Clinical outcomes of patients with adenocarcinoma in situ of the cervix treated by conization

OBJECTIVE

To describe the clinical outcomes of histologically confirmed adenocarcinoma in situ (AIS) of the cervix treated with cervical conization.

MATERIALS AND METHODS

A retrospective chart review of patients with histologically confirmed AIS from July 1998 to February 2011 included 52 patients. The rates of residual disease in subsequent excisions, the clinical recurrence rate, the average disease-free interval, and risk of progression to adenocarcinoma were described. The clinical outcomes of patients treated with cold knife cone (CKC) and loop electrosurgical excisional procedure (LEEP) were compared.

RESULTS

Fifteen LEEPs and 37 CKC procedures were performed as initial treatment and 26 patients (50%) had positive margins. There was no significant difference in rate of positive margins between LEEP and CKC (40% vs. 54%, respectively. p = 0.55). LEEPs and CKCs resulted in similar volumes of cervical tissue resected (4.98 cm3 vs. 5.04 cm3, p = 0.40). Of patients with positive margins, ten underwent immediate hysterectomy, six underwent a second cone biopsy, seven were managed expectantly, and four were lost to follow up. Residual AIS was found in 47% (eight of 17) of repeat cone biopsy and hysterectomy specimens performed for positive cone margins. Of the 26 patients with negative cone margins, no residual or recurrent disease was found after an average follow-up of 32 months.

CONCLUSIONS

A positive surgical margin was associated with residual disease in 47% of patients with AIS treated with conization. No patient with negative cone margins had recurrent or progressive disease. Cervical conization with negative margins appears to be a safe treatment option for patients with AIS but requires further investigation. CKC and LEEP were equally efficacious treatments in our study population.

Phase I trial of ixabepilone plus pegylated liposomal doxorubicin in patients with adenocarcinoma of breast or ovary

BACKGROUND

Ixabepilone is a semisynthetic epothilone B analogue that is active in taxane-resistant cell lines and has shown activity in patients with refractory breast and ovarian cancer. We carried out a phase I trial of ixabepilone plus pegylated liposomal doxorubicin (PLD) in patients with advanced taxane-pretreated ovarian and breast cancer.

METHODS

Patients with recurrent ovarian or breast carcinoma received PLD every 3 or 4 weeks plus five different dose schemas of ixabepilone in cohorts of three to six patients.

RESULTS

Thirty patients received a total of 142 treatment cycles of the PLD-ixabepilone combination. The recommended phase II dose and schedule of ixabepilone was 16 mg/m(2) on days 1, 8, and 15 plus PLD 30 mg/m(2) given on day 1, repeated every 4 weeks. Hand-foot syndrome and mucositis were dose limiting when both ixabepilone and PLD were given every 3 or 4 weeks. Objective responses were observed in 3 of 13 patients (23%) with breast cancer and 5 of 17 patients (29%) with ovarian cancer.

CONCLUSION

Ixabepilone may be safely combined with PLD, but tolerability is highly dependent upon the scheduling of both agents. This combination demonstrated efficacy in patients with breast and ovarian cancer and merits further evaluation in these settings.

Phase I clinical trial of ixabepilone and pegylated liposomal doxorubicin in patients with advanced breast or ovarian cancers: New York Cancer Consortium Trial P7229

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Background: Ixabepilone (IX) is a semisynthetic epothilone B analog with activity in patients (pts) with taxane refractory cancer. Two phase III clinical trials in breast cancer (BC) and a phase II study in ovarian cancer (OC) have recently been completed. Pegylated liposomal doxorubicin (PLD) is used for the treatment of platinum refractory OC and has activity in patients with metastatic BC. Methods: We have completed enrollment of a phase I study of PLD IV and ixabepilone IV over 3 hours. 18 pts with metastatic cancer (10 BC and 8 OC) with median age 51 were enrolled from 1/13/06 to 12/22/06. A total of 60 cycles has been administered to date. 3 OC patients enrolled at dose level 3 have not yet completed 2 cycles of treatment and are not yet evaluable. Results: Dose limiting toxicities (DLT) based on toxicities experienced during the first 2 cycles is provided in the table below. Adverse events (AE) occurring in any cycle were: Grade 4 AE: neutropenia < 7 days (1 pt). Grade 3 AE: palmar plantar erythrodysesthesia (PPE) (4), mucositis (3), infection (2), fatigue (2), neutropenia (2), thrombocytopenia (2), anemia (1), neuropathy (1), bilirubin (1). Non-hematological grade 2 AEs included: mucositis (4), PPE (3), infection (2), neuropathy (2), rash (3), pain (3), fever (1), myalgias (1), and anorexia (1). Responses so far for 10 BC pts are PR (1) SD (3) PD (6) and for 5 OC pts are PR (1) SD (2) PD (2). Updated results will be presented. Conclusions: Although the recommended phase II dose when given every 3 weeks is 30 mg/m2 for PLD and 32 mg/m2 for IX by our criteria, PPE and mucositis became problematic when treatment was continued beyond 2 cycles. We are therefore exploring a 4 week PLD schedule, evaluating IX given either every 4 weeks (as shown) or weekly (on days 1, 8, and 15). A phase II trial of the combination in platinum refractory OC will be initiated upon completion of the phase I. Supported by N01-CM-62204

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Epithelial ovarian carcinoma and European birthplace of grandparents

OBJECTIVE

The aim of this study was to determine whether the risk of ovarian carcinoma was related to latitude or to genetically based patterns of European geographic origin.

PATIENTS AND METHODS

We studied the countries of origin of European-born grandparents of 168 newly diagnosed patients in two hospitals in New York City, compared with 159 controls from similar neighborhoods. We measured the risk of this cancer associated with having one or more white, non-Jewish grandparents born in North Europe versus none or in South Europe versus none. We also classified geographic origins in other ways to reflect the two main trends in genetic variations between Europeans mapped by Cavalli-Sforza et al. (The History and Geography of Human Genes, Princeton University Press, Princeton, 1994). Unconditional logistic regression was used to control for age, parity, years of use of oral contraception, age at menarche, education, Catholic religion, and area of residence and for numbers of Jewish grandparents, siblings, and first-degree relatives with breast or ovarian cancer.

RESULTS

Approximately half of the subjects had least one white, non-Jewish grandparent born in Europe. There was no significant effect of ancestral latitude: among women born in the United States the odds ratio (OR) and 95% confidence limits associated with North European ancestry were 0.87 (0.47--1.63) compared with a reference group of women with no such ancestry. The corresponding OR for South Europe was 0.73 (0.39--1.74). Using the genetically based classifications of countries of origin, however, we found significant differences between cases and controls; ancestries from North West Europe and those from countries concentrically near Spain showed lower risks of ovarian carcinoma.

CONCLUSIONS

The results support the hypothesis that the previously observed effects of latitude must act through environmental effects or through gene-environment interactions. Other variations in risk related to geographic origins are consistent with known patterns of genetic differences, but require confirmation in larger, population-based studies.

Infrared spectroscopic study of cervical smears in patients with HIV: implications for cervical carcinogenesis

Patients with HIV have an increased incidence of cervical cancer, necessitating increased surveillance. Infrared spectroscopy (IRS) has the potential of aiding the diagnosis of cervical neoplasia and also of providing clues into its pathogenesis. We studied by IRS cervical scrapings from 22 HIV-infected and 23 control women; 8 of the former and none of the latter had dysplasia. The infrared spectra followed three patterns, designated pattern I (similar to that previously associated with normal cervical samples), pattern II (intermediate between patterns I and III), and pattern III (associated with cervical neoplasia). Compared with HIV-negative controls, HIV-infected women had a higher prevalence of pattern III and a lower prevalence of pattern II; these differences were statistically significant (P = .015 by chi2 analysis). Similar spectroscopic changes were present even when only the cytologically normal samples from HIV-positive and HIV-negative women were analyzed. We speculate that these changes may reflect early structural changes associated with cervical neoplasia that are not detectable cytologically. The infrared spectra in the region 950 to 1,300 cm(-1) could not differentiate cervical samples from HIV-infected and uninfected patients. The potential practical applications of IRS in HIV cervical disease are discussed.

Postoperative high dose-rate intravaginal brachytherapy combined with external irradiation for early stage endometrial cancer: a long-term follow-up

PURPOSE

To evaluate the long-term control of disease and cure rate, complications, second malignancy, and survival of early-stage endometrial cancer patients treated with surgery, high dose-rate brachytherapy, and external beam radiation therapy.

METHODS AND MATERIALS

From 1969 through 1979, 300 patients with clinically staged Stage I-II endometrial cancer underwent total abdominal hysterectomy and bilateral salpingo-oopherectomy, followed by high dose-rate intravaginal radiation, 7 Gy x 3 to 0.5 cm from the mucosal surface, using a remote afterloading technique. External beam radiation therapy, 40 Gy to midplane in 4 weeks, was delivered to high risk patients through AP/PA and lateral fields.

RESULTS

The patients were followed for 5-24 years (median 12). The actuarial progression-free survival rate was 96.6%. Post-treatment grade 1-2 actuarial complication rate was 9.5%, including cystitis (4.5%), vaginal stenosis (2.5%), proctitis (1.5%), vaginal necrosis (0.5%), and partial bowel obstruction (0.5%). Neither grade 3-4 complications nor additional late complications were observed in any of our patients. Relapse rate was only 3.7%, of which 45.5% were local, 45.5% were distant, and 9% were mixed. All the patients with relapse were postmenopausal, age range of 58-77 years, with tumor grade 2-3 in 64%. Second primary cancer rate was 12.8% (mostly breast and colon). Factors that were associated with improved prognosis were young age, premenopausal, low grade, no extrauterine disease, and a histology of adenocarcinoma (adenocarcinoma with squamous metaplasia).

CONCLUSION

High dose rate intravaginal radiation therapy combined with surgery and external beam radiation therapy achieved a high cure rate small number of minor complications. No long-term treatment-related complications were noted in any of the patients. This treatment combination may be safely applied to patients with early stage endometrial cancer.

Advanced-stage endometrial cancer: contributions of estrogen use, smoking, and other risk factors

The contributions of estrogen replacement therapy, smoking, and other risk factors to the development of advanced-stage (2-4) endometrial cancer were evaluated in a case-control study of women 40-69 years old from upstate New York. Eighty-four cases and 168 matched community controls were interviewed in person about estrogen exposure and other risk factors. Despite a statistically significant increase in risk with longer use of estrogen pills (P less than 0.05), estrogen exposure actually contributed little to the overall risk of advanced-stage endometrial cancer. Other physical conditions (increased weight, lower parity, diabetes) and socioeconomic factors (education, access to medical services) largely accounted for advanced-stage disease. The evidence in this study does not support the hypothesis that women who smoke have a lower risk than nonsmokers of developing advanced-stage endometrial cancer.

Smoking, body weight, and early-stage endometrial cancer

The effect of cigarette smoking on the risk of early-stage endometrial cancer was evaluated in a population-based case-control study of women aged 40 to 69 years from upstate New York. Two hundred women with early-stage endometrial cancer diagnosed between 1979 and 1981, and 200 matched community controls were interviewed in person and asked about smoking habits and other risk factors. Statistical analysis revealed a significant decline in relative risk with increased smoking (P less than 0.05). This effect strongly modified the well-known increase in risk with body weight. Among smokers risk did not increase with body weight, whereas among nonsmokers risk increased rapidly with body weight, especially among nonsmokers in whom the peripheral conversion of androgens was the primary source of serum estrogen. Despite this apparent reduced risk for endometrial cancer, smoking remains a major health hazard for women as well as men.

Antibodies to the neutral glycolipid asialo ganglio-N-tetraosylceramide: association with gynecologic cancers

As part of our efforts to define subpopulations at increased risk for gynecologic malignancies, sera from 145 women were obtained prior to diagnosis and analyzed for antibody to asialo ganglio-N-tetraosylceramide. This neutral glycolipid is present on the surface of thymocytes and natural killer cells, and asialo ganglio-N-tetraosylceramide antibody has been shown in animals to block natural killer cell activity and promote tumor cell proliferation. With the use of an enzyme-linked immunosorbent assay and with a value of 2 SD above the mean for healthy women designated as the boundary for a positive response, antibody to asialo ganglio-N-tetraosylceramide was detected in only one of 30 (3%) healthy women, none of 16 pregnant women, none of 18 women with benign masses, and two of 24 (8%) women with microbial infections. All of the above samples that contained antibodies were barely over the 2 SD limit. In marked contrast, 19 of 35 (54%) women with gynecologic malignancies had asialo ganglio-N-tetraosylceramide antibodies, with positive values ranging to greater than 10 SD above the control mean. Asialo ganglio-N-tetraosylceramide antibody was found in six of eight (75%) patients with cervical cancer, five of eight (63%) with endometrial cancer, and seven of 15 (47%) with ovarian cancer. Of the eight patients with Stage I gynecologic cancer at any site, five (62%) had asialo ganglio-N-tetraosylceramide antibodies. Four of 22 (18%) women with Hodgkin's disease also had antibodies, with values just exceeding 2 SD above control levels. The presence of these antibodies may contribute to an impaired immune surveillance system in these women and so increase their susceptibility to malignancy.

Analysis of sera from ovarian cancer patients for immune complexes

In contrast to other malignancies, circulating immune complexes (CICS) are usually not detected by conventional assays in the sera of ovarian cancer patients. However, a polyethylene glycol (PEG) precipitation assay has been reported to detect putative CICS in ovarian cancer. To determine if CICS were indeed present, we analyzed sera from 12 women with ovarian cancer. All were negative for CICS by the Raji cell assay; 5 (42%) were positive by the PEG assay. However, the PEG precipitate did not possess characteristics of immune complexes. IgG in sera or in the precipitate sedimented in sucrose gradients solely at the same rate as 7S monomeric IgG. In addition, the precipitates were not able to activate the complement system and the four IgG subclasses were present in the same relative concentration as that found in normal serum. The results suggest that it is probably a misnomer to label the material detected in ovarian cancer sera by the PEG precipitation assay as CICS. Instead a non-immune interaction of IgG with other components, possibly membrane fragments, is probably being measured.

An epidemiologic case-control study of ovarian cancer and reproductive factors

A population-based case-control study was conducted with 403 white, ovarian cancer patients, 20-79 years of age, who were diagnosed from October 1977 through February 1980 in 11 New York State counties. The study also included 806 controls who were matched to the cases by age, race, and county of residence. The contraceptive and reproductive patterns observed in this study suggest that infertility plays an important role in determining the relationship between reduced parity and gravidity and increased ovarian cancer risk. Ovarian cancer patients were less likely than controls to have ever used nonpermanent birth control methods (relative risk = 0.63, 95% confidence interval = 0.45-0.89), and they tended to practice contraception less often. A direct graded-response relationship was observed between ovarian cancer risk and the number of contraceptive-free years of marriage (chi 2 Linear trend = 5.911, p = 0.02). An inverse graded-response relationship was observed between gravidity and risk. This relationship persisted even after contraception was taken into account (chi 2 Linear trend = 13.002, p = 0.0003). Ovarian cancer risk was not found to be associated with an excess in reported fetal loss.