Platelet function testing: dead or alive

Essentials Pharmacodynamic response to antiplatelet medication is heterogeneous. Platelet reactivity to dual antiplatelet therapy was analyzed by three platelet function assays. The prevalence of high and low platelet reactivity differed significantly between assays. Future trials are needed to determine the best assay to analyze platelet function.

SUMMARY

Background High on-treatment platelet reactivity (HTPR) to antiplatelet medication leads to ischemic events, whereas low on-treatment platelet reactivity (LTPR) increases bleeding risk. However, various trials have failed to demonstrate superiority of tailored antiplatelet regimens (ARCTIC, ANTARCTIC, Trigger-PCI, and GRAVITAS). TROPICAL-ACS was the first study that demonstrated the benefit of tailoring antiplatelet medication according to platelet function analysis. A potential reason may be that different platelet function assays were used in these trials. Objectives To evaluate whether the results of platelet function tests are comparable. Patients/Methods We tested three commonly used assays - light transmission aggregometry (LTA), (Multiplate impedance aggregometry [MP]), and vasodilator-stimulated phosphoprotein phosphorylation assay (VASP) - in 23 patients receiving dual antiplatelet therapy with aspirin and clopidogrel. Results With LTA, HTPR occurred in 57% of patients; with VASP, it occurred in 43% of patients; and with MP, it occurred in 13% of patients. According to LTA, only 35% of patients were in the therapeutic window; according to VASP, 57% of patients were in the therapeutic window; and according to MP, 48% of patients were in the therapeutic window. With LTA, LTPR occurred in 9% of patients; with VASP, it occurred in 0% of patients; and with MP, it occurred in 39% of patients. Therefore, the prevalences of HTPR and LTPR differed significantly between assays. Remarkably, in 17% of patients, one assay showed HTPR whereas another showed LTPR. Conclusions The results of different platelet function assays differ substantially. Up to now, only TROPICAL-ACS had demonstrated a benefit of tailoring antiplatelet medication according to platelet function analysis. Future trials are needed to evaluate whether the platelet function assay used in TROPICAL-ACS is the 'correct' one and revives platelet function testing.

Adjuvant therapy for Stage IA uterine clear cell carcinoma with no myometrial invasion: a critical review of literature

Uterine clear cell carcinoma (UCC) is an aggressive variant of endometrial cancer. Comprehensive surgical staging is strongly recommended for these patients as an upstaging to Stage 3-4 occur in 35-50% of patients. Stage 1A (no myometrial invasion) according to FIGO 1988 staging system are seen very rarely in patients. In most of the studies, regarding adjuvant treatment, clear cell carcinoma were all evaluated with papillary serous carcinoma (PSC). Studies on clear cell histology are low in number and also a limited number of patients were included. Proportion of patients with complete surgical staging, number of lymph nodes excised, and rate of omentectomy were all heterogenous and were not presented uniformly in studies. There is no concensus regarding adjuvant treatment for Stage 1A patients. Some authors suggest only close observation. Vaginal brachytherapy is also strongly recommended in some studies of this review. Multi-institutional studies with homogenous patient characteristics with homogeneous surgery is warranted.

Genetic abnormalities and expression of p53 in human colon carcinomas

Genetic alteration and expression of p53 was examined on matched pairs of tumor and nonneoplastic tissues of colon carcinomas and compared with clinicopathological findings. Loss of heterozygosity (LOH) of p53 locus was found in 83% (44/53) of carcinomas and the incidence of LOH increased as tumor stage progressed. Among LOH cases, 63% (5/8) showed p53 mutations, most of which occured at CpG site. Although the level of p53 mRNA in tumor tissues was lower than its nonneoplastic counterpart in 55% (6/11) of the cases, no obvious relation was detected between mRNA expression and gene alteration. Accumulation of p53 protein determined by immunohistochemistry was found in 47% (25/53) of cases regardless of allelic status nor mRNA level. p53 immunoreactivity showed a tendency to increase with tumor stage. These results indicate the diversity of p53 alterations in the development and progression of colon carcinoma.

Predictors of survival in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery based on the pooled analysis of an international collaborative cohort

BACKGROUND

This study aims to identify prognostic factors and to develop a risk model predicting survival in patients undergoing secondary cytoreductive surgery (SCR) for recurrent epithelial ovarian cancer.

METHODS

Individual data of 1100 patients with recurrent ovarian cancer of a progression-free interval at least 6 months who underwent SCR were pooled analysed. A simplified scoring system for each independent prognostic factor was developed according to its coefficient. Internal validation was performed to assess the discrimination of the model.

RESULTS

Complete SCR was strongly associated with the improvement of survival, with a median survival of 57.7 months, when compared with 27.0 months in those with residual disease of 0.1-1 cm and 15.6 months in those with residual disease of >1 cm, respectively (P<0.0001). Progression-free interval (≤23.1 months vs >23.1 months, hazard ratio (HR): 1.72; score: 2), ascites at recurrence (present vs absent, HR: 1.27; score: 1), extent of recurrence (multiple vs localised disease, HR: 1.38; score: 1) as well as residual disease after SCR (R1 vs R0, HR: 1.90, score: 2; R2 vs R0, HR: 3.0, score: 4) entered into the risk model.

CONCLUSION

This prognostic model may provide evidence to predict survival benefit from secondary cytoreduction in patients with recurrent ovarian cancer.

First measurement of Bose-Einstein correlations in proton-proton collisions at √s=0.9 and 2.36 TeV at the LHC

Bose-Einstein correlations have been measured using samples of proton-proton collisions at 0.9 and 2.36 TeV center-of-mass energies, recorded by the CMS experiment at the CERN Large Hadron Collider. The signal is observed in the form of an enhancement of pairs of same-sign charged particles with small relative four-momentum. The size of the correlated particle emission region is seen to increase significantly with the particle multiplicity of the event.

Transverse-momentum and pseudorapidity distributions of charged hadrons in pp collisions at square root of s = 7 TeV

Charged-hadron transverse-momentum and pseudorapidity distributions in proton-proton collisions at square root of s = 7  TeV are measured with the inner tracking system of the CMS detector at the LHC. The charged-hadron yield is obtained by counting the number of reconstructed hits, hit pairs, and fully reconstructed charged-particle tracks. The combination of the three methods gives a charged-particle multiplicity per unit of pseudorapidity dN(ch)/dη|(|η|<0.5) = 5.78 ± 0.01(stat) ± 0.23(syst) for non-single-diffractive events, higher than predicted by commonly used models. The relative increase in charged-particle multiplicity from square root of s = 0.9 to 7 TeV is [66.1 ± 1.0(stat) ± 4.2(syst)]%. The mean transverse momentum is measured to be 0.545 ± 0.005(stat) ± 0.015(syst)  GeV/c. The results are compared with similar measurements at lower energies.

The spread pattern of right and left epithelial ovarian cancers

OBJECTIVE

No attention has been paid in the past to the spread pattern of right and left epithelial carcinomas of the ovaries. We aimed to investigate the incidence, spread pattern and distribution of lymph node metastasis in epithelial ovarian cancer (EOC), comparing right versus left EOC of any stage, where the contralateral ovary is apparently and histologically tumor-free.

METHODS

Out of a total of 442 patients with EOC, 318 (72%) patients in the study had bilateral and 124 (28%) patients had unilateral ovarian cancer. The study enrolled 60 (48%) patients with right and 64 patients with left ovarian involvement (52%) where the contralateral ovary was tumor-free. Groups Right and Left were compared in terms of age, the tumor status of the lymph nodes, surgical stage, histology, grade, tumor extension out of the ovaries, omental tumor involvement and also omental and nodal involvement together.

RESULTS

The comparisons of the variables between Groups Right and Left did not show significant differences except for metastasis patterns in the left iliac lymph nodes and omentum (p < 0.05). Independent of age and histological type of the tumor, women with left-side EOC showed a significantly higher incidence of metastasis in the left iliac lymph nodes (OR: 7.04, 95% CI, 1.36-36.44) and omentum (OR: 2.87, 95% CI, 1.03-8.01), when compared to right-side EOC (p < 0.05).

CONCLUSION

In this cohort of patients, we found that left-side unilateral EOC was more likely to metastasize to the left iliac lymph nodes and omentum than the right side where the contralateral ovary was tumor-free. This might be due to the difference in lymphatic drainage on the right and left side and/or the influence of peritoneal fluid movements. This suggestion needs to be supported by further studies.

Temperament and Character Inventory Dimensions in Alcohol Dependency

Aim:

The aim of this study is to evaluate the differences in dimensions of temperament between alcohol dependent inpatients and healthy control subjects.

Method:

The study is consisted of 77 alcohol-dependent patients according to the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition and 80 healthy control subjects. Cloninger's Temperament and Character Inventory (TCI), Temperament Evaluation of Memphis, Pisa, Paris and San Diego Autoquestionnaire (TEMPS-A) scale and semi structured sociodemographic form were applied to the subjects after detoxification period.

Results:

Age and education level were similar rates in both alcohol dependent (mean age= 43.7 ± 10.1 and education level= 9.0 ± 4.2) and healthy control subjects (mean age: 42.5 ± 11.8 and education level: 10.2 ± 3.8). Alcohol-dependent patients were characterized by higher Novelty-Seeking (p=0.006) and Harm Avoidance (p=0.002) than non-psychiatric control subjects. Also, subjects suffering from Alcohol-dependence exhibited significantly more depressive (p=0.003), anxious (p=0.001), irritable (p=0.004) and cyclothymic (p=0.001) temperament. Novelty-Seeking [95% C.I = 1.08 (1.07-1.16)] and cyclothymic temperament [95% C.I = 1.13 (1.03-1.23)] were predictors of alcohol dependency.

Conclusion:

Novelty seeking and harm avoidance were significantly higher in the patients than in the healthy subjects. Novelty-Seeking and cyclothymic temperament were predictors for alcohol dependency. It seems to be important to consider TCI dimensions and affective temperaments in planning the treatment and maybe in preventing of alcohol dependence.

Ovarian transposition for the preservation of ovarian function in young patients with cervical carcinoma

Radiotherapy with or without surgery for the treatment of pelvic malignancies irreversibly destroys the hormonal activity and reproductive capacity of ovaries in young women. On the other hand, menopausal symptoms associated with estrogen deficiency is an important contributor to the poor quality of life scores in gynecologic cancer survivors. Transposing of the ovaries into the paracolic gutters (ovarian transposition) was described in 1958 with the aim of protecting gonadal functions in reproductive-aged women treated by pelvic radiotherapy and/or surgery. Although the laparatomic approach has been used as a parallel to development in endoscopic surgery, today it is generally performed laparoscopically. However, there is ongoing debate about the effectiveness of ovarian tranposition with respect to protecting gonadal functions. Moreover, metastasis to the transposed ovaries and port sites is another concern about this procedure. In this short review, indications, techniques and functional outcomes of ovarian transposition have been summarized.

Bilateral breast metastasis of ovarian carcinoma

Primary breast carcinoma is the most common malignancy in women, however, metastatic breast carcinoma is rarely seen in clinical practice. It has been reported that lymphoma-leukemia, melanoma and sarcomas, the most common primary malignancies, can metastasize to the breast. On the other hand, ovarian carcinoma and other gynecologic cancers rarely develop into breast metastasis. However, the incidence of breast metastasis arising from ovarian carcinoma might be increasing as a result of prolongation in survival and improvement in treatment modalities. Bilateral breast metastasis originating from an ovarian carcinoma is an extremely rare clinico-pathological situation. In our literature review we found just nine cases of bilateral breast metastasis from primary ovarian carcinoma. In this study, the mean age was 46 years (range 16-68). Mean interval from initial diagnosis of ovarian carcinoma to bilateral breast metastases was 22 months (range 11-24) and mean survival was 12 (range 5-27) months after the diagnosis of breast metastasis. Serous papillary adenocarcinoma was the predominant histological subtype. Interestingly, five of the nine (56%) cases reported were from Turkey. This interesting observation can be explained by a genetic predisposition, but it requires further research. In conclusion, although it is a rare entity, breast metastasis should not be ruled out in patients with a history of ovarian carcinoma, if patients present with any symptoms of breast diseases.

Current management of endometrial hyperplasia and endometrial intraepithelial neoplasia (EIN)

Endometrial hyperplasia is a commonly seen disorder in daily gynecology practice. The clinical importance of this pathological entity is the underlying risk of carrying a concomittant genital cancer or risk of progression to endometrial carcinoma during the follow-up. Despite recent advances in non-invasive techniques to define underlying endometrial cancer during the initial diagnosis of endometrial hyperplasia, none of these studies are conclusive yet. Today, in spite of intense discussions and related studies which aimed to define certain prognostic factors (WHO94 vs EIN) to predict cases that would progress to cancer, we still do not have a practical and accurate system available to use during daily practice. Treatment of endometrial hyperplasias depends on the patient's age, fertility desire and the type of hyperplasia. Progestagens are still the most commonly used medical treatment modality in these patients. Response rates are higher for cases without atypia. In selected cases, hysterectomy may be performed as a definitive treatment modality. In this review article, the current management of endometrial hyperplasias is summarized in light of the associated literature. We also give a brief overview of the EIN classification and its clinical importance.

Vaginal high dose rate brachytherapy alone in patients with intermediate- to high-risk stage I endometrial carcinoma after radical surgery

The objective of this study was to analyze the efficacy and morbidity of vaginal cuff brachytherapy alone in intermediate- to high-risk stage I endometrial cancer patients after complete surgical staging. Between October 1994 and November 2005, 128 patients with intermediate- to high-risk stage I endometrial adenocarcinoma were treated with high dose rate (HDR) brachytherapy alone after complete surgical staging. The intermediate- to high-risk group was defined as any stage I with grade 3 histology or stage IB grade 2 or any stage IC disease. The comprehensive surgery was in the form of total abdominal hysterectomy, bilateral salpingo-oophorectomy in addition to infracolic omentectomy, and routine pelvic and para-aortic lymphadenectomy. The median number of the lymph nodes dissected was 33. The median age at the time of diagnosis was 60 years. Forty patients were staged as IB (grade 2: 25 and grade 3: 15), and 88 patients were staged as IC (grade 1: 31, grade 2: 41, and grade 3: 16). A total dose of 27.5 Gy with HDR brachytherapy, prescribed at 0.5 cm, was delivered in five fractions in 5 consecutive days. Median follow-up was 48 months. Six (4.7%) patients developed either local recurrence (n= 2) or distant metastases (n= 4). Five-year overall survival and disease-free survival (DFS) rates are 96% and 93%, respectively. Only age was found to be significant prognostic factor for DFS. Patients younger than 60 years have significantly higher DFS (P= 0.006). None of the patients experienced grade 3/4 complications due to the vaginal HDR brachytherapy. Vaginal cuff brachytherapy alone is an adequate treatment modality in stage I endometrial adenocarcinoma patients with intermediate- to high-risk features after complete surgical staging with low complication rates.

Radiotherapy in congenital vulvar lymphangioma circumscriptum

Congenital lymphangioma circumscriptum (LC) of the vulva is a rare disorder with unknown etiology. Treatment options include ablative approaches such as laser therapy, sclerotherapy, and surgery. Radiotherapy has been shown to be effective in the management of congenital lymphangioma especially in the thoracic and abdominal lesions. In this report, we describe a patient with persistent vulvar LC despite sclerosing therapy and several surgical excisions. She was treated with a course of external radiotherapy and showed a dramatic objective response with relief of all symptoms

Interval debulking in epithelial ovarian carcinomas: the past, present and the future

Primary cytoreductive surgery followed by combination chemotherapy of paclitaxel and cisplatinum is the standard treatment for advanced staged epithelial ovarian cancers. Despite the maximal efforts to increase optimal cytoreductive success rates and related ultra-radical surgeries, five-year survival rates are still poor. Primary cytoreductive surgeries and their radicalities have been criticized since the early nineties. Interval debulking surgery (IDS) and neo-adjuvant chemotherapy (NAC) are the two suggested alternatives to the primary debulking approaches. In this article, the authors summarize and discuss the IDS approach with an associated literature review.

New surgical approaches for the management of cervical carcinoma

Cervical carcinoma remains an important health problem in both developed and developing countries even though population-based screening programs are widely available. The classical surgical management of early-stage cervical carcinoma, known as radical hysterectomy (RH), was first described by Wertheim more than one hundred years ago and was then modified and re-popularized by Meigs in 1950s. The surgical principles of this operation have undergone only minor modifications and remain the basis for the surgical approach utilized by gynecologic oncologists today. However, some recent studies have questioned the role of RH due to a high rate of postoperative complications involving the pelvic autonomic nerve system and poor oncological outcomes despite postoperative adjuvant chemoradiation. During the last 2 decades, new surgical operations (radical vaginal trachelectomy, nerve-sparing hysterectomy, total mesometrial resection, laterally extended endopelvic resection, laparoscopic assisted radical vaginal hysterectomy, laparoscopic lumbo-aortic lymph node dissection, and laparoscopic pelvic exenteration) have been proposed for the management of both early- and late-stage cervical carcinoma. In this manuscript, some technical details and oncological outcomes of these new surgical approaches are summarized.

Radiotherapy in the adjuvant setting of cervical carcinoma: treatment, results, and prognostic factors

To evaluate the efficacy of postoperative radiotherapy and to investigate prognostic factors for early-stage cervical cancer patients. From December 1993 to December 2001, 141 patients with stage I-II cervical cancer without para-aortic lymph node (LN) metastases and treated by surgery and postoperative radiotherapy (RT) were included in this study. Indications for postoperative external RT were based on pathologic findings, including LN metastasis, positive surgical margins, parametrial involvement, pT2 tumor, and presence of any two minor risk factors like lymphvascular space involvement, deep stromal invasion, and tumor diameter between 2-4 cm. Sixty-six (47%) patients received RT alone, whereas 59 (42%) were treated with RT and concomitant chemotherapy (CT), and 16 received neoadjuvant CT. Patients with positive vaginal margins also received 27.5 Gy high-dose rate vaginal cuff brachytherapy in five fractions. Median follow-up time was 55 months. The actuarial 5-year overall (OS), disease-free (DFS), locoregional recurrence-free (LRFS), and distant metastases-free (DMFS) survival rates are 70%, 68%, 77%, and 88%, respectively. Univariate and multivariate analyses revealed that level and number of metastatic LNs and concomitant CT were unique significant prognostic factors for OS, DFS, and LRFS. Endometrial involvement, on the other hand, was proven to be significant for DFS and DMFS. Patients with less than three LN metastases or having only obturator LN involvement showed similar prognosis with their counterparts having no LN metastases. On the other hand, patients with either common iliac LN or more than three LN metastases had significantly worse outcome. Our results indicate that level and number of metastatic LNs are the most important prognostic factors determining the survival rates, and patients with upper lymphatic involvement or more than three metastatic LNs seem to need more effective treatment approaches.

Genetic intra-tumour heterogeneity in epithelial ovarian cancer and its implications for molecular diagnosis of tumours

Genetic analysis of solid tumours using DNA or cDNA expression microarrays may enable individualized treatment based on the profiles of genetic changes that are identified from each patient. This could result in better response to adjuvant chemotherapy and, consequently, improved clinical outcome. So far, most research studies that have tested the efficacy of such an approach have sampled only single areas of neoplastic tissue from tumours; this assumes that the genetic profile within solid tumours is homogeneous throughout. The aim of this study was to evaluate the extent of genetic intra-tumour heterogeneity (ITH) within a series of epithelial ovarian cancers. Several different regions (five to eight regions) of tumour tissue from 16 grade 3, serous epithelial ovarian cancers were analysed for genetic alterations using a combination of microsatellite analysis and single nucleotide polymorphism (SNP) analysis, in order to establish the extent of ITH. Maximum parsimony tree analysis was applied to the genetic data from each tumour to evaluate the clonal relationship between different regions within tumours. Extensive ITH was identified within all ovarian cancers using both microsatellite and SNP analysis. Evolutionary analysis of microsatellite data suggested that the origin of all tumours was monoclonal, but that subsequent clonal divergence created mixed populations of genetically distinct cells within the tumour. SNP analysis suggested that ITH was not restricted to random genetic changes, but affected genes that have an important functional role in ovarian cancer development. The frequent occurrence of ITH within epithelial ovarian cancers may have implications for the interpretation of genetic data generated from emerging technologies such as DNA and mRNA expression microarrays, and their use in the clinical management of patients with ovarian cancer. The basis of genetic ITH and the possible implications for molecular approaches to clinical diagnosis of ovarian cancers may apply to other tumour types.

Vaginal hysterectomy: results and complications of 886 patients

The aim of this study was to determine the feasibility, results and complications of vaginal hysterectomy. A total of 886 consecutive patients who had undergone vaginal hysterectomy for benign gynecological diseases were retrospectively analysed. Vaginal hysterectomy was successfully performed in 96.1% of the nulliparous and 99.9% of the parous patients. The mean duration (min) of the operation was 89.1+/-29.1. The operation time (min) of the nulliparous women was significantly higher than that of the primiparous and multiparous women (109.3+/-40.2 vs 81.1+/-33.2 and 85.1+/-28.3, respectively). The overall complication rate was 14.6%. The intraoperative and postoperative complication rates were 4.1% and 10.5%, respectively. The most common intraoperative complication was bladder injury (2.5%). Vaginal hysterectomy for benign gynaecological diseases has high feasibility with acceptable complication rates.

Ascites and epithelial ovarian cancers: a reappraisal with respect to different aspects

Ascites is a common finding in patients with epithelial ovarian cancer (EOC). Clinico-pathologic correlations with respect to the presence of ascites, positive cytology and prognostic role of ascites, and the impact of ascitic volumes were not previously studied extensively. A total of 372 patients with EOC were retrospectively evaluated with respect to presence and amount of ascites, cytologic findings, and survival. Two groups were compared by using Chi-square, Student's t and Mann-Whitney U, binary logistic regression, Kaplan Meier and Cox-regression analysis tests, where appropriate. Omental metastasis (P < 0.001; OR: 3.21, 95% CI = 1.945-5.297) and mean number of metastatic lymph nodes (P= 0.008; OR: 1.063, 95% CI = 1.016-1.112) were significantly related with presence of ascites. Evaluation of ascitic volume at different thresholds revealed lymphatic-omental metastasis, and also the disease stage to be significantly different among patient groups at lower threshold values and the positive cytology and high-grade diseases at higher threshold values. In conclusion, presence of ascites correlates with both the intraperitoneal and also the retroperitoneal tumor spread. Amount of ascites has different correlations with the clinico-pathologic factors depending on the thresholds chosen. At lower volumes, lymphatic and omental metastasis seems to correlate with the development of ascites. Once ascites develops, tumor grade seems to be important for larger ascites volumes. Neither the presence of ascites or its volume nor the cytologic positivity was an independent predictor of survival.

Cyclooxygenase-2 expression in cervical intraepithelial neoplasia III and squamous cell cervical carcinoma, and its correlation with clinicopathologic variables

The objective of the study was to compare cyclooxygenase-2 (COX-2) expression in cervical intraepithelial neoplasia III (CIN III) and squamous cell carcinoma (SCC) of the cervix, and its correlation with clinicopathologic factors of SCC with a review of the available literature. This study included 25 patients with CIN III and 67 patients with stage I-IIa SCC. All patients in the SCC group were treated with radical hysterectomy plus pelvic and para-aortic lymphadenectomy and postoperative chemoradiotherapy based on their histopathologic risk factors. Immunohistochemical analysis was performed on paraffin-embedded sections with COX-2 antibody. COX-2 expression in the SCC group was significantly higher than in the CIN III group (55.2% [37/67] vs 24% [6/25]; P= 0.008). Significantly higher expression of COX-2 was observed in patients with lymphovascular space invasion (LVSI) compared to patients without LVSI (61.9% [34/55] vs 33.3% [3/9]; P= 0.02). Additionally, patients with tumor sizes >4 cm had significantly higher COX-2 expression than patients with tumor sizes <4 cm (65.9% [27/41] vs 39% [10/26] P= 0.028). There was no significant relationship with respect to COX-2 expression and parametrial involvement, lymph node metastasis, recurrences, and survival. In multivariate analysis, LVSI was the only statistically significant determinant for COX-2 expression (P= 0.024; OR = 2.35; 95% CI = 1.1-4.9). Our results and a review of the literature both suggest that COX-2 expression may have a role in the development and progression of CIN III and it is related to some clinicopathologic variables of cervical carcinoma. Further studies are needed to clarify the role of COX-2 inhibitors in the management of CIN and SCC.

Loss of epithelium cadherin expression is associated with reduced overall survival and disease-free survival in early-stage squamous cell cervical carcinoma

Epithelium cadherin (E-cad) is important for cell-to-cell adhesion of epithelial cells. Impairment of E-cad may have a role in the development and spreading of different malignancies and associated with poor differentiation, increased invasiveness, and poor prognostic factors in nongynecological carcinomas. However, prognostic significance of E-cad expression has not been investigated properly in cervical squamous cell carcinoma (SCC). The objective of this study was to investigate the association between reduced E-cad expression and clinicopathologic variables of cervical carcinoma. Specimens from 53 consecutive patients with stage IB-IIA SCC were evaluated immunohistochemically for E-cad expression, and the results were compared to grade, lymphvascular space invasion (LVSI), deep stromal involvement (DSI), parametrial involvement, lymph node metastasis, recurrences, and survival. Patients were divided into two groups arbitrarily: E-cad expression less than 10% (group 1) and E-cad expression more than 10% (group 2). There was no significant relationship between E-cad expression and DSI, LVSI, lymphatic metastasis. However, there was significant relationship between reduced E-cad expression and parametrial involvement (P= 0.024). Kaplan-Meier survival analysis revealed that reduced E-cad expression is significantly associated with reduced overall survival (OS) and disease-free survival (DFS). Furthermore, Cox regression analysis revealed that reduced E-cad expression is significantly associated with OS (P= 0.004, RR = 6.08, 95% CI: 1.75-21.1) and recurrences (P= 0.027, RR = 1.75, 95% CI: 1.06-2.88). We conclude that loss of E-cad expression is significantly associated with reduced OS and DFS in patients with SCC. Therefore, it might be used as an indicator of aggressive clinical behavior and tailoring aggressive adjuvant therapy in early-stage SCC. Further studies with larger number of patients are needed to evaluate the clinical significance of reduced E-cad expression in SCC.

Topical testosterone versus clobetasol for vulvar lichen sclerosus

OBJECTIVE

To compare the effects of topical testosterone and clobetasol treatments on symptoms remission and recurrence rates in patients with vulvar lichen sclerosus (LS).

METHODS

A retrospective review of the records showed that, of 140 patients with biopsy-proven vulvar LS, 80 were treated with applications of testosterone propionate 2% in petrolatum and 60 with clobetasol 17-propionate 0.05%.

RESULTS

The response rates after 6 months were 77.5% for patients treated with testosterone and 91.7% for those treated with clobetasol (P=0.02). The recurrence rates were 20% and 6.7% in the 2 groups, respectively (P=0.02). Premenopausal patients had higher remission rates and lower recurrence rates than postmenopausal patients (P>0.05). Considering whole patients, low remission rates and high recurrence rates were observed in patients who had had a hysterectomy (P>0.05).

CONCLUSION

Treatment of LS with a corticosteroid provided excellent remission rates. In this study, clobetasol 17-propionate 0.05% was superior to testosterone for both remission induction and maintenance therapy.

Skeletal carcinomatosis in endometrial clear cell carcinoma at initial presentation: a case report

Bone metastasis is frequently seen in different solid tissue malignancies. However, it is a very rare entity in endometrial cancers and most of the previous reports were localized to a single bone. To the best of our knowledge, this is the first report of a case with disseminated bone metastasis from endometrial clear cell carcinoma. A 69-year-old, multiparous woman presented with the complaint of postmenopausal bleeding. Diagnostic workup revealed endometrial clear cell carcinoma. After comprehensive surgical staging, the patient was found to be at FIGO stage IIIC. Three weeks after the operation, an intractable back pain developed. Direct graphics of the lumbosacral region were suspicious of metastasis, and further evaluation of the patient revealed metastasis in multiple bones including calvarium, thoracolumbal vertebrae, pelvic bones, costae, collum of the right femur, and trochanter major of the left femur. Bone metastasis in endometrial clear cell carcinoma may be seen at initial presentation and may involve multiple bones. Whole-body scanning with scintigraphic evaluation is a reasonable approach to evaluate the extension of the bone involvement. Further studies are needed to elucidate the true incidence and management of bone metastasis in endometrial clear cell carcinoma.

Long-term survival after paclitaxel plus platinum-based combination chemotherapy for extraovarian peritoneal serous papillary carcinoma: is it different from that for ovarian serous papillary cancer?

The purpose of this study was to compare the effect of paclitaxel plus platinum-based chemotherapy in the treatment of extraovarian peritoneal serous papillary carcinoma (EPSPC) and ovarian serous papillary cancer (OSPC). Only the patients treated with initial surgery plus postoperative adjuvant chemotherapy and having FIGO stage IIIC disease with omental and/or peritoneal involvement were analyzed. Thirty-two patients with EPSPC and 43 with OSPC were included in this study. The median age, mean CA-125, and volume of ascitis were higher in patients with EPSPC. There was no significant difference between the two groups with respect to other prognosticators. The median overall survival (OS) durations were 30 months (95% CI 24.8-35.3) in patients with EPSPC and 28 months (95% CI 21.1-34.9) in those with OSPC (P= 0.35). The 3-year OS rates in the patients and controls were 28% and 31%, respectively (P= 0.84). In patients with EPSPC, only optimal cytoreduction was significantly related to progression-free survival and OS durations as a prognostic factor. In the EPSPC group, 65.5% of the patients (19/29) had lymphatic involvement, compared to 88.4% (38/43) in the OSPC group (P= 0.02). As an adjuvant therapy, the paclitaxel plus platinum-based combination regimen had similar effects on survival in the EPSPC and OSPC groups.

Does immediate hormone replacement therapy affect the oncologic outcome in endometrial cancer survivors?

The purpose of this study was to evaluate the effect of immediate hormone replacement therapy (HRT) on oncologic outcome of patients with endometrial cancer. The patients were recruited prospectively after extensive discussion of risks and benefits of HRT. Continuous daily regimen of 0.625 mg conjugated equine estrogen plus 2.5 mg medroxyprogesterone acetate was initiated 4-8 weeks after surgery at first postoperative visit. The patients who had the same characteristics with the HRT group were assigned as a control group. Overall, 50 patients received HRT. There was no significant difference with respect to prognosticators between the HRT users and the control group. Seven patients (14%) stopped the use of HRT. Only two patients stopped the therapy before 24 months, and all the remaining patients used HRT for at least 24 months, with a mean value of 49.1 months. Neither the patients who used HRT nor the ones who left the therapy had recurrence at the time of writing of this article. This prospective case-control study showed that immediate postoperative use of HRT did not increase the recurrence or death rates in endometrial cancer survivors.

Medical treatment of vulvar squamous cell hyperplasia

OBJECTIVE

To evaluate symptomatic response and recurrence rates of graduated topical fluorinated corticosteroid in patients with vulvar squamous cell hyperplasia.

METHODS

Nine hundred seventy-six patients with biopsy-proven vulvar squamous cell hyperplasia from 1990 to 2003 were reviewed in this retrospective study. All patients were treated with graduated topical fluorinated corticosteroid. Data were obtained from hospital records. Symptomatic remission and recurrence rates were noted following six months local therapy.

RESULTS

The mean age was 42.55+/-10.93 (15-85). The remission rate was 93.8% in six months. The remission rate was non-significantly higher in postmenopausal patients than that in their premenopausal counterpart (94.9% vs 93.0%, p=0.15). The disease recurred in 6.9% of patients. Of the patients that suffered recurrence 47.5% had persistent disease initially. The patients with following factors older ages (>40 years), postmenopausal period had significantly higher recurrence rates. Four patients with recurrent disease and six patients with persistent disease in the form of vulvar intraepithelial neoplasia I-II or atypical squamous hyperplasia, were treated with skinning vulvectomy.

CONCLUSION

Corticosteroid in the treatment of vulvar squamous cell hyperplasia yielded excellent response rates. In the evaluation of patients without symptomatic relief, the first step should be a vulvar biopsy to exclude the presence of atypical components.

Triple simultaneous primary gynecological malignancies in a 56-year-old patient

The occurrence of double simultaneous primary cancers is common. However, the occurrence of synchronous primary triple gynecological malignancies is an extremely rare event. In this report, the clinical and pathologic findings of a 56-year-old female patient with synchronous triple primary gynecological cancers including well-differentiated ovarian mucinous cystadenocarcinoma, well-differentiated endometrial endometrioid adenocarcinoma, and uterine leiomyosarcoma were presented. Synchronous primary, well-differentiated endometrial endometrioid adenocarcinoma and leiomyosarcoma of uterus without any ovarian neoplasm has only been once described in the English literature. To our knowledge, the presented patient is the first case in aspect of accompanying ovarian mucinous adenocarcinoma to endometrial endometrioid adenocarcinoma and leiomyosarcoma of uterus.