNPCC) is caused by inherited mutations in DNA mismatch-repair genes, most commonly MLH1 or MSH2. The role MSH6 plays in inherited cancer susceptibility is less well defined. The aim of this study was to investigate the penetrance and expressivity of MSH6 mutations in kindreds ascertained through endometrial cancer probands unselected for family history. Detailed pedigrees were constructed for six MSH6 mutation carriers. All reported cancers and precancers were confirmed, and tissues were obtained when available. Tumors were analyzed for microsatellite instability (MSI) and for expression of MSH2, MLH1, and MSH6. MSH6 mutation status was determined for 59 family members. Of these 59 individuals, 19 (32%) had confirmed cancers and precancers. There was an excess of mutation carriers among the 19 affected family members (11 [58%] of 19) compared with those among the 40 unaffecteds (8 [20%] of 40, P=.0065, odds ratio = 5.5, 95% CI = 1.66-18.19). In four of the seven tumors analyzed from mutation carriers other than the probands, MSI and/or MMR protein expression was consistent with the involvement of MSH6. Overall estimated penetrance of the MHS6 mutations was 57.7%. Of the tumors in mutation carriers, 78% were part of the extended HNPCC spectrum. This study demonstrates that MSH6 germline mutations are, indeed, associated with increased cancer risk and that the penetrance of mutations may be higher than appreciated elsewhere. A combination of MSI and immunohistochemistry analyses may be helpful in screening for MSH6 mutation carriers.

Synchronous ovarian metastases at the time of laparotomy for colon cancer

OBJECTIVE

The aim of the study was to identify clinical features, define prognostic factors and optimize treatment in patients with colorectal cancer with synchronous ovarian metastases at the time of initial diagnosis.

METHODS

A retrospective analysis of patients treated by the gynecologic oncology service at Barnes Jewish Hospital between 1990 and 2001 was performed. Twenty-eight patients with colorectal carcinomas with synchronous ovarian metastases at the time of diagnosis were identified. Clinical and pathological characteristics were evaluated, and survival was analyzed by the method of Kaplan and Meier.

RESULTS

Abdominal pain was the most common symptom at presentation. Only 14% of the patients presented with gastrointestinal bleeding. Fifty-four percent of patients who underwent barium enema had intrinsic colonic lesions, while 40% of patients who had endoscopies performed had their colonic tumors identified. Preoperatively colon cancer was considered in the differential diagnosis of 71% of the patients. At exploration, the ovarian metastases were significantly larger than the primary colon tumors. Overall, 68% of patients had intraperitoneal nodal metastasis and 86% had transmural extension of their tumors. The only pathological variable associated with survival was tumor grade. The median disease-free survival was 10.3 months while the median overall survival was 18.4 months.

CONCLUSION

Most patients with colon cancer with synchronous ovarian metastases present with vague symptoms. At exploration, locally advanced tumors and other distant metastases such as in the liver are common. Surgical management should include extirpation of the primary tumor and any bulky ovarian metastases. Cytoreduction may be considered in highly selected patients.

Increased Risk for Hereditary Nonpolyposis Colorectal Cancer-Associated Synchronous and Metachronous Malignancies in Patients with Microsatellite Instability-Positive Endometrial Carcinoma Lacking MLH1 Promoter Methylation

PURPOSE

The aim of this study was to evaluate number and types of synchronous and metachronous malignancies in patients with endometrial carcinoma with and without microsatellite instability (MSI).

EXPERIMENTAL DESIGN

From a series of 413 endometrial cancer patients, we identified 94 patients with MSI-positive (MSI+) cancers and grouped them by tumor MLH1 promoter methylation status. These 94 patients were matched by year of surgery to 94 patients with MSI-negative (MSI-) endometrial cancers from the same series. Medical records were reviewed for clinicopathologic information including rates and types of synchronous and metachronous malignancies. Hereditary nonpolyposis colorectal cancer (HNPCC)-associated second and third cancers were analyzed for MSI and MSH2, MSH6, and MLH1 expression for comparison with the corresponding endometrial cancers.

RESULTS

The MSI+ and MSI- cohorts were similar with regard to age, race, grade, and histology. Twenty-eight MSI+ endometrial cancers (29.8%) were MLH1 unmethylated. Rates of synchronous and metachronous cancers were also similar in the MSI+ and MSI- groups at 20 and 23%, respectively. However, patients with MSI+ MLH1 unmethylated endometrial cancers had an excess of HNPCC-associated second and third cancers compared with those with MSI+ MLH1 methylated and MSI- endometrial cancers (18% versus 4.5%, P = 0.034, and 2.1%, P = 0.002). Six of seven second tumors from 5 patients with MSI+ MLH1 unmethylated endometrial cancers showed concordant MSI and mismatch repair protein expression status.

CONCLUSIONS

Our observation that patients with MSI-positive MLH1 unmethylated endometrial carcinoma are at increased risk for HNPCC-associated synchronous and metachronous malignancies suggests inherited cancer susceptibility. These patients and their families may warrant more intense cancer surveillance.

Cervical carcinoma in the elderly

BACKGROUND

Advanced age often is considered a poor prognostic factor for cervical carcinoma. The authors investigated the patterns of care and treatment outcomes of elderly women with cervical carcinoma.

METHODS

A hospital-based tumor registry was used to identify patients with invasive cervical carcinoma who were treated between 1986 and 2003. Patients were divided into 2 cohorts: women age < 70 years and women age > or = 70 years. Survival was examined using the Kaplan-Meier method. Single and multivariate Cox proportional hazards modeling was used to estimate hazard ratios with 95% confidence intervals (95% CI).

RESULTS

In total, 1582 patients were identified, including 1385 patients age < 70 years and 197 patients age > or = 70 years. The elderly patients presented with more advanced stage tumors at diagnosis (P <0.0001) and were more likely to have nonsquamous neoplasms (P=0.002). A marked difference in treatment was noted for the elderly cohort, even after stratifying by disease stage. Only 16% of the older patients underwent surgical treatment compared with 54% of the younger patients (P <0.0001). Elderly women were 9 times more likely to receive no treatment (P <0.0001). In a multivariate model of known prognostic factors, the hazard ratio for death from any cause in women age > 70 years was 2.1 (95% CI, 1.5-3.0). The hazard ratio for death from cervical carcinoma in the elderly women was 1.6 (95% CI, 1.1-2.5).

CONCLUSIONS

Age is an important factor in the allocation of treatment and survival for patients with cervical carcinoma. Elderly women with cervical carcinoma are more likely to receive primary radiotherapy, to forego treatment, and to die from their disease.

Liquid-based cytology for the postirradiation surveillance of women with gynecologic malignancies

OBJECTIVE

To determine the performance of liquid-based cytology using ThinPrep in the postirradiation surveillance of women with gynecologic malignancies.

METHODS

Patients with endometrial and cervical cancer treated with primary or adjuvant radiotherapy between 2000 and 2002 were identified. Details regarding tumor characteristics, treatment, and cytologic and histologic results were abstracted. Binomial variables were compared with the chi-square test. The performance characteristics of liquid-based cytology were evaluated.

RESULTS

A total of 302 liquid-based cytologic samples from 121 women were evaluated. Overall, 294 (97.4%) of the specimens were adequate for interpretation and 132 (44.9%) were within normal limits. Benign cellular changes, including benign radiation changes, were identified in 141 (47.6%). Atypical squamous cells (ASCUS) were found in 15 (5.1%), recurrent dysplasia in 4 (1.3%), and recurrent carcinoma in 2 (0.7%). Follow-up of the 15 ASCUS smears revealed 13 (86.7%) normal smears and 2 cases of squamous intraepithelial lesions. Benign findings were noted in three of the four smears with SIL. The sensitivity for the detection of SIL was 33%, the specificity 99%, and the positive predictive value (PPV) 25%. Of the 4 patients with local recurrences, 2 were detected by cytology. The sensitivity for the detection of recurrent carcinoma was 50%, with a specificity and PPV of 100%.

CONCLUSIONS

ThinPrep for the surveillance of women with gynecologic malignancies treated with radiotherapy is associated with a high rate of satisfactory samples and a low rate of equivocal and ASCUS cytology.

Frequent HOXA11 and THBS2 promoter methylation, and a methylator phenotype in endometrial adenocarcinoma

PURPOSE

This study was designed to determine whether there is a methylator phenotype in stage I and II endometrioid endometrial adenocarcinoma, and if so, whether methylation correlates with recurrence.

EXPERIMENTAL DESIGN

Bisulfite-converted DNAs from 24 stage I and II primary cancers (12 recurrent and 12 nonrecurrent), and 5 endometrial cancer cell lines were analyzed for methylation in the promoter regions of seven genes. A methylation index (MeI) was calculated for each tumor. Frequent HOXA11 and THBS2 methylation prompted analysis of case-matched bloods and 25 additional nonrecurrent primary cancers. Statistical analysis included Fisher's exact and Student t tests.

RESULTS

Rates of methylation in the initial tumor series were as follows: HOXA11, 70.8%; THBS2, 62.5%; MLH1, 33.3%; CTNNB1, 16.7%; VDR, 4.2%; CDKN2A, 4.2%; and THBS1, 0%. There was no difference in the MeI of recurrent and nonrecurrent cases. However, cell lines had higher mean MeI. High rates of HOXA11 and THBS2 methylation were confirmed in the additional nonrecurrent tumors. None of the 24 case-matched bloods had HOXA11 methylation, whereas three blood DNAs showed THBS2 methylation. There was a statistically significant difference in the rate of HOXA11 methylation in recurrent and nonrecurrent tumors (P = 0.0167).

CONCLUSIONS

Endometrial adenocarcinomas have a methylator phenotype. No correlation between MeI and clinicopathologic variables in early stage tumors was observed. High rates of methylation were found in the HOXA11 and THBS2 promoter regions. HOXA11 promoter methylation was significantly more frequent in recurrent than nonrecurrent cases. HOXA11 methylation in early stage endometrial cancer is associated with poor outcome.