Cisplatin Reduces the Frequencies of Radiotherapy-Induced Micronuclei in Peripheral Blood Lymphocytes of Patients with Gynaecological Cancer: Possible Implications for the Risk of Second Malignant Neoplasms

Gynaecologic cancers are common among women and treatment includes surgery, radiotherapy or chemotherapy, where the last two methods induce DNA damage in non-targeted cells like peripheral blood lymphocytes (PBL). Damaged normal cells can transform leading to second malignant neoplasms (SMN) but the level of risk and impact of risk modifiers is not well defined. We investigated how radiotherapy alone or in combination with chemotherapy induce DNA damage in PBL of cervix and endometrial cancer patients during therapy. Blood samples were collected from nine endometrial cancer patients (treatment with radiotherapy + chemotherapy-RC) and nine cervical cancer patients (treatment with radiotherapy alone-R) before radiotherapy, 3 weeks after onset of radiotherapy and at the end of radiotherapy. Half of each blood sample was irradiated ex vivo with 2 Gy of gamma radiation in order to check how therapy influenced the sensitivity of PBL to radiation. Analysed endpoints were micronucleus (MN) frequencies, apoptosis frequencies and cell proliferation index. The results were characterised by strong individual variation, especially the MN frequencies and proliferation index. On average, despite higher total dose and larger fields, therapy alone induced the same level of MN in PBL of RC patients as compared to R. This result was accompanied by a higher level of apoptosis and stronger inhibition of cell proliferation in RC patients. The ex vivo dose induced fewer MN, more apoptosis and more strongly inhibited proliferation of PBL of RC as compared to R patients. These results are interpreted as evidence for a sensitizing effect of chemotherapy on radiation cytotoxicity. The possible implications for the risk of second malignant neoplasms are discussed.

Incidence and clinical course of septic shock in neutropenic patients during chemotherapy for gynecological cancers

OBJECTIVE

To identify the incidence and clinical course of septic shock combined with neutropenia during chemotherapy in gynecological cancer patients.

METHODS

We retrospectively reviewed the medical records of all gynecological cancer patients who received intravenous chemotherapy between March 2009 and March 2018. Patients diagnosed with neutropenic septic shock (NSS) during the course of chemotherapy were identified. We calculated the overall incidence and mortality rate of NSS, and analyzed risk factors and clinical course.

RESULTS

A total of 1,009 patients received 10,239 cycles of chemotherapy during the study period. Among these, 30 (3.0%) patients had 32 NSS events, of which 12 (1.2%) died. With respect to patient age during the first course of chemotherapy, the incidence of NSS after the age of 50 was significantly higher than that in patients under 50 (3.9% vs. 1.4%, p=0.034). As the number of chemotherapy courses increased, the incidence of NSS increased, and linear-by-linear association analysis showed a positive correlation (p=0.004). NSS events occurred on average 7.8 days after the last cycle of chemotherapy, and the median duration of vasopressor administration was 23.3 hours. The median age (64.0 vs. 56.5, p=0.017) and peak heart rate (149.5 min-1 vs. 123.5 min-1, p=0.015) were significantly higher in the group of patients who subsequently died of NSS than in those who survived.

CONCLUSION

The overall incidence of NSS in gynecological cancer patients receiving chemotherapy was 3.0%, which is higher than previously estimated. Peak heart rate during NSS events may be an indicator for predicting survival.

Targeted therapies in gynecological cancers: a comprehensive review of clinical evidence

Advanced and recurrent gynecological cancers are associated with poor prognosis and lack of effective treatment. The developments of the molecular mechanisms on cancer progression provide insight into novel targeted therapies, which are emerging as groundbreaking and promising cancer treatment strategies. In gynecologic malignancies, potential therapeutic targeted agents include antiangiogenic agents, poly (ADP-ribose) polymerase (PARP) inhibitors, tumor-intrinsic signaling pathway inhibitors, selective estrogen receptor downregulators, and immune checkpoint inhibitors. In this article, we provide a comprehensive review of the clinical evidence of targeted agents in gynecological cancers and discuss the future implication.

Risk factors for bloodstream infections in gynecological cancer

OBJECTIVE

Infections are a threat to frail patients as they have a higher risk of developing serious complications from bloodstream pathogens. The aim of this study was to determine which factors can predict or diagnose bloodstream infections in patients with an underlying gynecologic malignancy.

MATERIALS AND METHODS

Between July 2016 and December 2017, 68 patients visiting the emergency room with an underlying gynecologic malignancy were evaluated. Variables concerning underlying disease, invasive procedures, and laboratory and clinical parameters were analyzed. Patients were divided into three groups based on their blood and urine specimens (positive blood specimens, positive urine specimens, and no positive specimens; patients who had both positive blood and urine specimens were included in the group of positive blood specimens). Risk factors for surgical site infections, recent (<30 days) surgery, and chemotherapy were studied separately.

RESULTS

68 patients were included in the analysis. Mean age was 55.6 years (standard deviation 14.1). 44% of patients had ovarian cancer, 35% cervical cancer, 12% endometrial cancer, and 9% had other cancer types. In total, 96% of all patients had undergone surgery. Patients who had been treated with chemotherapy were at a higher risk of developing bloodstream infection (P=0.04; odds ratio (OR)=7.9). C reactive protein, bilirubin, and oxygen saturation (SO₂) were significantly different between patients with an underlying infection and those who had none. Only C reactive protein maintained its significance in a linear model, with a cut-off of 180 mg/L (linear regression, P=0.03; OR=4).

CONCLUSIONS

Chemotherapy is a risk factor for the development of bloodstream infections in patients with an underlying gynecologic malignancy; C reactive protein could be a useful tool in making this diagnosis.

Clinical Evaluation of Serum Aminoterminal Propeptide of Type III Procollagen as Tumor Marker in Gynecologic Malignancies

Aims

The aim of this study was to determine the possible usefulness of the assay of the aminoterminal propeptide of type III procollagen and fibronectin in detecting connective tissue changes associated with gynecologic malignancies.

Study Design

Serum aminoterminal propeptide of type III procollagen and plasma fibronectin were measured in 36 women with gynecologic malignancies, 20 women with benign gynecologic tumors and 10 healthy women serving as controls.

Results

A significant serum propeptide was significantly high In the group with gynecologic malignancies and normal in the benign tumor group. The serum propeptide levels were related to of disease stage and presence of ascites in patients with ovarian carcinoma but not in those with cervical or endometrial carcinoma. In the follow-up study, a favorable clinical response was associated with normalizing propeptide levels whereas in rapidly progressive disease the levels fell initially but rose again. In partial response with ultimate progression, the propeptide concentration decreased but remained clearly above the normal range. No difference in plasma fibronectin was found among the malignant tumor, benign tumor and control groups.

Conclusions

The present study indicates that the aminoterminal propeptide of type III procollagen could serve as an additional, non specific marker to follow the clinical behavior of gynecologic malignancies and consequently of connective tissue metabolism reflecting tumor matrix interaction.

Plasma D-Dimer Measurement as a Marker of Gynecologic Tumors: Comparison with CA 125

Background

Fibrin is formed and degraded Intra-abdominally in ovarian cancer, and the cross-linked fibrin degradation product, D-dimer (D-D), has been found in increased concentrations In the plasma of these patients.

Methods

D-dimer and Ca 125 levels were determined simultaneously in 110 patients with gynecologic neoplasms. D-dimer and Ca 125 assays were performed using the Dimertest Stripwell EIA Kit (Ortho) and CA 125-11 EIA assay (Roche), respectively.

Results

D-dimer plasma and Ca 125 serum levels were significantly higher in patients with ovarian cancer (mean ± SE = 894.2 ± 173.7 ng/ml and 760.5 ± 292.7 U/ml, respectively) than in those with uterine cancer (mean DD ± SE = 109.7 ± 23.5 ng/ml and mean Ca 125 ± SE = 50.0 ± 23.1 U/ml) or those with benign disease (mean D-D ± SE = 70.5 ± 5.5 ng/ml and mean Ca 125 ± SE = 6.6 ± 2.8 U/ml). The levels of both markers Increased with regard to ovarian cancer disease status. Mean D-D ± SE was 90.0 ± 22.8 ng/ml and mean Ca 125 ± SE was 2.1 ±1.2 U/ml in patients with complete remission; mean D-D ± SE was 143.3 ± 33.5 ng/ml and mean Ca 125 ± SE was 26.2 ± 13.6 U/ml in patients with partial remission. In active disease, both markers had very high levels: D-D mean ± SE = 1021.6 ± 173.0 ng/ml and Ca 125 mean ± SE = 1154.7 ± 458.1 U/ml. In all groups of ovarian cancer patients, D-dimer sensitivity was better than that of Ca 125. In advanced ovarian cancer patients, the D-dimer concentration in ascites was up to 100 fold that in plasma.

Conclusions

Our results suggest that D-dimer can serve as a sensitive indicator to monitor the extent and course of the disease in ovarian cancer patients. The patient follow-up is ongoing to establish the predictive value of D-dimer measurement with respect to prognosis.

Associations between serum vitamin D and the risk of female reproductive tumors: A meta-analysis with trial sequential analysis

BACKGROUND

Female reproductive tumors are common with high morbidity and mortality worldwide; however, the association between gynecological tumors and serum vitamin D is controversial. The aim of this meta-analysis was to evaluate the relationship between insufficiency of serum vitamin D and the occurrence of benign and malignant gynecological tumors.

METHODS

Studies from inception to June 2017 were searched in the electronic databases: National Library of Medicine (PubMed), Web of Science (Clerivate), and Cochrane Database of Systematic Reviews (Cochrane Library, CDSR) by 2 investigators independently. Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using a random-effects model. STATA 12.0 Software and Trial Sequential Analysis (TSA) software were applied for data analyses.

RESULTS

Overall, 8 studies (including 2391 patients and 5798 patients with and without female reproductive tumors, respectively) were eligible for the present meta-analysis. In the subsequent meta-analysis, the occurrence of vitamin D deficiency in the case and control groups were 52.36% and 48.70%, respectively; women with female reproductive benign and malignant tumors were 55.57% and 50.59%, respectively. Although, no conclusive association was found between vitamin D deficiency and female reproductive tumors (OR, 1.05; 95% CI, 0.85-1.31); vitamin D deficiency may be a risk factor of malignant female reproductive neoplasm, as shown by the pooled OR (95% CI):1.17 (1.02-1.33). Furthermore, based on the OR values, association of vitamin D insufficiency with disease type, study location, number of patients, and methods for detecting CLA was observed. Similar results in the sensitivity analysis were observed. TSA showed that the cumulative Z-curve crossed the traditional boundary line, rather than crossing the trial sequential monitoring boundary. However, the cumulative information failed to reach the required information size.

CONCLUSIONS

Currently, vitamin D deficiency appears to be a common issue in females, and there may be an urgent need to improve the level of vitamin D. Furthermore, vitamin D deficiency may be a non-negligible risk factor of malignant female reproductive neoplasm. Undoubtedly, more trials are required in the future according to TSA.

The clinical value of serum TPS in gynecological malignancies

This study included 75 cases; 39 with gynecological cancer of different types, stages, and grades (14 ovarian, 11 endometrial, 9 cervical, and 5 vulvovaginal); 23 patients with benign gynecological diseases and 13 normal healthy controls. Serum TPS was estimated using the ELISA kit supplied by Beki Diagnostic AB, Bromma, Sweden. The results of the present study revealed that serum TPS was significantly elevated in cancer patients followed by those with benign diseases. When the cutoff values were adjusted to 137 and 101 U/L, we obtained sensitivities of 56.4% and 82.1% at specifities of 100% and 85%, respectively. The benign diseases group had false positive rates of 13% and 34.8%, respectively. When considering tumor site, vulvo vaginal cancer showed the highest sensitivity (80%) followed by cervical (66.7%), ovarian (50%), and lastly endometrial cancer (45.5%). Serial measurement of TPS was shown to be of important value in the post-surgical follow-up of cancer patients.

Combined detection of tumor markers and serum inflammatory factors in the diagnosis and treatment of gynecologic oncology

In recent years, gynecologic cancer has become the third leading cause of death for women world-wide. Serum tumor markers and inflammatory factors have been shown to be useful in the diagnosis of gynecological tumors. Therefore, the clinical value of the combined detection of tumor markers and serum inflammatory factors in the diagnosis of gynecologic oncology was studied. One hundred patients with gynecological tumors admitted to our hospital were selected as the tumor group, and 50 healthy volunteers were selected as the control group. According to clinical diagnosis, the tumor group was divided into a malignant tumor group and a benign tumor group. The levels of CA199, CA125, and CEA in each serum were measured by the Elecsys2010 automatic electrochemiluminescence immunoassay system. The levels of serum TNF-α and IL-17 were determined by enzyme-linked immunosorbent assay (ELISA). Our results showed that, when compared with the control group, the levels of CA199, CA125, CEA, TNF-α, and IL-17 in serum of the benign tumor group were significantly increased (P<0.001), and were further increased in the malignant tumor group. Moreover, the positive detection rates of combined detection of CA199, CA125, CEA, TNF-α, and IL-17 for malignant and benign tumors were significantly higher than that of single detection (P<0.05), and the positive detection rate of combined detection of malignant tumors was significantly higher than that of benign tumors (P<0.05). These results indicate that the combined detection of inflammatory factors and tumor markers has a high clinical value in the diagnosis and treatment of gynecological tumors and is worth adopting.

Incidence of Venous Thromboembolism by Type of Gynecologic Malignancy and Surgical Modality in the National Surgical Quality Improvement Program

BACKGROUND

Women with gynecologic cancer are at higher risk of venous thromboembolism (VTE) due to malignancy, pelvic surgery, increased age, and frequently comorbidities. The rate of VTE among different gynecologic cancers and relative to benign gynecologic surgeries has not been reported in a nationally representative cohort.

METHODS

Using the American College of Surgeons National Surgical Quality Improvement Program database, gynecologic surgeries were identified retrospectively from 2006 to 2012. Clinical characteristics, surgical procedures, and 30-day postoperative complications were abstracted. Multivariable logistic regression models were performed.

RESULTS

Of all gynecologic surgeries (n = 104,368), 11,427 were performed for malignancy: 2.7% (n = 2800) for ovarian cancer, 6.8% (n = 7114) for uterine cancer, 1.0% (n = 1026) for cervical cancer, and 0.5%(n = 487) for vulvar cancer. 202 (1.8%) patients experienced a VTE. Ovarian cancer had a deep venous thrombosis and pulmonary embolism rates of 1.6% and 1.5% compared with uterine cancer, 0.8% and 0.8%, respectively. Ovarian cancer patients were 1.8 (95% confidence interval [CI], 1.19-2.65) times more likely to have a deep venous thrombosis and 1.7 (95% CI, 1.11-2.51) times more likely to have a pulmonary embolism than patients with uterine cancer. Compared with all gynecologic cancer surgeries, ovarian cancer patients were 1.5 times more likely to have a VTE (95% CI, 1.10-2.16). Patients undergoing minimally invasive surgery were 64% less likely to have a VTE regardless of malignancy site; however, if they had disseminated disease, they remained at higher risk of VTE (odds ratio, 5.96; P = 0.027).

CONCLUSIONS

Of gynecologic cancer surgeries, ovarian cancer patients had the highest rate of VTE. Venous thromboembolism rates were lower in those who had minimally invasive surgery but remained higher in those with disseminated disease.

Serum lipid profile in gynecologic tumors: a retrospective clinical study of 1,550 patients

BACKGROUND

The study was performed to characterize and compare the serum lipid profile in gynecologic cancers and benign diseases.

MATERIALS AND METHODS

A total of 1,550 age-matched females were included in this study: 760 patients with gynecologic cancers and 790 patients with benign diseases. Serum levels of triglycerides (TG), high density lipoprotein cholesterol (HDL-c), low density lipoprotein cholesterol (LDL-c), total cholesterol (TC), and lipoprotein (a) were measured.

RESULTS

Compared to gynecologic benign disease group, gynecologic cancer group was associated with higher level of TG (p = 0.0002), as well as lower level of HDL-c (p < 0.0001), LDL-c (p = 0.004) and TC (p = 0.003). Compared to benign ovarian tumor group, ovarian cancer group had significantly lower levels of HDL-c (p < 0.0001), LDL-c (p = 0.0009), and TC (p < 0.0001), as well as a trend of higher level of lipoprotein (a) (p = 0.10). Compared to endometriosis group, endometrial cancer group showed higher levels of TG (p < 0.0001) and lower levels of HDL-c (p = 0.002). There was no significant difference in any lipid parameters between cervical cancer group and uterine leiomyomas group.

CONCLUSION

In conclusion, compared with benign diseases, gynecologic cancers are associated with a disordered lipid profile characterized by higher TG and lipoprotein (a) levels, and lower HDL-c, LDL-c, and TC levels. The association is most conspicuous in ovarian cancers. Endometrial cancer is accompanied by alterations only in TG and HDL-c levels, while cervical cancer does not appear to be associated with disordered lipid profile.

Personalized Circulating Tumor DNA Biomarkers Dynamically Predict Treatment Response and Survival In Gynecologic Cancers

BACKGROUND

High-grade serous ovarian and endometrial cancers are the most lethal female reproductive tract malignancies worldwide. In part, failure to treat these two aggressive cancers successfully centers on the fact that while the majority of patients are diagnosed based on current surveillance strategies as having a complete clinical response to their primary therapy, nearly half will develop disease recurrence within 18 months and the majority will die from disease recurrence within 5 years. Moreover, no currently used biomarkers or imaging studies can predict outcome following initial treatment. Circulating tumor DNA (ctDNA) represents a theoretically powerful biomarker for detecting otherwise occult disease. We therefore explored the use of personalized ctDNA markers as both a surveillance and prognostic biomarker in gynecologic cancers and compared this to current FDA-approved surveillance tools.

METHODS AND FINDINGS

Tumor and serum samples were collected at time of surgery and then throughout treatment course for 44 patients with gynecologic cancers, representing 22 ovarian cancer cases, 17 uterine cancer cases, one peritoneal, three fallopian tube, and one patient with synchronous fallopian tube and uterine cancer. Patient/tumor-specific mutations were identified using whole-exome and targeted gene sequencing and ctDNA levels quantified using droplet digital PCR. CtDNA was detected in 93.8% of patients for whom probes were designed and levels were highly correlated with CA-125 serum and computed tomography (CT) scanning results. In six patients, ctDNA detected the presence of cancer even when CT scanning was negative and, on average, had a predictive lead time of seven months over CT imaging. Most notably, undetectable levels of ctDNA at six months following initial treatment was associated with markedly improved progression free and overall survival.

CONCLUSIONS

Detection of residual disease in gynecologic, and indeed all cancers, represents a diagnostic dilemma and a potential critical inflection point in precision medicine. This study suggests that the use of personalized ctDNA biomarkers in gynecologic cancers can identify the presence of residual tumor while also more dynamically predicting response to treatment relative to currently used serum and imaging studies. Of particular interest, ctDNA was an independent predictor of survival in patients with ovarian and endometrial cancers. Earlier recognition of disease persistence and/or recurrence and the ability to stratify into better and worse outcome groups through ctDNA surveillance may open the window for improved survival and quality and life in these cancers.

Serum levels of the progesterone induced blocking factor do not precipitously rise in women with gynecologic cancer in contrast to women exposed to progesterone

PURPOSE

To determine if an immunomodulatory protein (progesterone induced blocking factor [PIBF]) that is progesterone induced and found in higher concentration during pregnancy is similarly found with increased levels in women with gynecologic cancers.

MATERIALS AND METHODS

A newly developed enzyme linked immunoabsorbent assay (ELISA) assay was used to measure PIBF in the sera of six women with various gynecologic cancers and compare them to five controls (three with benign tumors and two having gynecologic procedures for non-tumors.

RESULTS

The PIBF levels in women with gynecologic cancer did not rise precipitously as historical controls of women or men exposed to progesterone. The two highest PIBF levels of the 11 subjects were in women with gynecologic cancer.

CONCLUSIONS

The data suggest that if PIBF helps cancer cells to evade immune surveillance, it probably operates through an intracytoplasmic presence. If an increase in sera PIBF could have been detected in women with gynecologic cancer, then this ELISA test could have been used to detect tumor recurrence. Future studies may concentrate on evaluating intracytoplasmic PIBF to possibly help determine which tumors may respond to progesterone antagonist receptors.

A prospective study of gynecological cancer risk in relation to adiposity factors: cumulative incidence and association with plasma adipokine levels

Background

Associations of obesity and obesity-related metabolic factors (adiposity factors) with uterine corpus cancer (UCC) and ovarian cancer (OVC) risk have been described. Still, a cause-effect relationship and the underlying mediators remain unclear, particularly for low-incidence populations. We aimed to prospectively determine whether adiposity factors could predict the development of UCC and OVC in Taiwanese women. To explore the biological mediators linking adiposity factors to cancer risk, we examined the association of two adipokines, leptin and adiponectin, with the gynecological cancers.

Methods

Totally, 11,258 women, aged 30–65, were recruited into the Community-Based Cancer Screening Program (CBCSP) study during 1991–1993, and were followed for UCC and OVC cases until December 31, 2011. Cox proportional hazard models were used to estimate hazard ratios (HRs). Adiposity factors and risk covariates were assessed at recruitment. Newly-developed cancer cases were determined from data in the government’s National Cancer Registry and Death Certification System. For adipokienes study, a nested case-control study was conducted within the cohort. Baseline plasma samples of 40 incident gynecological cancer cases and 240 age-menopause-matched controls were assayed for adipokines levels.

Findings

There were 38 and 30 incident cases of UCC and OVC, respectively, diagnosed during a median 19.9 years of follow-up. Multivariate analysis showed that alcohol intake (HR = 16.00, 95% = 4.83–53.00), high triglyceride levels (HR = 2.58, 95% = 1.28–5.17), and years of endogenous estrogen exposure per 5-year increment (HR = 1.91, 95% = 1.08–3.38) were associated with increased UCC risk. High body mass index (BMI≥27 kg/m², HR = 2.90, 95% = 1.30–6.46) was associated with increased OVC risk. Analysis further showed an independent effect of adipokines on UCC and OVC risk after adjustment of the risk covariates.

Conclusion

We provided evidence that alcohol intake, high triglyceride levels and long endogenous estrogen exposure increase UCC risk, whereas obesity positively predicts OVC risk. Circulating adipokines may mediate the link of adiposity factors to gynecological cancer risk.

Perioperative venous thromboembolism in patients with gynecological malignancies: a lesson from four years of recent clinical experience

AIM

To analyze clinical characteristics of venous thromboembolisms (VTE) in gynecological malignancies, and to find a cost-effective prophylaxis procedure for post-operative VTE.

PATIENTS AND METHODS

We analyzed clinical characteristics of 751 patients who underwent definitive surgery for gynecologic malignancies, and cost-effectiveness of VTE prophylaxis.

RESULTS

VTE was diagnosed preoperatively in 4.5% of ovarian cancer cases, more frequently than any other type (p<0.005). Older age and greater length of operation were independent risk factors for postoperative VTE. To prevent eight VTEs in 738 malignant cases, which occurred during day 2 to 10, $617,783, $726,185, or $994,222 were necessary for continuous VTE prophylaxis, using either unfractionated heparin (UFH), low-molecular weight heparin or fondaparinux, respectively.

CONCLUSION

A strategy which might be cost-effective for post-surgical management of gynecological malignances is use of UFH three times combined with graduated compression stockings and intermittent pneumatic compression, thorough SpO2 monitoring, and perioperative measurements of the circumference of both sides of thighs and calves.

Venous thromboembolism (VTE) rates following the implementation of extended duration prophylaxis for patients undergoing surgery for gynecologic malignancies

OBJECTIVE

To compare the incidence of venous thromboembolism (VTE) before and after the implementation of standardized extended duration prophylaxis guidelines in women undergoing laparotomy for gynecologic cancer.

METHODS

In October 2009, departmental practice guidelines were implemented for VTE prevention. Patients undergoing laparotomy for gynecologic cancer were started on low molecular weight heparin (LMWH) within 24h of surgery and it was continued for a total of 28 days postoperatively. The incidence of VTE diagnosed within 30 and 90 days of surgery was determined and compared to a historic cohort of patients who underwent surgery prior to implementation of the guidelines.

RESULTS

The incidence of VTE within 30 days of surgery decreased from 2.7% (8/300) to 0.6% (2/334) following implementation of VTE prevention guidelines (78% reduction, p=0.040). However, when the pre and post-guideline implementation groups were compared for the development of VTE within 90 days of surgery, there was no significant difference (11/300 (3.7%) vs. 10/334 (3.0%) respectively, p=0.619). The median time between surgery and VTE diagnosis was 12 days in the pre-guideline implementation group, compared with 57 days in the post-guideline implementation group (p=0.012).

CONCLUSION

Patients receiving extended duration LMWH were found to have significantly lower rates of VTE within 30 days of surgery when compared with similar patients who did not receive extended duration LMWH. However, this effect was not sustained when the groups were compared for VTE diagnosis within 90 days of surgery. Additional study is needed to further reduce long-term VTE rates in this high-risk population.

Physiologic variations of serum tumor markers in gynecological malignancies during pregnancy: a systematic review

BACKGROUND

Recent insights provide support for the treatment of cancer during pregnancy, a coincidence that poses both mother and fetus at risk. Our aim was to critically review studies on the physiologic variations during pregnancy, the most common tumor markers used in diagnosis and follow-up of gynecological cancers.

METHODS

We conducted a systematic review of six tumor markers during normal pregnancy: carbohydrate antigen (CA) 15-3 (breast cancer); squamous cell carcinoma antigen (cervical cancer); and CA 125, anti-Müllerian hormone, inhibin B and lactate dehydrogenase (ovarian cancer).

RESULTS

For CA 15-3, 3.3% to 20.0% of all measurements were above the cut-off (maximum 56 U/mL in the third trimester). Squamous cell carcinoma antigen values were above cut-off in 3.1% and 10.5% of the measurements (maximum 4.3 µg/L in the third trimester). Up to 35% of CA 125 levels were above cut-off: levels were highest in the first trimester, with a maximum value up to 550 U/mL. Inhibin B, anti-Müllerian hormone and lactate dehydrogenase levels were not elevated in maternal serum during normal pregnancy.

CONCLUSION

During normal pregnancy, tumor markers including CA 15.3, squamous cell carcinoma antigen and CA 125 can be elevated; inhibin B, anti-Müllerian hormone and lactate dehydrogenase levels remain below normal cut-off values. Knowledge of physiological variations during pregnancy can be clinically important when managing gynecological cancers in pregnant patients.

Frequency of myeloid dendritic cells can predict the efficacy of Wilms' tumor 1 peptide vaccination

BACKGROUND

The object of this study was to investigate the clinical predictive capability of peripheral myeloid dendritic cells (DCs) in Wilms' tumor 1 (WT1) vaccine therapy for patients with gynaecological cancer.

PATIENTS AND METHODS

Six patients with WT1/human leukocyte antigen (HLA)-A*2402-positive gynaecological cancer were included in this study. The patients received intradermal injections of a modified 9-mer WT1 peptide every week for 12 weeks. Peripheral blood samples were obtained at 0, 4, 8 and 12 weeks after the initial vaccination. Circulating DCs were detected by flow cytometry.

RESULTS

The frequencies of CD14(+)CD16(+)CD33(+)CD85(+) myeloid DCs were significantly higher in the therapeutically effective group than in therapeutically inert group (p<0.05).

CONCLUSION

These results suggested that myeloid DCs, which should be associated with inducing cytotoxic T-cells, provided additional prognostic information in the use of cancer peptide vaccine.

[A new approach to studying anemia in patients with gynecological diseases and gynecological neoplasms]

The authors have used a coefficient that characterizes the functional activity of red blood cells. Evidence is provided for the significance of the coefficient, by comparing the groups of gynecological and gynecological cancer patients.

[Adnexal tumor and pregnancy: diagnosis and treatment]

BACKGROUND

The finding of adnexal masses during pregnancy is an exceptional event. Its reported incidence is less than 5% and most cases resolve spontaneously as the pregnancy progresses.

OBJECTIVE

Describe a case series of patients with adnexal mass and pregnancy.

MATERIAL AND METHODS

We retrospectively reviewed the medical records of patients who had diagnosis of pregnancy and adnexal over a period of five years.

RESULTS

The incidence was 0.22%. The mean age was 26 +/- 7.3 years, mean gestational age was 17 +/- 6.6 weeks. The diagnosis was established by ultrasound (USG) in 95% of cases, 48% had cystic characteristics, the mean diameter of the tumor was 99 +/- 42 mm. Cistectomy was performed during pregnancy or trans-cesarean section in 30% and 58% of patients respectably. The mean tumor size was 118 mm (range 2 a 40 mm), weight 1,370 g (range 10 a 5,800 g). The most frequent histological diagnosis were serous cyst (40%), mature teratoma (28%), mucinous (6%), malignancy (4%). There were not complications related to the surgical procedure.

CONCLUSIONS

The USG constitute a safe method for the diagnosis, but the image method with the highest positive predictive value is the MRI. Tumor markers (CA-125, AFP, GCH-B,DHL, ACE), are not useful during pregnancy. If the tumor doesn't achieve surgical criteria the recommended follow up is clinical observation and USG. If surgery is decided, it should be performed between 16 a 23 weeks of pregnancy, and it's recommended to send the tumor to histological diagnosis, in case of malignancy the surgery will continue according to the tumor stage. The time and delivery route will be decided by the obstetrician.

Fibronectin plasma levels in gynecological cancers

PURPOSE

Fibronectin (FBN) is involved in the motility and migration of malignant cells. The purpose of this study was to investigate FBN plasma levels in gynecological cancers patients and in healthy women.

METHODS

The study took place between 1998 and 2003. One hundred women with histologically diagnosed cancer of gynecological organs (cervix, ovary, endometrium, breast) formed the study group (group A), whereas the control group (group B) consisted of 100 healthy women. FBN plasma levels were measured with the radial immunodiffusion method.

RESULTS

The average age of group A patients was 42.08 years (range 33-77), and of group B it was 41.1 years (range 32-65). Both groups were compared with the Student's-t test. The median plasma value of FBN in all gynecological malignancies was 258.4 mg/l (standard deviation/SD 163.9, p=0.0066, t-statistics: 2.768, (t95): 1.984, 95% CI: 225.4-290.9). The plasma levels were significantly elevated when compared to the control group (median=213 mg/l). The distribution of values showed a statistically important "tail" in high plasma levels (FBN >400 mg/l). Plasma levels of FBN were more increased in breast and cervical malignancies when compared to ovarian and endometrial cancers.

CONCLUSION

FBN plasma levels were significantly increased in the total of group A patients, but not significantly increased in the endometrial and ovarian subgroup. Whether or not FBN could reliably be a marker for gynecological cancers should be confirmed in studies with larger number of patients.

Evaluation of the Risk of Malignancy Index in daily clinical management of adnexal masses

OBJECTIVE

To verify the effectiveness of the Risk of Malignancy Index in the discrimination between non-invasive (benign and borderline) lesions and invasive malignant adnexal masses in daily clinical practice.

METHODS

This prospective observational study was conducted in a multicentre cooperation of 11 hospitals. A total of 548 women with adnexal masses were included. Ultrasound characteristics, menopausal status and serum CA 125 level were registered preoperatively, and combined into the RMI afterwards. Final diagnosis was based on routine histopathologic examination. The decision to have patients operated by or with a gynecologic oncologist was based on the clinical impression of the gynecologist in the local hospital, based on physical examination, testing of serum samples, and ultrasound examination. This was compared with the hypothetical situation in which the RMI would have been applied as method of selection.

RESULTS

An RMI of 200 achieved a sensitivity of 81% and specificity of 85% in the detection of ovarian cancer. Positive and negative predictive values were 48% and 96% respectively. In current practice, 64% of ovarian cancer patients were operated by a gynecologic oncologist. This percentage would have increased to 80% if the RMI with a cutoff value of 200 would have been used as method of selection.

CONCLUSIONS

In our study population, introduction of the RMI would improve the management of adnexal masses, with a higher percentage of ovarian cancer patients that are operated by a gynecologic oncologist. At the same time, referral of patients with non-invasive (benign and borderline) lesions would be reduced.

The role of immunonutrition in gynecologic oncologic surgery

BACKGROUND

This study assesses the effect of immunonutrition on biochemical and hematological parameters, incidence of infection, postoperative complications, mortality rate and length of hospital stay.

MATERIAL AND METHODS

A total of 50 patients operated on for gynecological malignancies were randomly assigned to two groups, each receiving two days preoperative and seven days postoperative enteral nutrition after intestinal movements started. The patients in group 1 were given 1000 kcal/d immun-enhancing enteral nutrition (IEN). The patients in group 2 received 1000 kcal/d standard enteral nutrition. The nutritional (albumin, prealbumin), immunologic (CRP, white blood cell (WBC) count, lymphocyte population) parameters, length of hospital stay (LOS) and clinical outcomes were examined.

RESULTS

The two groups did not differ in terms of demographic data, nutritional status, surgical status, mortality rate (p > 0.05). WBC count, lymphocyte population, CRP levels were significantly higher in group 1 compared with group 2 in the postoperative period (p < 0.05). Pulmonary and urinary tract infection rates were similar in both groups (p > 0.05) but wound infection, and LOS rate were significantly lower in group 1 than group 2 (p < 0.05).

CONCLUSION

Perioperative immunonutrition proved to be safe and useful in increasing the immunologic response. It may decrease postoperative complications and LOS in patients undergoing surgery for gynecological malignancy.

Erythropoetin beta twice weekly versus standard therapy in patients with gynaecological malignancies--a randomised Austrian AGO trial

BACKGROUND

The influence of two regimens of erythropoetin beta on haemoglobin level, quality of life (QoL) and side-effects in patients with gynaecological malignancies was assessed.

PATIENTS AND METHODS

A total of 119 patients during chemotherapy were randomised to either standard therapy with 10,000 IU erythropoetin beta three times a week (group A) or 20,000 IU twice a week (group B). Haemoglobin level and QoL were measured. Characteristics of the study population were analysed with descriptive statistical methods. Analysis of variance for repeated measurements was performed with haemoglobin level as dependent variable, and time and study arms as factors.

RESULTS

The rise in haemoglobin levels and QoL improvement were significant, without any difference between study arms. Adverse events were similar, except significantly more thromboembolic events in group B (0 vs. 8 events; p = 0.003).

CONCLUSION

Our results show similar improvements in haemoglobin level and QoL, but raise the question whether less frequent dosing regimes may result in increased rates of thromboembolic events.

[Methylnitrosourea as challenge mutagen in assessment of the DNA mismatch repair (MMR) activity: association with some types of cancer]

Total repair capability is a widely used phenotypic marker of predisposition to cancer. Evaluation of this parameter implies using a challenge mutagen in an in vitro system to unmask latent genetic instability and repair insufficiency in the target cells. Traditionally, these investigations involve two tests, evaluation of mutagenic susceptibility (chromosomal aberrations) and genotoxic effect (DNA comet assay). The present study was focused on analysis of the effect of methylnitrosourea (MNU) on resting and PHA-stimulated lymphocytes from healthy donors and patients with gynecological cancer. Cytotoxic effect of MNU (apoptotic lymphocyte death) was estimated using two parameters, interaction of the cells with the annexin V-FITC complex, and morphological changes of the nuclei after their staining with the mixture of two DNA tropic dyes. The genotoxic effect of MNU, namely, secondary double-strand DNA breaks, was scored using the neutral comet assay, modified for the calculation of the comets produced exclusively by BrUdr-labeled proliferating lymphocytes. The proportion of these comets was represented as the proliferative cell index. It was shown that resting lymphocytes were resistant to genotoxic and cytotoxic effects of MNU. The response of proliferating cells to the action of MNU was expressed as the development of secondary DNA breaks (P <0.01), along with the increased frequency of apoptosis (P <0.05). The genotoxic effect of MNU on stimulated lymphocytes of gynecological cancer patients was fourfold lower compared to healthy donor lymphocytes. In response to the MNU action, patient lymphocytes did not change their proliferative index, while in healthy donor lymphocytes proliferative index was two times decreased in response to the MNU action. The data obtained pointed to the association between the cytotoxic response of the lymphocytes to the action of MNU and gynecological cancer. Since only proliferating lymphocytes response to the genotoxic effect of MNU, and the effect is revealed a day after the mutagen action, it is suggested that this phenomenon is associated with postreplicative repair, MMR, the substrate of which is O6-methylguanin. The MMR deficiency in patient lymphocytes determines their tolerance to the action of MNU. Genotoxic effect of lymphocytes to the action of MNU can serve as a marker of MMR, as well as of the MMR deficiency-associated gynecological cancer.

Urinary cyclic GMP after treatment of gynecological cancer. A prognostic marker of clinical outcome

BACKGROUND

The search for biological markers to predict malignant disease and its recurrence, or to monitor the effectiveness of treatment is a continuous process in medicine. Several years ago, urinary excretion of cGMP in urine was found to be a sensitive predictor in the follow-up of ovarian cancer and of monitoring treatment of cancer of the uterine cervix.

PATIENTS AND METHODS

In the present study, 27 patients with gynecological cancer, including cancer of the uterine cervix (n=13), cancer of the uterine corpus (n=8) and cancer of the ovaries (n=6), were monitored for 10 years. Blood and urinary samples were taken before primary treatment (baseline sample) and three months thereafter (three-month sample). The serum levels of CEA, CA-125 and PIIINP and urine excretion of cGMP and cAMP were determined. Creatinine levels in serum and urine were employed to determine renal clearance.

RESULTS

After 10 years' observation of women with cancer of the uterine cervix, seven patients showed no relapse and cGMP levels in baseline samples and three-month samples were 36.8+/-4.1 and 24.9+/-4.4 nmol cGMP/micromol creatinine (mean+/-SEM, p<0.01), respectively. The levels in patients (n=6) with relapse after 10 years' observation were 32.8+/-4.0 (baseline sample) and 43.5+/-4.2 (three-month sample) nmol cGMP/micromol creatinine (mean+/-SEM, p<0.02). Among the patients treated for cancer of the uterine corpus (n=9), none showed recurrent disease within the observation period of 10 years. The cGMP levels fell from 37.9+/-6.3 (baseline sample) to 22.3+/-2.3 (three-month sample) nmol cGMP/micromol creatinine (p<0.005). In the patients with ovarian cancer (n=6), 4 patients relapsed during the observation period of 10 years. In these women the cGMP levels increased from 34.5+/-2.7 (baseline sample) to 46.3+/-4.7 nmol cGMP/micromol creatinine whilst in both patients without relapse the levels decreased from 31.8 (range: 26.5-37.1) to 27.3 (range: 25.7-28.8) nmol cGMP/micromol creatinine, respectively. The changes in levels of cAMP, CEA, CA-125 and PIINP did not show statistically significant differences. Early changes in cGMP levels appear to predict long-term prognosis in gynecological cancers.

[Erythropoietin levels in perioperative period in cancer patients]

Anemia is frequent in cancer patients, is the result of decreased erythropoietin production. In fact in cancer, alteration of immune system alters iron metabolism and inhibits erythropoietin production. In this study we proposed to determine the profile of erythropoietin secretion in anaemic cancer patients in the pre and postoperative period. Our prospective study from January to March 2005 included 41 anemic cancer patients from 30 to 79 years old and 31 healthy individuals with iron deficiency anemia. A measure of erythropoietin, CRP, ferritin, iron levels and hemoglobin were released in healthy individuals and in cancer patients in preoperative period (J0) and postoperative period (J3, J8, J21). In preoperative period, the increase of serum erythropoietin was significantly lower in patients than in healthy individuals. In postoperative period, the levels of erythropoietin at J3 and hemoglobin's at J8 and J21 were significantly higher than in preoperative period (J0) (p < 0.05). In conclusion, despite the presence of inflammatory syndrome caused by surgery, cancer patients with anaemia increase their erythropoietin production in immediate postoperative period.

A diagnostic evaluation of serum human telomerase reverse transcriptase mRNA as a novel tumor marker for gynecologic malignancies

Human telomerase reverse transcriptase (hTERT) and epidermal growth factor receptor (EGFR) play an important role in many cancers including gynecological cancers. We previously reported the usefulness of a quantitative highly sensitive detection method for hTERT mRNA in the serum of cancer patients. By this method, we attempted to elucidate the diagnostic evaluation of serum hTERT mRNA for gynecologic malignancies. In 174 female patients with gynecological lesions (47 with ovarian lesions, 63 with uterine lesions, 2 with malignancies in other gynecological lesions, and 62 benign lesions) and 20 healthy individuals, we measured serum hTERT mRNA and EGFR mRNA by using the newly developed real-time quantitative RT-PCR. We examined their sensitivity and specificity in cancer diagnosis, clinical significance in comparison with conventional tumor markers, and their correlations with the clinical parameters by using multivariate analyses. Serum hTERT mRNA showed higher values in patients with gynecologic cancers than in those with benign diseases and healthy individuals. The hTERT mRNA level independently correlated with the presence of cancers (P=0.004 for both ovarian and uterine cancer) and clinical stage (P<0.001). The sensitivity and specificity of hTERT mRNA in cancer diagnosis was 74.4% and 74.1%, respectively. The hTERT mRNA level showed a significant correlation with CA125 by Pearson's relative test (P=0.035) and with histological findings in ovarian cancer by the Friedman test (P<0.004). EGFR mRNA did not display any differences between the diseases. hTERT mRNA is useful for diagnosing gynecologic cancer and is superior to conventional tumor markers. Therefore, serum hTERT mRNA is a novel and available biomarker for gynecologic malignancies.

Hematologic changes after splenectomy for cytoreduction: implications for predicting infection and effects on chemotherapy

Postsplenectomy leukocytosis and thrombocytosis are common findings in trauma patients. The intent of this study is to describe postsplenectomy hematologic changes in gynecological oncology surgery and subsequent chemotherapy. We performed a retrospective record review of gynecological oncology patients at our institutions. Postsurgical hematologic changes, infectious morbidity, and pre- and post-chemotherapy hematologic changes were noted. Data were analyzed using repeated measures analysis of variance. We identified 27 patients who underwent cytoreductive surgery with splenectomy. Thirteen patients with splenectomy had postoperative chemotherapy data available, and we matched these patients with 13 control patients who underwent cytoreduction surgery without splenectomy and postoperative chemotherapy. Nine of the 27 splenectomy patients had documented infectious morbidity. There was a significant difference in postoperative platelet counts between the infected and the noninfected splenectomy patients (P= 0.037), and a significant difference between splenectomy and control patients for white blood cell (WBC) counts (P = 0.007). Patients with splenectomy had higher precycle WBC, absolute neutrophil count (ANC), platelet counts, and higher postcycle nadir levels in all cycles compared to control patients. There was a significant overall difference between splenectomy patients and controls with regard to WBC (P = 0.001), ANC (P = 0.005), and platelet counts (P = 0.016) during chemotherapy cycles. Median postchemotherapy nadir WBC was 4.4 (range: 3.4-4.8) for the splenectomy group versus 2.8 (range: 2.5-3.0) for the control group. Median postchemotherapy nadir ANC was 1800 (range: 1320-2450) for the splenectomy group and 1001 (range: 864-1064) for the control group. Median postchemotherapy nadir platelet count was 222 (range: 181-277) for the splenectomy patients and 169 (range 164-215) for the control patients. In conclusion, the patients who undergo splenectomy as part of cytoreductive surgeries have a statistically significant leukocytosis and insignificant thrombocytosis relative to the control patients. Leukocytosis alone is not an accurate indicator of infection. Splenectomy is not associated with an increased risk of chemotherapy-related neutropenia and thrombocytopenia.

The antioxidative role of selenium in pathogenesis of cancer of the female reproductive system

Selenium, as a component of few antioxidant enzymes, participates indirectly in elimination of reactive oxygen species and in antioxidative defense of the organism. There is a correlation between the concentration of selenium, activity of glutathione peroxidases (GSH-Px), and other parameters of antioxidative defense in blood components. The above mentioned factors were suggested to play an important role in etiopathogenesis of neoplastic diseases. Therefore, the aim of our present study was to compare the selenium status and GSH-Px activity in the plasma of 22 healthy women, 50 individuals suffering from cancer of uterine cervix, uterine corpus or ovary, and 49 women diagnosed with benign neoplasia of the uterine corpus or ovary. In addition, the selenium concentration was measured in postoperative cancer tissues, benign tumors, and histopatologically healthy surgical margins of the aforementioned patients. An average selenium concentration and GSH-Px activity in blood plasma of cancer patients and benign neoplasia patients was significantly lower than in the plasma of healthy women. It suggests that lower overall selenium status and lower selenium-dependent antioxidative capacity of the organism might partly contribute to development of neoplastic diseases of reproductive system. Postoperative tissues of patients revealed significantly higher selenium concentrations in cancer tissues of uterine cervix and corpus, and benign tumors of uterine corpus, as compared to corresponding healthy tissue margins. Higher accumulation of selenium in these neoplastic tissues might reflect a compensatory up-regulation of antioxidant defense systems in tumors that often undergo a persistent oxidative stress.

Vaccination of Healthy Volunteers with Human Papillomavirus Type 16 L2E7E6 Fusion Protein Induces Serum Antibody that Neutralizes across Papillomavirus Species

Oncogenic human papillomavirus (HPV) infection is a necessary cause of cervical cancer. Therefore, vaccination to prevent or eliminate HPV infection could reduce the incidence of cervical cancer. A fusion protein comprising HPV16 L2, E6, and E7 is a candidate combination preventive and therapeutic HPV vaccine. The L1- and L2-specific and neutralizing serum antibody titers and peripheral blood mononucleocyte antigen-specific proliferative responses generated by vaccination thrice at monthly intervals with HPV16 L2E7E6 were compared in two studies: a phase I randomized double-blind placebo controlled dose escalation trial in 40 healthy volunteers and a phase II trial of HPV16 L2E7E6 at the maximum dose in 29 women with high-grade anogenital intraepithelial neoplasia (AGIN). Vaccination of healthy volunteers induced L2-specific serum antibodies that were detected 1 month after the final vaccination (P(binomial) < 0.001). There was a significant trend to seroconversion for HPV16 and HPV18 neutralizing antibodies with increasing vaccine dose (P = 0.006 and P = 0.03, respectively). Seroconversion for HPV18 neutralizing antibodies showed a significant positive trend with increasing dose (P = 0.03) and was associated with seroconversion for HPV16 neutralizing antibodies (P(exact) = 0.04). The antigen-specific proliferative response of vaccinated healthy volunteers also showed a significant trend with increasing vaccine dose (P = 0.04). However, AGIN patients responded less effectively to vaccination than healthy patients for induction of HPV16 L2-specific antibody (P < 0.001) and proliferative responses (P < 0.001). Vaccination of healthy volunteers thrice with 533-mug HPV16 L2E7E6 at monthly intervals induced L2-specific serum antibodies that neutralized across papillomavirus species. Responses in AGIN patients were infrequent.

Effectiveness of darbepoetin alfa versus epoetin alfa for the treatment of chemotherapy induced anemia in patients with gynecologic malignancies

OBJECTIVE

Chemotherapy induced anemia (CIA) commonly occurs in gynecologic oncology patients. This often leads to treatment with erythropoietic stimulating agents in order to prevent chemotherapy delays, dose modifications and transfusion of red blood cells. Our objective was to determine the subsequent transfusion rates following administration of either darbepoetin alfa or epoetin alfa.

METHODS

A single institution retrospective chart review was performed utilizing patients from January 2003 to September 2004 who received either darbepoetin alfa or epoetin alfa for CIA (Hgb < or = 10.0). Data collection variables included patient demographics, cancer diagnosis, chemotherapy treatment(s), laboratory data, erythropoeisis stimulation data, and transfusions. Sample size calculations were set to detect a 20% transfusion rate difference between the two groups. Chi-square, Fisher exact test and student t tests were used for statistical analysis.

RESULTS

123 patients were eligible for analysis (60 darbepoetin alfa; 62 epoetin alfa). 93% of darbepoetin alfa patients received 200 mg every other week, while 86% of epoetin alfa patients received 40,000 U weekly. The darbepoetin alfa and epoetin alfa groups were similar in respect to age, race, tumor type, histology, previous chemotherapy, number of chemotherapy agents, weeks of erythropoietic stimulation, and baseline serum levels of creatinine and hemoglobin. The mean baseline Hgb and change in Hgb was similar for each group (darbepoetin alfa = 11.2, 2.5 and epoetin alfa = 11.3, 2.3). Twenty one (35%) of the darbepoetin alfa patients received a transfusion of packed red blood cells compared to 12 (19%) of epoetin alfa patients (p = 0.05).

CONCLUSIONS

This retrospective analysis powered to detect differences in transfusion rates revealed a statistically significant difference in transfusion rates between darbepoetin alfa and epoetin alfa for the treatment of CIA. These data warrant a randomized prospective trial in gynecologic oncology patients with careful attention to the timing of initiation of treatment, dosing regimens, and titration of growth factor.

Mean of CA 125 in making therapy decision in adnexal inflammatory tumors

Laboratory findings such are white blood count and sedimentation rate are of relative value in inflammations of the upper genital tract and adnexal inflammatory tumors. Antibiotics are administrated in all cases according to the protocol but some of them need operative treatment also. Inflammatory tumors can develop in endometriotic and even in cancer adnexal masses. CA 125 is elevated in great number of patients with advanced ovarian cancer. It can also be elevated in endometriosis, inflammations and in non-gynecological malignancies. Adnexal inflammatory tumor was confirmed in 57 patients. Laboratory findings: white blood count and sedimentation rate were in normal levels in 17 patients. CA 125 was elevated in 27 patients. 49 patients were operated and CA 125 decreased in the first 5 days after the operation. Only 8 patients without CA 125 elevation were successfully treated by mean of antibiotics. Even there is no need for routine examining of serum CA 125 in adnexal inflammatory tumors it can be examined in cases with suspected Doppler ultrasonographic findings or unclear clinical findings. Endometriosis brings some risk of malignancy. Inflammatory tumor can develop in endometriotic tumor as well as in necrotic malignant ovary tissue. These could be reasons for making decision to do the operation in cases with inflammatory tumor followed with increased CA 125, hystological assessment and serious interpretation of final results.

Positron emission tomography application for gynecologic tumors

Positron emission tomography (PET) using fluorine-18-fluoro-2-deoxy-d-glucose (FDG), which originated as a research tool to evaluate glucose metabolism in cancer tissues, has now become an essential imaging modality for determining the appropriate therapeutic management of various cancer patients. The clinical role of FDG-PET for gynecologic tumors has not been established yet, but FDG-PET has come to be considered one of the important imaging modalities for evaluating patients with gynecological cancers. The objective was to review the literature regarding the utility of FDG-PET in the clinical setting of gynecological malignancies. Many articles reported that FDG-PET could be used for staging and restaging in patients with uterine cervical cancer. Although there is limited data about the feasibility of FDG-PET for endometrial cancer, preliminary results for detecting recurrence were promising. Furthermore, FDG-PET has been reported as a useful imaging modality, especially for restaging, in ovarian cancer, although the prognostic value needs to be fully investigated. Currently, a combined PET/computed tomography scanner is available, and its clinical application has begun. It is expected that this modality will contribute to the management of gynecological cancers, as has been reported recently for other malignancies.

A6, a urokinase plasminogen activator (uPA)-derived peptide in patients with advanced gynecologic cancer: a phase I trial

OBJECTIVES

The aim of this study was to define the toxicity, maximum feasible dose (MFD), and pharmacokinetics (PK) of A6, a peptide derived from human urokinase plasminogen activator (uPA), in patients with advanced gynecologic cancers, and to explore anti-tumor activity and the effects of A6 on biomarkers of the urokinase system.

METHODS

A6 was administered subcutaneously daily, and doses were escalated in cohorts of three to six subjects. Serial blood specimens were obtained for pharmacokinetics and levels of urokinase plasminogen activator (uPA), uPA receptor (uPAR), and plasminogen activator inhibitor-1 (PAI-1).

RESULTS

Sixteen patients were enrolled and eligible for evaluation. No serious drug-related adverse events or dose-limiting toxicity occurred. A6-related toxicities were limited to grades 1 and 2 adverse effects including local injection site reactions. Five patients had stable tumor measurements for at least 4 cycles, one of whom stayed on study for 12 months. One patient had a confirmed cancer antigen (CA)-125 response (decrease in CA-125 of >50%) with stable disease on CT scan after 14 cycles and continues on study. Time to peak plasma level of A6 was 1-2 h. C(max) is proportional to dose. The half-life of A6 was approximately 2 h. Baseline biomarker levels did not predict response and trends over time did not correlate with outcome.

CONCLUSIONS

A6 given daily continuously is well tolerated at all dose levels, without any dose-limiting toxicity. Based on the preliminary activity of A6, a phase II trial is underway in ovarian cancer.

Relationship between homocysteine and neopterin concentrations in patients with gynecological cancer

Elevated concentrations of vascular risk factor homocysteine have been described in patients with malignant diseases, and homocysteine was supposed to be useful as tumor marker. Likewise, elevated concentrations of Th1-type immune activation marker neopterin are frequently observed in patients suffering from cancer and serve as prognostic marker for the survival of patients. In this study, the relationship between homocysteine and neopterin concentrations was examined in 18 patients with gynecological cancer. Concentrations of homocysteine and cysteine were measured by HPLC in sera of patients, folic acid and vitamin B(12) levels were determined by radioimmunoassay, and neopterin concentrations were measured by ELISA. Median homocysteine concentration was 11.2 microM (interquartile range: 9.9-13.2 microM), 3 patients had levels higher than 15 microM, the upper limit of the normal range. Neopterin concentrations were increased in 13 patients (median: 11.6; 7.7-24.9 nM), cysteine (median: 234; 216-255 microM), folate (median: 7.8; 6.2-11.7 ng/ml) and vitamin B(12) (median: 352; 258-570 pg/ml) concentrations were all within reference ranges although rather at the lower side. Higher homocysteine concentrations correlated inversely with low folate concentrations (r(s)=-0.605; P<0.01) and tended to be higher in patients with higher cysteine levels (r(s)=0.457; P<0.06; ). No correlation was found between homocysteine and immune activation marker neopterin, although the three patients with elevated homocysteine concentrations tended to have higher neopterin levels as well (P<0.07). In conclusion, only a few patients with gynecological cancer present with elevated homocysteine concentrations and hyperhomocysteinemia seems only weakly related to immune activation phenomena, tumor cell proliferation probably is more important for the increase of homocysteine.

Difference of carboplatin clearance estimated by the Cockroft–Gault, Jelliffe, Modified-Jelliffe, Wright or Chatelut formula

OBJECTIVE

Although the Calvert formula is the standard method to calculate the dose of carboplatin, there is no consensus how to determine the glomerular filtration rate (GFR) without using [51Cr]-ethylenediamine tetraacetic acid (51Cr-EDTA). Creatinine clearance (Ccr), calculated using the Cockroft-Gault, Jelliffe, Modified-Jelliffe or Wright formulae, has been used as a substitute for the GFR. In addition to these four formulae, the Chatelut formula has been proposed as a way to calculate carboplatin clearance. Among these formulae, Jelliffe formula does not include body surface area (BSA) or body weight to adjust the body size and thus may have greater bias than the other four formulae in estimating carboplatin clearance. The purpose of this study is to evaluate if these five formulae could equally estimate the carboplatin clearance.

METHODS

: Carboplatin clearance was estimated in 253 patients with gynecologic cancer who received carboplatin-based chemotherapy between January 1996 and August 2004. Ccr was estimated using the Cockroft-Gault, Jelliffe, Modified-Jelliffe or Wright formulae. Carboplatin clearance was also calculated directly by using the Chatelut formula. The five estimations of carboplatin clearance were compared with each other using the post-hoc Wilcoxon signed rank test. The median percent error (MPE) and the median absolute percent error (MAPE) were evaluated by comparing carboplatin clearance. The relationships between BSA and ratios of estimated carboplatin clearance (Jelliffe/Cockroft-Gault, Jelliffe/Modified-Jelliffe, Jelliffe/Wright, Jelliffe/Chatelut) were evaluated by using simple regression.

RESULTS

: The estimated carboplatin clearances were: Cockroft-Gault formula, 109.8 +/- 28.4; Jelliffe formula, 128.5 +/- 28.2; Modified-Jelliffe formula, 110.8 +/- 25.7; Wright formula, 112.2 +/- 24.3; Chatelut formula, 114.1 +/- 33.0. A statistically significant difference was observed between carboplatin clearance calculated using Jelliffe formula and that given by each of the other four formulae. Comparing the results of the Cockroft-Gault formula with the Jellife, Modified-Jelliffe, Wright and Chatelut formulae yielded MPEs of +19%, +2%, +3% and +3% and MAPEs of 27%, 5%, 6% and 6%, respectively. There was a significant correlation between BSA and ratio of estimated carboplatin clearance (Jelliffe/Cockroft-Gault, Jelliffe/Modified-Jelliffe, Jelliffe/Wright, Jelliffe/Chatelut), with Pearson correlation coefficients of 0.928, 0.847, 0.965 and 0.839 respectively. As the BSA of patient became smaller, the differences between the carboplatin clearance calculated by the Jelliffe formula from other four formulas became larger.

CONCLUSIONS

: Estimates of carboplatin clearance calculated by the Jelliffe formula tend to have greater positive bias compared to the other four formulae, particularly when the BSA of the patient is small. In order to conduct collaborative international studies, it may be necessary to standardize the formula used to estimate carboplatin clearance to perform international collaboration studies.

Positron emission tomography application for gynecologic tumors

Positron emission tomography (PET) using fluorine-18-fluoro-2-deoxy-d-glucose (FDG), which originated as a research tool to evaluate glucose metabolism in cancer tissues, has now become an essential imaging modality for determining the appropriate therapeutic management of various cancer patients. The clinical role of FDG-PET for gynecologic tumors has not been established yet, but FDG-PET has come to be considered one of the important imaging modalities for evaluating patients with gynecological cancers. The objective was to review the literature regarding the utility of FDG-PET in the clinical setting of gynecological malignancies. Many articles reported that FDG-PET could be used for staging and restaging in patients with uterine cervical cancer. Although there is limited data about the feasibility of FDG-PET for endometrial cancer, preliminary results for detecting recurrence were promising. Furthermore, FDG-PET has been reported as a useful imaging modality, especially for restaging, in ovarian cancer, although the prognostic value needs to be fully investigated. Currently, a combined PET/computed tomography scanner is available, and its clinical application has begun. It is expected that this modality will contribute to the management of gynecological cancers, as has been reported recently for other malignancies.

Radiotherapy-induced lymphocytopenia: changes in total lymphocyte count and in lymphocyte subpopulations under pelvic irradiation in gynecologic neoplasms

Lymphocytopenia is one of the most negative biological prognostic factors in cancer patients. Lymphocytopenia may depend on tumor progression, or on various anticancer therapies. In particular, radiotherapy (RT) may induce direct lymphocyte damage. The present study was carried out to evaluate the influence of pelvic irradiation on lymphocyte number and lymphocyte subpopulations in patients with gynecologic tumors. The study included 40 patients affected by locally limited or advanced uterine tumors, who underwent pelvic irradiation for a total dose of 50.4 Gy. RT induced a significant decline in total lymphocyte number, with values lower than 500/mm3 in 29/40 (73%) patients and with a mean decrease of 71 +/- 4%. In the same way, T lymphocyte, CD4, CD8 and NK cell mean numbers significantly decreased under RT. The decline in NK and CD8 cells was limited to the first 2-3 weeks of irradiation, whereas that involving T lymphocytes and CD4 cells was progressive and persistent until the end of RT. Finally, the decline in total lymphocyte number was significantly greater in patients who had no tumor regression in response to RT. This study confirms that pelvic RT may induce severe lymphocytopenia which could negatively influence the efficacy of RT itself.

The activity of cancer procoagulant in cases of uterine leiomyomas

PURPOSE

It is currently believed that cancer procoagulant (CP), an enzymatic protein, is a product of malignant neoplastic cells. The present study was designed to test whether it is also synthesized by benign neoplastic cells, namely uterine leiomyomas.

MATERIALS AND METHODS

We determined the activity of CP in the blood serum of women with uterine leiomyomas (N = 24), normal women (N = 15), and genital cancer patients (N = 6) by the coagulative method according to Gordon and Benson. Also, the CP activity in 10% tissue homogenates of uterine leiomyomas, normal uterine muscle and tissues of cervical and endometrial carcinoma was determined by the chromogenic method according to Colucci et al.

RESULTS

The mean CP activity in the sera of women with uterine leiomyomas was 181.1 seconds (s) +/- 19.9 s, in healthy women--293.2 s +/- 33.8 s, and in genital cancer patients--78.8 +/- 18.5 s (all differences: p < 0.001). Similarly, in homogenates of uterine leiomyomas the CP activity was 19.6 +/- 3.8 nmoles pNa/ml, in normal uterine muscle it was 13.2 +/- 2.2 nmoles pNa/ml, and in cancerous tissue--28.0 +/- 6.6 nmol pNa/ml (all values being significantly different from each other). There was a strong correlation (r = -0.8122; p < 0.001) between the CP activity in uterine leiomyomas and serum activity, suggesting that the source of the serum CP activity was from the leiomyoma. The coagulation time of 120 to 240 s by the Gordon and Benson method supported the diagnosis of uterine leiomyoma, and a value below 120 s--the suspicion of genital cancer.

CONCLUSIONS

Uterine leiomyomas, representing benign genital neoplasia, synthesize CP and are the likely origin of CP activity in blood, as has been described for malignant tumors, but to a lesser degree. There may be a role for CP as a tumor marker of genital neoplasia.

Proteomics in cancer screening and management in gynecologic cancer

Biomarkers are used routinely for population screening, disease diagnosis and prognosis, monitoring of therapy, and prediction of therapeutic response. Unfortunately, most biomarkers have low sensitivity and specificity and little predictive value. Novel techniques for better screening and early diagnosis of ovarian cancer are urgently needed. Proteomics, the study of the cellular proteins and their activation states, integrates some fundamental techniques, including high-throughput protein purification and profiling, genomic and proteomic databases, and mass spectrometry. In oncology, proteomics will contribute greatly to our understanding of gene functions in tumor development and provide information in clinical applications. This article reviews proteomic techniques and their potential applications in gynecologic cancer screening and management.

Inhibins as Biomarkers for Reproductive Cancers

Inhibin is a dimeric (alpha and either betaA or betaB subunit) protein involved in the regulation of fertility. Inhibin A and B or its free alpha subunit monomer are elevated in various gonadal and prostate cancers and thus serve as useful diagnostic tools for certain ovarian tumors either as a serum marker or as an immunocytochemical marker for tissue sections. Serum inhibin levels are of value in the initial diagnosis and subsequent follow-up of sex cord stromal tumors, in particular granulosa cell tumors, and mucinous epithelial adenocarcinomas primarily after menopause. Immunocytochemistry using inhibin alpha subunit antisera can aid in the classification of sex cord stromal tumors and their differentiation from other cancers. Although serum inhibins are elevated in prostatic and testicular cancers, this is of little diagnostic value at the present time.

A novel method of preoperative autologous blood donation with a large volume of plasma for surgery in gynecologic malignancies

The objective of this study was to establish a novel method of preoperative autologous blood donation (PAD) for surgery of gynecologic malignancies, which requires considerable amounts of plasma relative to the red blood cell component. To collect a double volume of plasma over the amount obtained from whole blood without using an aphaeresis system, we first collected 500 ml of whole blood (2.5 units), and centrifuged it. We gave back the resultant red cell component alone, and retained the plasma component. We further collected an additional 500 ml of whole blood, and centrifuged it. The red cell component (2.5 units) was stored in the refrigerator (as a concentrated red cell, CRC). The resultant plasma together with the plasma collected first (5 units) was frozen and stored in the freezer (fresh frozen plasma, FFP), We repeated this procedure at most three times at intervals of 1 week. Erythropoietin was injected once a week and iron tablets were prescribed. Ninety-nine patients undergoing surgery for a gynecological malignancy were subjected to this method and 86 patients without PAD served as a control. We conducted the procedure for PAD without any noticeable side effects. The amount of actual use of allogeneic CRC and FFP were significantly reduced in the PAD group compared with the control group. In particular, 93.6% of the PAD cases who gave 10 or less units of FFP could go without allogeneic FFP. Postoperative serum albumin levels were higher in the PAD group compared with the control. We have established a novel PAD method which can yield a greater volume of FFP relative to CRC, thus meeting requirements for surgery for gynecological malignancies.

Thrombocytosis in gynecologic malignancies

Recent studies have addressed the prevalence and prognostic impact of thrombocytosis in various gynecologic and non-gynecologic malignancies. Thrombocytosis appears to be of prognostic value in certain patients with gynecologic malignancies. In this survey we review the published data and attempt to analyze the prognostic implications of thrombocytosis in patients with gynecologic malignancies.

Experience with the management of neutropenia in gynecologic cancer patients receiving carboplatin-based chemotherapy

Objective. There exists limited information in the medical literature regarding the incidence and severity of carboplatin-associated neutropenia, outside the setting of a clinical trial. We wished to examine this issue in a large single institution experience involving patients receiving both single agent and combination carboplatin-based chemotherapy for management of a female pelvic malignancy. Patients and methods. The medical records of women with gynecologic cancers treated with carboplatin-based chemotherapy at the Cleveland Clinic from January 1, 1998 through December 31, 2002 were retrospectively reviewed to determine the incidence and severity of neutropenia. Results. During the time period encompassed by this analysis, a total of 323 patients received 2145 cycles of carboplatin-based chemotherapy (total of 441 courses; median cycles/patient: 6 [range 1-27]). The total number of each program utilized, and the incidence of grades 3 and 4 neutropenia observed (lowest nadir/regimen), were as follows: single agent carboplatin (178 courses; 5% grade 3, and <1% grade 4), carboplatin/paclitaxel (198; 23% and 6%), carboplatin/docetaxel (42; 17% and 73%) and carboplatin/paclitaxel/irinotecan (23; 39% and 61%). Febrile neutropenia was uncommon, and there was only a single neutropenic-related death. Conclusion. Both single-agent carboplatin and carboplatin/paclitaxel result in a very low incidence of grade 4 neutropenia. While combining docetaxel with carboplatin or adding a "third drug" to carboplatin/paclitaxel substantially increases the incidence of severe neutropenia, neutropenic fever, and required hospitalizations for septic episodes are uncommon. The prophylactic oral administration of a broad-spectrum antibiotic (e.g., ciprofloxicin) in the presence of grade 4 neutropenia appears to be an effective strategy to minimize the risk of subsequent febrile events.

Alfa-epoietin and anaemia in gynaecological cancer

The incidence and severity of anaemia in gynaecological cancer patients depends on several factors including age, histology and tumor stage, site of neoplasm and treatment. At present, two principal opinions are available for the management of chronic anaemia in cancer patients: blood transfusions and treatment with recombinant human Erythropoietin (rHuEPO). Clinical studies showed that rHuEPO can ameliorate chronic and chemotherapy-induced anaemia and reduce transfusions in patients with various malignant diseases. In this review we discuss the role of alfa-epoetin in the management of gynaecological and breast cancers.

Preliminary results of monitoring research on zearalenone presence in blood of women with neoplastic lesions in reproductive system

The aim of the monitoring of zearalenone presence in the blood plasma of women with neoplastic lesions in the reproductive tract was to asses whether the phytosteride is noted in the patients blood and whether the correlation exists between its presence and the incidence of particular neoplasm. The presence of zearalenone or its metabolite--alpha-zearalenole, was noted in 13.51% of the examined women. In 60% of the patients with the confirmed presence of the xenobiotic it was noted in the lowest concentrations. These patients had neoplastic lesions of Carcinoma corpus uteri type.

Viability of gynecological malignant cultured cells after 4 degrees C storage in citrate-phosphate-dextrose solution

For the surgery of gynecological malignant tumors, a predeposit type of autologous blood transfusion has been widely used. However, using molecular biologic techniques, malignant cells have been found in the peripheral blood of cancer patients. Therefore, to evaluate the utility of presurgical blood deposits, we studied the survival of gynecological malignant cultured cells after 4 degrees C storage in citrate-phosphate-dextrose solution. Ten cultured cell lines derived from gynecological malignant tumors were used. Mixtures of 1 x 105 cells, culture medium, and citrate-phosphate-dextrose (CPD) solution were stored at 4 degrees C. After 0, 1, 4, 8, 15, or 22 days of storage, cells were placed in 96-well microtiter plates in culture medium with 1 x 104 cells/100 micro l/well. After 24 h culture in the incubator, the survival rate was calculated from the optical density by 3-(4,5-dimethyl-2-thiazolyl)-2,5-diphenyl-2H tetrazolium bromide (MTT) assay. More than 10% of surviving cells were seen in nine cell lines after 4 days of storage, in seven cell lines after 8 days, in three cell lines after 15 days, and in two cell lines after 22 days. Cancer cells in presurgical blood deposits may survive a 3-week storage period at 4 degrees C in CPD solution.

[Tumor markers in gynecological and breast cancer]

Serum tumor markers are useful in diagnosis and follow-up for patients with gynecological malignancy or breast cancer. In epithelial ovarian cancer, CA125 has been identified as the most sensitive marker. Unfortunately, CA125 detection in the serum of patients with minimal malignant tumor has not been possible. Many nonmalignant conditions including endometriosis, menstruation and massive ascites may elevate the CA125, and almost 50% of patients with clear cell adenocarcinoma do not show CA125 elevated above 100 U/ml. To improve sensitivity and specificity in the diagnosis of ovarian cancer, the use of multiple tumor markers and the simultaneous use of image diagnosis should be employed. The value of tumor markers in the screening for cervical cancer and endometrial cancer has received little attention. However, the utility of serum SCC as a marker for monitoring cervical squamous cell carcinoma has been established. Since hCG is produced by gestational trophoblastic neoplasia and is a sensitive marker of trophoblastic cells in the body, patients with choriocarcinoma or invasive mole must be followed closely for this parameter. The improvement of the hCG detection technique has reduced the mortality rate from trophoblastic neoplasia. In breast cancer, many markers including CEA and CA15-3 are used, and they are reported to be useful as markers for monitoring.