Pharmacological inhibition of the LIF/LIFR autocrine loop reveals vulnerability of ovarian cancer cells to ferroptosis

Of all gynecologic cancers, epithelial-ovarian cancer (OCa) stands out with the highest mortality rates. Despite all efforts, 90% of individuals who receive standard surgical and cytotoxic therapy experience disease recurrence. The precise mechanism by which leukemia inhibitory factor (LIF) and its receptor (LIFR) contribute to the progression of OCa remains unknown. Analysis of cancer databases revealed that elevated expression of LIF or LIFR was associated with poor progression-free survival of OCa patients and a predictor of poor response to chemotherapy. Using multiple primary and established OCa cell lines or tissues that represent five subtypes of epithelial-OCa, we demonstrated that LIF/LIFR autocrine signaling is active in OCa. Moreover, treatment with LIFR inhibitor, EC359 significantly reduced OCa cell viability and cell survival with an IC50 ranging from 5-50 nM. Furthermore, EC359 diminished the stemness of OCa cells. Mechanistic studies using RNA-seq and rescue experiments unveiled that EC359 primarily induced ferroptosis by suppressing the glutathione antioxidant defense system. Using multiple in vitro, ex vivo and in vivo models including cell-based xenografts, patient-derived explants, organoids, and xenograft tumors, we demonstrated that EC359 dramatically reduced the growth and progression of OCa. Additionally, EC359 therapy considerably improved tumor immunogenicity by robust CD45+ leukocyte tumor infiltration and polarizing tumor-associated macrophages (TAMs) toward M1 phenotype while showing no impact on normal T-, B-, and other immune cells. Collectively, our findings indicate that the LIF/LIFR autocrine loop plays an essential role in OCa progression and that EC359 could be a promising therapeutic agent for OCa.

Novel LIPA-Targeted Therapy for Treating Ovarian Cancer

Ovarian cancer (OCa) is the most lethal form of gynecologic cancer, and the tumor heterogeneities at the molecular, cellular, and tissue levels fuel tumor resistance to standard therapies and pose a substantial clinical challenge. Here, we tested the hypothesis that the heightened basal endoplasmic reticulum stress (ERS) observed in OCa represents an exploitable vulnerability and may overcome tumor heterogeneity. Our recent studies identified LIPA as a novel target to induce ERS in cancer cells using the small molecule ERX-41. However, the role of LIPA and theutility of ERX-41 to treat OCa remain unknown. Expression analysis using the TNMplot web tool, TCGA data sets, and immunohistochemistry analysis using a tumor tissue array showed that LIPA is highly expressed in OCa tissues, compared to normal tissues. ERX-41 treatment significantly reduced the cell viability and colony formation ability and promoted the apoptosis of OCa cells. Mechanistic studies revealed a robust and consistent induction of ERS markers, including CHOP, elF2α, PERK, and ATF4, upon ERX-41 treatment. In xenograft and PDX studies, ERX-41 treatment resulted in a significant reduction in tumor growth. Collectively, our results suggest that ERX-41 is a novel therapeutic agent that targets the LIPA with a unique mechanism of ERS induction, which could be exploited to treat heterogeneity in OCa.

The LIFR Inhibitor EC359 Effectively Targets Type II Endometrial Cancer by Blocking LIF/LIFR Oncogenic Signaling

Endometrial cancer (ECa) is the most common female gynecologic cancer. When comparing the two histological subtypes of endometrial cancer, Type II tumors are biologically more aggressive and have a worse prognosis than Type I tumors. Current treatments for Type II tumors are ineffective, and new targeted therapies are urgently needed. LIFR and its ligand, LIF, have been shown to play a critical role in the progression of multiple solid cancers and therapy resistance. The role of LIF/LIFR in the progression of Type II ECa, on the other hand, is unknown. We investigated the role of LIF/LIFR signaling in Type II ECa and tested the efficacy of EC359, a novel small-molecule LIFR inhibitor, against Type II ECa. The analysis of tumor databases has uncovered a correlation between diminished survival rates and increased expression of leukemia inhibitory factor (LIF), suggesting a potential connection between altered LIF expression and unfavorable overall survival in Type II ECa. The results obtained from cell viability and colony formation assays demonstrated a significant decrease in the growth of Type II ECa LIFR knockdown cells in comparison to vector control cells. Furthermore, in both primary and established Type II ECa cells, pharmacological inhibition of the LIF/LIFR axis with EC359 markedly decreased cell viability, long-term cell survival, and invasion, and promoted apoptosis. Additionally, EC359 treatment reduced the activation of pathways driven by LIF/LIFR, such as AKT, mTOR, and STAT3. Tumor progression was markedly inhibited by EC359 treatment in two different patient-derived xenograft models in vivo and patient-derived organoids ex vivo. Collectively, these results suggest LIFR inhibitor EC359 as a possible new small-molecule therapeutics for the management of Type II ECa.

Pharmacological inhibition of KDM1A/LSD1 enhances estrogen receptor beta-mediated tumor suppression in ovarian cancer

Ovarian cancer (OCa) is the most lethal gynecologic cancer. Emerging data indicates that estrogen receptor beta (ERβ) functions as a tumor suppressor in OCa. Lysine-specific histone demethylase 1A (KDM1A) is an epigenetic modifier that acts as a coregulator for steroid hormone receptors. However, it remain unknown if KDM1A interacts with ERβ and regulates its expression/functions in OCa. Analysis of TCGA data sets indicated KDM1A and ERβ expression showed an inverse relationship in OCa. Knockout (KO), knockdown (KD), or inhibition of KDM1A increased ERβ isoform 1 expression in established and patient-derived OCa cells. Further, KDM1A interacts with and functions as a corepressor of ERβ, and its inhibition enhances ERβ target gene expression via alterations of histone methylation marks at their promoters. Importantly, KDM1A-KO or -KD enhanced the efficacy of ERβ agonist LY500307, and the combination of KDM1A inhibitor (KDM1Ai) NCD38 with ERβ agonist synergistically reduced the cell viability, colony formation, and invasion of OCa cells. RNA-seq and DIA mass spectrometry analyses showed that KDM1A-KO resulted in enhanced ERβ signaling and that genes altered by KDM1A-KO and ERβ agonist were related to apoptosis, cell cycle, and EMT. Moreover, combination treatment significantly reduced the tumor growth in OCa orthotopic, syngeneic, and patient-derived xenograft models and proliferation in patient-derived explant models. Our results demonstrate that KDM1A regulates ERβ expression/functions, and its inhibition improves ERβ mediated tumor suppression. Overall, our findings suggest that KDM1Ai and ERβ agonist combination therapy is a promising strategy for OCa.

PELP1 inhibition by SMIP34 reduces endometrial cancer progression via attenuation of ribosomal biogenesis

Endometrial carcinoma (ECa) is the fourth most common cancer among women. The oncogene PELP1 is frequently overexpressed in a variety of cancers, including ECa. We recently generated SMIP34, a small-molecule inhibitor of PELP1 that suppresses PELP1 oncogenic signaling. In this study, we assessed the effectiveness of SMIP34 in treating ECa. Treatment of established and primary patient-derived ECa cells with SMIP34 resulted in a significant reduction of cell viability, colony formation ability, and induction of apoptosis. RNA-seq analyses showed that SMIP34-regulated genes were negatively correlated with ribosome biogenesis and eukaryotic translation pathways. Mechanistic studies showed that the Rix complex, which is essential for ribosomal biogenesis, is disrupted upon SMIP34 binding to PELP1. Biochemical assays confirmed that SMIP34 reduced ribosomal biogenesis and new protein synthesis. Further, SMIP34 enhanced the efficacy of mTOR inhibitors in reducing viability of ECa cells. SMIP34 is also effective in reducing cell viability in ECa organoids in vitro and explants ex vivo. Importantly, SMIP34 treatment resulted in a significant reduction of the growth of ECa xenografts. Collectively, these findings underscore the potential of SMIP34 in treating ECa.

Abstract 3986: Novel LIPA targeted therapy for treating ovarian cancer

BACKGROUND: Ovarian cancer (OCa) is the deadliest of all gynecologic cancers in the United States. Currently approved therapies have improved OCa survival for clinically localized disease, however, the majority (~90%) of patients with high-grade serous OCa (HGSOC) experience relapse with incurable metastases. There is a dire need for new therapeutic approaches. We hypothesized that the high basal endoplasmic reticulum stress (ERS) in OCa represents a critical and targetable vulnerability and may overcome the tumor heterogeneity. The objective of this project is to exploit increased ERS in ovarian cancer cells by engaging the novel target LIPA using the unique compound ERX-41.

METHODS: The utility of ERX-41 as a new therapy was evaluated using MTT and CellTiter-Glo Cell Viability Assays. We used multiple established and patient derived OCa cell lines. The effect of ERX-41 on the Cell viability of patient-derived organoids (PDO) was measured using CellTiter-Glo 3D Assay. Long term effects of ERX-41 on cell survival were measured using colony formation assays. Apoptosis was measured using Annexin V and Caspase-Glo® 3/7 Assays. Cell cycle analysis was analyzed by Flow Cytometry. Mechanistic studies were done using LIPA knockout (KO) cells, RT-qPCR, and western blotting. Status of LIPA in OCa was determined using TNMplot database. In vivo efficacy of ERX-41 was tested using both cell line derived (CDX) and patient derived (PDXs) xenografts.

RESULTS: TNM plot results showed that LIPA is highly expressed in OCa tumors compared to normal tissues and LIPA expression correlated with clinical grade. Kaplan-Meier plotter analyses of TCGA data revealed that LIPA expression is negatively correlated with overall survival in OCa patients. MTT and CellTitre-Glo assay results showed that ERX-41 significantly reduced the cell viability of both established and primary OCa cells, and PDO’s with an IC50 of ~500nM. ERX-41 treatment also significantly reduced the cell survival, increased S-phase arrest, and promoted apoptosis of OCa cells. A time course study revealed a robust and consistent induction of ERS markers (CHOP and sXBP1) in OCa cells by ERX-41 within 4h. Western blotting analyses also confirmed increased expression of ERS markers including CHOP, elF2α, PERK, and ATF4 upon ERX-41 treatment confirming that ERX-41 induces ERS. In xenograft studies, ERX-41 treatment resulted in ~66% reduction of tumor volume measured by Xenogen-IVIS. Further, in studies using PDX tumors, treatment with ERX-41 resulted in a significant reduction (~60%) of tumor volume and tumor weight.

CONCLUSION: Collectively, our results suggest that ERX-41 is a novel therapeutic agent that targets the LIPA with a unique mechanism of action and implicate ERX-41 binding to LIPA induces ER stress, and apoptosis of OCa cells. Further molecular characterization of how ERX-41 binding to LIPA induces ER stress in OCa cells is ongoing.

Citation Format: Alexia B. Collier, Suryavathi Viswanadhapalli, Tae-Kyung Lee, Kara Kassees, Karla Parra, Gaurav Sharma, Tanner Reese, Michael Hsieh, Xihui Liu, Xue Yang, Behnam Ebrahimi, Uday P. Pratap, Rahul Gopalam, Chia Yuan Chen, Scott Terry Elmore, Gangadhara Reddy Sareddy, Edward R. Kost, Jung-Mo Ahn, Ganesh V. Raj, Ratna K. Vadlamudi. Novel LIPA targeted therapy for treating ovarian cancer. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3986.

Abstract 3408: The role of obesity in promoting the LIF/LIFR signaling in triple negative breast cancer

Background: Triple-negative breast cancer (TNBC) is an aggressive subtype of breast cancer (BC) that accounts for a disproportionate amount of BC mortality. The relationship(s) between obesity and the TNBC is crucial because the obesity prevalence in the USA is on the rise. Obese patients are generally diagnosed with large primary tumors, more lymph node metastases, and obesity effects on tumor microenvironment (TME) are suspected to accelerate the development of TNBC, but the exact mechanism(s) by which this occurs remain unknown. The goal of this study is to investigate the hypothesis that obesity enhances leukemia inhibitory factor receptor (LIFR) oncogenic signaling in TNBC and to test the utility of LIFR inhibitor in blocking obesity driven progression of TNBC.

Methods: Established TNBC cell lines were co-cultured with human primary adipocytes, incubated with adipocyte conditioned media, or exposed to high glucose (HG), then treated with the LIFR inhibitor EC359. Cell viability, colony formation, and invasion assays were used to analyze the impact of obesity on TNBC cells and to test utility of EC359. RT-qPCR, Western blotting, reporter gene assays, and RNA-seq analyses were used in the mechanistic studies. Xenografts and patient-derived organoid (PDO) models were used to evaluate the effectiveness of the EC359.

Results: The cell proliferation and invasion of TNBC cells were accelerated by adipocyte conditioned media or when exposed to HG. RNA-seq and RT-qPCR analysis revealed a correlation between elevated LIFR expression and downstream LIFR signaling, including STAT3, as well as the subsequent activation of STAT3 target genes. The cell viability, colony formation, and invasion of TNBC cells under HG and adipose conditions were all markedly decreased after treatment with LIFR inhibitor EC359. Results from Western blotting demonstrated that co-culture with adipocytes or incubation with HG dramatically increased LIFR downstream signaling in TNBC model cells, and that this signaling is effectively suppressed by EC359 therapy. In addition, administration of EC359 prevented organoid proliferation that was mediated by the adipose conditioned media. Importantly, co-implantation of adipocytes greatly increased the growth of the TNBC xenograft tumor; however, therapy with EC359 significantly reduced the growth of TNBC caused by adipocyte co-implantation.

Conclusions: Collectively, these findings suggest that obesity conditions promote the activation of LIF/LIFR pathway, which in turn enhances TNBC cell proliferation. The LIFR inhibitor EC359 may be employed as a new therapeutic drug to treat obesity driven TNBC and LIF/LIFR axis represents a potential therapeutic target for obesity driven TNBC.

Citation Format: Lois Randolph, Alondra Rodriguez Sanchez, Logan Blankenship, Uday P. Pratap, Xue Yang, Durga Meenakshi Panneerdoss, Swapna Konda, Bindu Santhamma, Gangadhara R. Sareddy, Manjeet K. Rao, Edward R. Kost, Rajeshwar R. Tekmal, Hareesh B. Nair, Ratna K. Vadlamudi, Suryavathi Viswanadhapalli. The role of obesity in promoting the LIF/LIFR signaling in triple negative breast cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 3408.

Abstract 4966: Targeting LIF/LIFR autocrine loops with EC359 in ovarian cancer: A novel LIFR targeted therapy

Background: Of all gynecologic cancers, ovarian cancer (OCa) has the highest mortality rates. Nearly 90% of patients who receive standard surgical and cytotoxic treatment experience disease recurrence. Leukemia inhibitory factor (LIF) and its receptor LIFR are implicated in the progression of several cancers. A knowledge gap exists on whether LIF/LIFR plays a role in the evolution of OCa. We recently developed EC359, a first-in-class LIFR inhibitor. Here, we examined whether autocrine loops of LIF/LIFR contribute to OCa progression and tested the utility of EC359 as a potential targeted therapy.

Methods: Eighteen different OCa model cells, both established and primary, were used to profile the expression of LIF and LIFR. Cell viability, colony formation, apoptosis, and reporter assays were used to assess EC359 impact on OCa cells. Mechanistic studies were carried out using RNA-seq and RT-qPCR analysis. Using cell-based xenografts, syngeneic xenografts, patient derived organoids (PDO), and patient derived xenograft (PDX) models, the effectiveness of LIFR inhibitor EC359 as a targeted therapy was examined.

Results: Kaplan-Meier survival analysis (KMplot) revealed increased expression of LIF and LIFR was linked to poor progression-free survival in OCa patients. The levels of LIF and LIFR were considerably greater in OCa chemotherapy non-responders than responders. We validated the existence of LIF/LIFR autocrine signaling using 18 distinct OCa cells. Treatment with the LIFR inhibitor EC359 dramatically decreased OCa cell viability, cell survival and increased apoptosis, with an IC50 of 5 to 50 nM. The activation of STAT3, mTOR, AKT, and p42/44 MAPKs as well as other downstream LIFR signaling was markedly decreased by EC359 treatment. Treatment with EC359 also decreased the stemness of OCa cells, slowed PDO development, and sensitized chemotherapy-resistant OCa cells to chemotherapy. One of the significant pathways elevated by EC359, according to RNA-seq data, is the regulation of apoptosis. In six different cell-based xenografts and PDX tumors, we demonstrated that the EC359 at 5mg/kg dose significantly reduced the OCa xenograft growth. In comparison to the vehicle control, the tumor volume was significantly reduced by EC359 treatment of murine ID8 xenografts in C57BL6 mice. Our findings indicated that EC359 had both intrinsic and extrinsic effects on tumors. Tumor-associated macrophages (TAMs) with a significant M1 polarity (CD11b+Gr1-CD68high/phosphoSTAT1+/cMAF-) and robust tumor infiltration by (CD45+) leukocytes were enhanced with EC359 therapy of ID8 xenograft tumors. Importantly, normal T, B, and other immune cells in the blood demonstrated that EC359 had no effect on immune cell homeostasis.

Conclusions: Together, our findings support the existence of LIF/LIFR autocrine loops, and EC359 is a viable treatment option for OCa.

Citation Format: Behnam Ebrahimi, Suryavathi Viswanadhapalli, Uday P. Pratap, Rahul Gopalam, Xue Yang, Bindhu Santhamma, Swapna Konda, Xiaonan Li, Hui Yan, Gangadhara R. Sareddy, Zhenming Xu, Edward R. Kost, Rajeshwar R. Tekmal, Hareesh B. Nair, Ratna K. Vadlamudi. Targeting LIF/LIFR autocrine loops with EC359 in ovarian cancer: A novel LIFR targeted therapy. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4966.

Inhibition of LIFR Blocks Adiposity-Driven Endometrioid Endometrial Cancer Growth

Simple Summary

In this study, we utilized global RNA-seq to elucidate the molecular mechanisms by which obese conditions promote progression of endometrioid endometrial cancer (EEC). Our results suggest that obese conditions upregulate LIF/LIFR signaling, and EEC tumors collected from obese patients have high levels of LIF. Mechanistic studies suggest that LIF/LIFR signaling plays an important role in obesity-driven EEC progression and the LIFR inhibitor, EC359, has the potential to suppress the tumor progression driven by increased adiposity found in obese patients.

Abstract

Endometrial cancer (EC) is the fourth most common cancer in women, and half of the endometrioid EC (EEC) cases are attributable to obesity. However, the underlying mechanism(s) of obesity-driven EEC remain(s) unclear. In this study, we examined whether LIF signaling plays a role in the obesity-driven progression of EEC. RNA-seq analysis of EEC cells stimulated by adipose conditioned medium (ADP-CM) showed upregulation of LIF/LIFR-mediated signaling pathways including JAK/STAT and interleukin pathways. Immunohistochemistry analysis of normal and EEC tissues collected from obese patients revealed that LIF expression is upregulated in EEC tissues compared to the normal endometrium. Treatment of both primary and established EEC cells with ADP-CM increased the expression of LIF and its receptor LIFR and enhanced proliferation of EEC cells. Treatment of EEC cells with the LIFR inhibitor EC359 abolished ADP-CM induced colony formation andcell viability and decreased growth of EEC organoids. Mechanistic studies using Western blotting, RT-qPCR and reporter assays confirmed that ADP-CM activated LIF/LIFR downstream signaling, which can be effectively attenuated by the addition of EC359. In xenograft assays, co-implantation of adipocytes significantly enhanced EEC xenograft tumor growth. Further, treatment with EC359 significantly attenuated adipocyte-induced EEC progression in vivo. Collectively, our data support the premise that LIF/LIFR signaling plays an important role in obesity-driven EEC progression and the LIFR inhibitor EC359 has the potential to suppress adipocyte-driven tumor progression.

Therapeutic Targeting of Ovarian Cancer Stem Cells Using Estrogen Receptor Beta Agonist

Ovarian cancer (OCa) is the deadliest gynecologic cancer. Emerging studies suggest ovarian cancer stem cells (OCSCs) contribute to chemotherapy resistance and tumor relapse. Recent studies demonstrated estrogen receptor beta (ERβ) exerts tumor suppressor functions in OCa. However, the status of ERβ expression in OCSCs and the therapeutic utility of the ERβ agonist LY500307 for targeting OCSCs remain unknown. OCSCs were enriched from ES2, OV90, SKOV3, OVSAHO, and A2780 cells using ALDEFLUOR kit. RT-qPCR results showed ERβ, particularly ERβ isoform 1, is highly expressed in OCSCs and that ERβ agonist LY500307 significantly reduced the viability of OCSCs. Treatment of OCSCs with LY500307 significantly reduced sphere formation, self-renewal, and invasion, while also promoting apoptosis and G2/M cell cycle arrest. Mechanistic studies using RNA-seq analysis demonstrated that LY500307 treatment resulted in modulation of pathways related to cell cycle and apoptosis. Western blot and RT-qPCR assays demonstrated the upregulation of apoptosis and cell cycle arrest genes such as FDXR, p21/CDKN1A, cleaved PARP, and caspase 3, and the downregulation of stemness markers SOX2, Oct4, and Nanog. Importantly, treatment of LY500307 significantly attenuated the tumor-initiating capacity of OCSCs in orthotopic OCa murine xenograft models. Our results demonstrate that ERβ agonist LY500307 is highly efficacious in reducing the stemness and promoting apoptosis of OCSCs and shows significant promise as a novel therapeutic agent in treating OCa.

A rectovaginal septum mass in a BRCA1 positive patient years after risk reducing surgery: A case report

•Rectovaginal septum mass in BRCA1 positive patient after risk reducing BSO years prior.•Papillary serous carcinoma presenting as a rectovaginal septum mass.•PAOLA-1 trial discussion for rectovaginal septum mass in BRCA1 positive patient.

Adipokines Deregulate Cellular Communication via Epigenetic Repression of Gap Junction Loci in Obese Endometrial Cancer

Emerging evidence indicates that adipose stromal cells (ASC) are recruited to enhance cancer development. In this study, we examined the role these adipocyte progenitors play relating to intercellular communication in obesity-associated endometrial cancer. This is particularly relevant given that gap junctions have been implicated in tumor suppression. Examining the effects of ASCs on the transcriptome of endometrial epithelial cells (EEC) in an in vitro coculture system revealed transcriptional repression of GJA1 (encoding the gap junction protein Cx43) and other genes related to intercellular communication. This repression was recapitulated in an obesity mouse model of endometrial cancer. Furthermore, inhibition of plasminogen activator inhibitor 1 (PAI-1), which was the most abundant ASC adipokine, led to reversal of cellular distribution associated with the GJA1 repression profile, suggesting that PAI-1 may mediate actions of ASC on transcriptional regulation in EEC. In an endometrial cancer cohort (n = 141), DNA hypermethylation of GJA1 and related loci TJP2 and PRKCA was observed in primary endometrial endometrioid tumors and was associated with obesity. Pharmacologic reversal of DNA methylation enhanced gap-junction intercellular communication and cell-cell interactions in vitro. Restoring Cx43 expression in endometrial cancer cells reduced cellular migration; conversely, depletion of Cx43 increased cell migration in immortalized normal EEC. Our data suggest that persistent repression by ASC adipokines leads to promoter hypermethylation of GJA1 and related genes in the endometrium, triggering long-term silencing of these loci in endometrial tumors of obese patients. SIGNIFICANCE: Studies reveal that adipose-derived stem cells in endometrial cancer pathogenesis influence epigenetic repression of gap junction loci, which suggests targeting of gap junction activity as a preventive strategy for obesity-associated endometrial cancer.

Abstract 5875: Development of LIFR inhibitor EC359 as a novel therapeutic for ovarian cancer

Background: Ovarian cancer (OCa) is the deadliest of all gynecologic cancers. OCa patients initially respond to standard combinations of surgical and cytotoxic therapy; however, ~80% will develop recurrence and inevitably succumb to chemotherapy-resistant disease. OCa stem cells are implicated in the tumor initiation and therapy resistance. LIFR signaling plays a critical role in OCa progression and stemness. Further, high circulating LIF levels correlate with tumor recurrence and chemoresistance. The autocrine loop involving LIF, LIFR and STAT3 axis drives sustained fibroblast production of inflammatory mediators. This represents a significant problem and a critical need exists for development of novel therapies targeting the LIFR axis for treating OCa.

Methods: We have rationally designed and synthesized a small organic molecule (EC359) that emulates the LIF-LIFR binding site and functions as a LIFR inhibitor from a library of compounds. In silico docking studies were used to identify the putative interaction of the EC359 and LIF/LIFR complex. Binding of EC359 to LIFR was confirmed using surface plasmon resonance (SPR) and IP assays. Mechanistic studies were conducted using Western, RT-qPCR, and RNA-Seq analysis. Xenograft models were used for preclinical evaluation and toxicity. The efficacy of EC359 was tested using Patient-Derived eXplants (PDeX).

Results: Global analysis of online databases revealed negative correlation of OCa survival with LIFR expression. Molecular docking studies showed EC359 interacts at the LIF-LIFR binding interface. SPR studies confirmed interaction of EC359 to LIFR. Western analysis of eight cells that represent four subtypes of OCa confirmed higher expression of LIF and LIFR. EC359 reduced the growth of eight OCa cells with high potency (IC50 10-50 nM) and promoted apoptosis. EC359 treatment reduced stemness of OCa cells. EC359 activity is dependent on the level of expression of LIFR with little activity on cells that do not express LIFR. EC359 significantly reduced the viability of carboplatin- and taxol-resistant OCa cells. Mechanistic studies showed EC359 interacts with LIFR and block its interaction with LIF. EC359 treatment reduced the STAT3 phosphorylation, mTOR and downstream survival signaling cascades. RNA sequencing revealed unique pathways blocked by EC359. Treatment of xenograft tumors with EC359 significantly reduced the tumor volume compared to control. Further, using PDeX of OCa, we demonstrated that EC359 has potential to reduce the proliferation. Pharmacologically, EC359 exhibited high oral bioavailability and long half-life with a wide therapeutic window.

Conclusions: EC359 is a novel agent that targets LIF-LIFR axis and has activity against chemotherapy-resistant and primary OCa tumors. EC359 has the distinct pharmacologic advantages of oral bioavailability, in vivo stability, and is associated with minimal systemic side effects.

Citation Format: Suryavathi Viswanadhapalli, Hareesh B Nair, Bindu Santhamma, Gangadhara R Sareddy, Yiliao Luo, Xinlei Pan, Edward R Kost, Ramachandran Murali, Rajeshwar Rao Tekmal, Klaus J Nickisch, Ratna K Vadlamudi. Development of LIFR inhibitor EC359 as a novel therapeutic for ovarian cancer [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2018; 2018 Apr 14-18; Chicago, IL. Philadelphia (PA): AACR; Cancer Res 2018;78(13 Suppl):Abstract nr 5875.

Leiomyosarcoma of the uterine cervix associated with pregnancy: A case report and review of literature

•Management of cervical leiomyosarcoma in pregnancy requires a multidisciplinary approach.•Ovarian preservation is preferred in young patients with early stage cervical leiomyosarcoma.•Routine lymphadenectomy in patients with early stage cervical leiomyosarcoma is not useful.

Successful pregnancy following myomectomy for uterine smooth muscle tumor of uncertain malignant potential: A case report and review of the literature

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STUMPs are rare smooth muscle tumors with an overall favorable prognosis.

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Pregnancy is possible after diagnosis of STUMP treated with myomectomy

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Management of patients desiring fertility with STUMPs requires a multidisciplinary approach.

A randomized-clinical trial examining a neoprene abdominal binder in gynecologic surgery patients

PURPOSE OF INVESTIGATION

Pain control and early ambulation are two important postoperative goals. Strategies that decrease morphine use while increasing ambulation have the potential to decrease postoperative complications. In this study the authors sought to determine the effect of an abdominopelvic binder on postoperative morphine use, pain, and ambulation in the first day after surgery.

MATERIALS AND METHODS

The authors randomly assigned 75 patients undergoing abdominal gynecologic surgery to either binder or not after surgery. Demographic data and surgical characteristics were collected. Outcome variables included morphine use, pain score, time to ambulation, and number of ambulations.

RESULTS

A group at high risk for decreased mobility was identified and the binder increased the number of ambulatory events by 300%, 260%, and 240% in patients with vertical incisions, age over 50 years, and complex surgeries, respectively. Morphine use and pain scores were not significantly different.

CONCLUSION

The binder increased ambulations in the subset of patients at the highest risk for postoperative complications: elderly, cancer patients, and vertical incisions. Routine use of the binder may benefit particularly high-risk gynecologic surgical patients.

Surgically managed stage I endometrial cancer in a low-volume center: outcomes and complications in a military residency program

OBJECTIVE

The purpose of this study was to compare operative outcomes and complications for patients with endometrial cancer who underwent staging by laparoscopy vs laparotomy in a low-volume facility.

STUDY DESIGN

Research was conducted with a retrospective cohort of surgical patients with clinical stage I endometrial cancer from 2004-2009.

RESULTS

Eighty-six demographically similar patients (50 laparotomy and 36 laparoscopy) were identified. Laparoscopy had less estimated blood loss (339 vs 558 mL; P = .013) and lower rates of transfusion (5.6% vs 24%; P = .02). Laparoscopy was longer (281 vs 202 minutes; P < .0005) but required a shorter hospital stay (2.2 vs 5.5 days; P < .0005). Laparoscopy patients had fewer overall complications (16.7% vs 32%; P = .11). No differences in final surgical stage or lymph node yields between the groups were present.

CONCLUSION

Although a longer procedure, laparoscopy had fewer complications and shorter hospital stays. Prolonged operative time, compared with published experience, is potentially the result of unique factors in our center.

Delivery Complicated by Postpartum Hemorrhage and Lower Extremity Compartment Syndrome

BACKGROUND

Extremity compartment syndrome is a rare surgical complication in which increased intracompartmental pressure threatens the viability of the muscular and nervous tissue. We report a case of a delivery complicated by postpartum hemorrhage and a lower extremity compartment syndrome.

CASE

A multigravida in her late 20s was admitted for induction of labor at 41 weeks of gestation. She underwent a cesarean delivery for a nonreassuring fetal heart rate tracing. The delivery was complicated by severe postpartum hemorrhage due to uterine atony, resulting in a cesarean hysterectomy. The patient developed a lower extremity compartment syndrome and underwent an emergent anterior tibial fasciotomy.

CONCLUSION

Extremity compartment syndrome is rarely encountered in obstetric care; however, there may be an association with severe postpartum hemorrhage.

Characterization of human leukocyte antigen-G (HLA-G) expression in endometrial adenocarcinoma

OBJECTIVES

The current study sought to determine if endometrial adenocarcinomas express human leukocyte antigen-G (HLA-G), an immune-regulatory protein, and if degree of expression correlates with the stage of carcinoma.

METHODS

Forty-four primary endometrial adenocarcinomas were tested using immunohistochemical staining with the 4H84 anti-HLA-G monoclonal antibody. Metastatic implants were not included. A subset of 10 samples was tested using RNA in situ hybridization to confirm the presence of HLA-G transcript. Results of staining were analyzed with respect to grade, tumor histology, and stage of disease. Spearman rank correlation was used to assess tumor grade, histology, and disease stage as a function of HLA-G protein staining. Receiver-operator characteristic (ROC) curve analysis was used to determine the feasibility of HLA-G protein staining as a clinical marker for advanced stage disease.

RESULTS

Immunohistochemical staining for HLA-G protein was seen in 55% (24/44) of primary site endometrial adenocarcinomas and localized to glandular but not stromal epithelium. RNA in situ hybridization confirmed the presence of transcript in the majority of samples tested and also localized to glandular epithelium. A significant correlation was seen with increasing HLA-G protein staining and increasing stage of endometrial cancer, P < 0.01. HLA-G was found to be a fair discriminator as a test for metastatic disease with an area under the ROC curve of 0.75 for metastatic versus non-metastatic disease.

CONCLUSIONS

HLA-G protein is expressed in a significant number of endometrial adenocarcinomas, in which it is localized to the glandular epithelium. HLA-G may serve as a clinical marker for the preoperative prediction of metastatic endometrial cancer.

Coccidioidomycosis Mimicking Ovarian Cancer

BACKGROUND

Dissemination of coccidioidomycosis to the abdominal cavity is rare. No previous case of peritoneal coccidioidomycosis has presented as an adnexal mass.

CASE

We report a case of peritoneal coccidioidomycosis mimicking ovarian carcinoma. The patient presented with a complex ovarian mass, ascites, omental caking, and an elevated CA 125. The ultimate diagnosis was not made until frozen section histopathology was performed at staging laparotomy.

CONCLUSION

Peritoneal coccidioidomycosis can present with the clinical, radiographic, and serologic features of ovarian cancer. Although essential for diagnosis and staging, radiographic studies and tumor markers have limited specificity. Coccidioidomycosis now joins other benign conditions that comprise the differential diagnosis of patients who present with what seems to be advanced ovarian carcinoma. Infectious diseases consultation is recommended for the management of peritoneal coccidioidomycosis.

Asian-Pacific Islander race independently predicts poor outcome in patients with endometrial cancer

OBJECTIVE

The Department of Defense health care system provides access to care without respect to age, race, or socioeconomic status. We sought to determine the effect of race as a predictor of survival in patients with endometrial cancer treated in the Department of Defense medical system.

METHODS

Information on patients with endometrial carcinoma was extracted from the Department of Defense centralized tumor registry for the period 1988 to 1995. Data included age at diagnosis, military status, race, tumor histology, grade, FIGO surgical stage, adjuvant therapies, and disease-free survival. The chi(2) test was used for analysis of prognostic factors and adjuvant treatments between racial groups. Actuarial survival curves were calculated by using the method of Kaplan and Meier and compared by the log-rank test. Variables found to be significant on univariate analysis (P < 0.05) were entered into a multivariate Cox regression analysis.

RESULTS

Of 1811 patients meeting criteria for the study, racial distribution was 90% Caucasian, 4.4% African-American, and 5.5% Asian-Pacific Islander. African-Americans had more advanced stages of disease compared to Caucasians (P < 0.001). Both African-Americans and Asian-Pacific Islanders had higher grade tumors and less favorable histologic types than Caucasians (P < 0.05). The extent of adjuvant therapies was similar for racial groups. African-Americans and Asian-Pacific Islanders had significantly worse 5-year disease-free survivals than Caucasians (P = 0.007). Additional poor prognostic factors included age >60 years, grade, unfavorable histology, and stage. On multivariate analysis age >60 years, stage, and Asian-Pacific Islander race remained significant prognostic factors.

CONCLUSION

African-Americans and Asian-Pacific Islanders had worse survivals than Caucasians. After controlling for imbalances in clinicopathologic factors, Asian-Pacific Islander race was found to be a newly identified poor prognostic factor.

Adenosquamous histology predicts a poor outcome for patients with advanced-stage, but not early-stage, cervical carcinoma

BACKGROUND

The objective of this study was to compare survival between patients with adenocarcinoma and patients with adenosquamous carcinoma of the cervix.

METHODS

Patients who were diagnosed with invasive cervical carcinoma from 1988 to 1999 were identified from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data, including race, age at diagnosis, histology, tumor grade, disease stage, lymph node status, treatment modality, and survival, were collected. Survival analysis was performed with Kaplan-Meier survival curves and compared using the log-rank test.

RESULTS

A total of 273 women were identified, 185 women with a histologic diagnosis of adenocarcinoma (AC) and 88 women with a diagnosis of adenosquamous carcinoma (ASC). Among the women with ASC, only 5% had Grade 1 tumors, and 66% had Grade 3 tumors. By comparison, among the women with AC, 37% had Grade 1 tumors, and 26% had Grade 3 tumors (P < 0.001). There was no difference in the incidence of positive lymph nodes or in the number of patients who underwent radical hysterectomy as primary treatment between patients with ASC and patients with AC. More patients with ASC received radiation therapy (51% vs. 28%) or chemotherapy (29% vs. 12%) as treatment (P < 0.001). Patients who had tumors with ASC histology had a significantly decreased 5-year survival rate compared with patients who had tumors with AC histology (65% vs. 83%; P < 0.002). When patients with early-stage cervical carcinoma (International Federation of Gynecology and Obstetrics [FIGO] Stage I) were examined separately, there was no statistically significant difference in the 5-year survival rate (AC, 89%; ASC, 86%; P = 0.644). However, when patients with advanced-stage disease (FIGO Stages II-IV) were analyzed, ASC was associated with a significant decrease in median and overall survival (P = 0.01). When the results were analyzed by grade, patients who had tumors with ASC histology had a shorter survival compared with patients who had AC histology of any grade; however, this was a significant difference only for patients with Grade 1 tumors: The 5-year survival rate for patients with Grade 1 AC was 93%, compared with 50% for patients with Grade 1 ASC (P < 0.01).

CONCLUSIONS

ASC histology appears to be an independent predictor of poor outcome in women with cervical carcinoma compared with their counterparts who have pure AC. The significant decrease in survival was observed only in patients with advanced-stage cervical carcinoma. This decreased survival may be related mainly to the grade of ASC.

Hysteroscopy in the evaluation and treatment of mucinous adenocarcinoma

BACKGROUND

Hysteroscopy to evaluate abnormal uterine bleeding is gaining popularity. The standard methods of evaluation, endocervical curettage, and endometrial biopsy frequently diagnose adenocarcinoma without determining location. Because the treatments of endometrial and endocervical cancers are different, knowing the neoplastic origin is desirable.

CASES

Two postmenopausal women were referred for abnormal uterine bleeding. Endometrial biopsies were consistent with mucinous adenocarcinoma without distinction between cervical and endometrial sites. Endocervical curettages were inconclusive. Both patients underwent hysteroscopy at the time of exploratory laparotomy, which revealed the location of the adenocarcinomas, one in the endocervix and one in the uterine fundus.

CONCLUSION

The location of adenocarcinoma may be further clarified by the use of intraoperative hysteroscopy, which can aid in determining surgical treatment.

Diagnosis of culture-negative female genital tract tuberculosis with peritoneal involvement by polymerase chain reaction

BACKGROUND

Female genital tract tuberculosis (TB) is a common cause of infertility in developing countries. It is a paucibacillary form of the disease of which smears and cultures are usually negative.

CASE

We were able to use polymerase chain reaction (PCR) amplification of Mycobacterium tuberculosis DNA to support a clinical and histologic diagnosis of a typical case of culture negative female genital tract TB.

CONCLUSION

PCR may be a useful adjunct to diagnostic efforts in gynecologic tuberculosis.

Cervical adenocarcinoma in situ: a systematic review of therapeutic options and predictors of persistent or recurrent disease

The incidence of cervical adenocarcinoma in situ is increasing in frequency, and our limited knowledge about this lesion presents the physician with a therapeutic dilemma. Treatment for this lesion has included conservative therapy, large loop excision or cold-knife cone biopsy, or definitive therapy consisting of hysterectomy. But, rates of residual adenocarcinoma in situ after cone biopsy with negative margins vary from 0% to 40%, and residual disease rates as high as 80% have been noted when the margins are positive. Despite these recent data on follow-up after conservative therapy such as cone biopsy, it seems that this method is safe and gaining acceptance by many physicians and patients. However, the short follow-up duration and small number of patients limit the conclusions of many studies. The relative infrequency of this diagnosis has precluded extensive clinical experience with the natural history of this lesion.

The role of p27 in endometrial carcinoma

OBJECTIVE

The cyclin-dependent kinase inhibitor p27 has been shown to mediate cell growth arrest in response to various environmental stimuli. p27 protein levels have shown prognostic value in several different types of cancer. We examined the prognostic value of p27 protein expression in endometrial cancer, the most common gynecologic malignancy.

METHODS

A total of 95 paraffin-embedded tumor blocks were obtained and stained via immunohistochemical techniques with a monoclonal antibody against p27. Ten high-power fields were evaluated per slide with at least 1000 cells per slide and two slides per specimen evaluated by two reviewers for nuclear and cytoplasmic staining. The specimens were evaluated for associations with age, stage, grade, and histology. Statistical analysis was performed using the Student t test, chi(2) Kaplan-Meier, and likelihood ratios to assess the data and to generate P values.

RESULTS

A total of 91 patients met inclusion criteria for statistical analysis. Fifty-three patients were stage I, 13 stage II, 14 stage III and 11 stage IV with a positive stain (>50% of cells) for p27 obtained in 32.1, 23.1, 35.7, and 36.4%, respectively (Student t test P = 0.77). Survival data were available on 24 advanced stage patients. p27 protein immunostaining showed no association with patient survival. We also found no association of p27 staining with age or histology. Notably, we found a trend in increasing staining with increase in grade, particularly with stage I patients. Also, there was an association of the nuclear and cytoplasmic staining and stage (P = 0.05), but it had no correlation with patient survival.

CONCLUSION

Our study showed decreased p27 protein staining in endometrial cancers compared to normal endometrial cells. We found that p27 protein staining shows no association with stage, age, or histology and is not prognostic for survival in advanced endometrial cancers. However, there may be a trend associated with increased p27 protein staining with advanced grades of tumors.

Equal care ensures equal survival for African-American women with cervical carcinoma

BACKGROUND

[corrected] It was the purpose of this study to investigate whether race is an independent prognostic factor in the survival of patients with cervical carcinoma in a health care system with minimal racial bias, and few barriers to access to care.

METHODS

Records for patients with a diagnosis of invasive cervical carcinoma from 1988 to 1999 were obtained from the Automated Central Tumor Registry for the United States Military Health Care System. Clinical data including race, age at diagnosis, histology, grade, stage, socioeconomic status, treatment modality, and survival also were obtained. Survival analysis was performed with Kaplan-Meier survival curves.

RESULTS

One thousand five hundred fifty-three patients were obtained for review. Sixty-five percent of patients were Caucasian, and 35% were minorities. Of the minorities, 29% were African Americans (AAs). Mean age of diagnosis was similar among AAs and Caucasians, 44 and 42 years, respectively. There was no statistically significant difference between the distribution of age, stage, grade, or histology between Caucasians and AAs. Forty-six percent of patients were treated with surgery and 56% with radiation therapy, with no difference in type of treatment between the Caucasian and AA groups. Five- and 10-year survival rates for Caucasians and AAs were 75%, and 76%, and 64% 65% (P = 0.59), respectively.

CONCLUSIONS

In an equal access, unbiased, nonracial environment, race is not an independent predictor of survival for patients with cervical carcinoma. This study has shown, for the first time to the authors' knowledge, that when they receive equal treatment for cervical carcinoma, AA women's survival can approach that of their nonminority counterparts (75% at 10 years).

Recurrence of dysplasia after loop electrosurgical excision procedures with long-term follow-up

OBJECTIVE

The aim of this study was to determine the rates of recurrent dysplasia with longer follow-up durations and to determine whether margin status and other variables were associated with recurrence.

STUDY DESIGN

A retrospective chart review was performed for all women who underwent a loop electrosurgical excision procedure at Wilford Hall Medical Center, Lackland Air Force Base, Texas, between January 1993 and December 1994. Extracted information included age, parity, indication for the loop electrosurgical excision procedure, histologic classification of the loop electrosurgical excision procedure specimen, margin status, and whether a "deep" (endocervical) pass had been performed. Follow-up data included findings of repeated cytologic examination, colposcopy, and biopsy if performed.

RESULTS

The mean duration of follow-up for all women was 24 months. Margins were positive in 28%, with 73% of these being endocervical. The overall recurrent dysplasia rate was 31%, with a mean time to recurrence of 11.9 months. Participants with any positive margins had a higher recurrence rate than did those with negative margins (47% vs 26%; P = .009). High-grade lesions at the margin were more commonly associated with recurrence than were low-grade lesions relative to those with clear margins (high-grade lesion vs negative margins, 55% vs 26%; P = .003; low-grade lesion vs negative margins, 36% vs 26%; P = .34). Recurrence was not associated either with the performance of an endocervical pass or with the histologic diagnosis of the loop electrosurgical excision procedure specimen.

CONCLUSION

With comprehensive long-term follow-up, positive margins on loop electrosurgical excision procedure specimens were shown to be a risk factor for recurrence of cervical dysplasia, particularly when high-grade lesions were seen at the margin. Recurrence was also considerable among women with negative margins. Women should be counseled regarding this risk, and the importance of follow-up should be emphasized.

A descriptive evaluation with follow-up of the clinical significance of atypical immature squamous metaplasia of the cervix

OBJECTIVES

We set out to determine the clinical significance of atypical immature squamous metaplasia (AIM).

METHODS

We performed in a military, hospital-based colposcopy clinic a descriptive, retrospective review of patients who had a diagnosis of AIM. Patients were examined at 3- to 4-month intervals for at least 1 year after a diagnosis of AIM was established. A gynecological pathologist reviewed all histological and cytological specimens. Initial histological or cytological specimens were tested for the presence of HPV DNA using in situ hybridization.

RESULTS

High-risk HPV DNA types 16 or 18 were detected in 3% of patients with AIM. Concurrent cervical intraepithelial neoplasia 3 (CIN3) was noted in 3% of patients with AIM. One-third of patients with initially diagnosed AIM had complete resolution of this lesion after 1 year of follow-up.

CONCLUSIONS

This descriptive, retrospective review shows that AIM does not appear to be associated with high-risk HPV DNA or with CIN3. In this limited study, a concurrent diagnosis of AIM likely does not influence the 1-year behavior of CIN. The degree of CIN should dictate treatment recommendations. A larger prospective trial is needed.

Primary peritoneal psammocarcinoma: A case presenting with an upper abdominal mass and elevated CA-125

Primary peritoneal serous adenocarcinoma with predominating psammoma bodies, psammocarcinoma, is a very rare tumor with only seven cases documented in the English literature. Pathological classification of this entity was established in 1990 and clinical behavior of this tumor is uncertain. Based on limited data these tumors appear to behave similarly to low malignant potential tumors of the ovary. This case describes a 59-year-old woman who underwent exploratory laparotomy for a large upper abdominal cystic mass. Findings included a large tumor mass involving the gastrocolic omentum and dense small bowel adhesions. The patient had normal ovaries and was debulked to no macroscopic disease. Final pathologic diagnosis confirmed a stage IIIC primary peritoneal psammocarcinoma. The patient has received no adjunctive therapy and is without evidence of disease 2 years after surgery. Primary peritoneal psammocarcinoma is a neoplasm which can mimic serous adenocarcinoma of the ovary. In contrast, primary peritoneal psammocarcinoma appears to behave in an indolent fashion. Primary surgical debulking should be attempted, while the utility of postoperative chemotherapy remains unknown.

Interferon-gamma and tumor necrosis factor-alpha induce synergistic cytolytic effects in ovarian cancer cell lines-roles of the TR60 and TR80 tumor necrosis factor receptors

OBJECTIVE

Utilizing ovarian cancer cell lines, we examined the effect of IFN-gamma on each type of TNF receptor. Additionally, we sought to determine the effect of receptor modulation on TNF-alpha-mediated cytolysis.

METHODS

Ovarian cancer cell lines Caov-3, A2780, and SK-OV-3 were employed. The number of TNF receptors was determined by a TNF-alpha binding assay utilizing 125I-labeled TNF-alpha. Monoclonal antibodies specific for the 55- to 60-kDa (TR60) and the 75- to 80-kDa (TR80) TNF receptors were used to determine the relative density of each receptor type. Northern blot analyses were performed employing cDNA probes for the TR60 and TR80 mRNAs. To elucidate which receptor(s) was responsible for mediating the signal for cytolysis, 24-h MTT cytolytic assays were performed in the presence of receptor-specific monoclonal antibodies.

RESULTS

IFN-gamma treatment resulted in an increase in TNF receptors in the cell lines A2780 and Caov-3 (P < 0.001), but not SK-OV-3. Northern blot analyses suggested distinct regulatory mechanisms for the two receptors. In Caov-3 and SK-OV-3 cells a synergistic increase in TNF-alpha-mediated cytolysis was seen when cells were pretreated with IFN-gamma. In both cell lines, pretreatment with IFN-gamma markedly enhanced the ability of the TR60 receptor to mediate cell lysis. Conversely, under similar treatment conditions, the TR80 receptor did not appear capable of generating a cytolytic signal.

CONCLUSIONS

TNF receptor modulation by IFN-gamma appears to be unique to individual cell lines. The TR60 TNF receptor plays a central role in the synergistic cytolytic effects of IFN-gamma and TNF-alpha. Sequential therapy with IFN-gamma and TNF-alpha and specific TNF receptor activation may provide novel translational strategies for the use of cytokines in the treatment of ovarian cancer.

Recurrent ovarian tumor with low malignant potential and cardiac metastasis

BACKGROUND

Up to 20% of ovarian epithelial tumors are classified as being of low malignant potential. Most of these low malignant potential tumors are detected at an early stage and have an excellent prognosis. This is a report of a woman with cardiac metastasis from an ovarian low malignant potential tumor.

CASE

This case describes a 53-year-old woman who presented with congestive heart failure and was found to have a recurrent stage III ovarian tumor of low malignant potential. A transesophageal echocardiogram revealed compression of the inferior vena cava and a mass encompassing the right atrium. Findings at autopsy confirmed a low malignant potential ovarian tumor thrombus involving the inferior vena cava and right atrium.

CONCLUSION

Ovarian low malignant potential tumors can metastasize in an aggressive manner. A transesophageal echocardiogram may be useful when the diagnosis of cardiac tumor thrombus is considered.

The role of tumor necrosis factor receptors in tumor necrosis factor-alpha-mediated cytolysis of ovarian cancer cell lines

OBJECTIVE

Our purpose was to define the expression of tumor necrosis factor receptors on ovarian cancer cells and determine what role these receptors play in tumor necrosis factor-alpha-mediated cytolysis.

STUDY DESIGN

Cell surface expression of tumor necrosis factor-alpha receptors was determined on ovarian cancer cell lines Caov-3, SK-OV-3, NIH:OVCAR-3, and A2780 by a tumor necrosis factor-alpha-binding assay that used iodine 125-labeled tumor necrosis factor-alpha. Monoclonal antibodies specific for the 55 to 60 kd (TR60) and 75 to 80 kd (TR80) tumor necrosis factor receptors were used to determine the relative density of each receptor type. To elucidate which receptor(s) was responsible for mediating the signal for cytolysis, 24-hour MTT cytolytic assays that used tumor necrosis factor-alpha and emetine were performed in the presence or absence of receptor-specific monoclonal antibodies.

RESULTS

The four ovarian cell lines expressed a similar number of surface receptors, 4500 to 7000 per cell, had similar dissociation constants, 0.3 to 0.6 nmol/L, and expressed predominately the TR60 receptor subtype. Receptor function studies showed that the presence of the monoclonal antibody to the TR60 receptor completely inhibited tumor necrosis factor-alpha-mediated cytolysis, whereas the monoclonal antibody to the TR80 receptor only partially blocked cytolysis.

CONCLUSIONS

Ovarian cancer cell lines express both tumor necrosis factor receptors, with the TR60 receptor being the dominant subtype. Tumor necrosis factor-alpha-mediated cytolysis appears to be dependent on the presence of a functional TR60 receptor. The TR80 receptor does not appear requisite for cytolysis; however, a complementary role cannot be excluded. Manipulation of tumor necrosis factor receptor subtypes on ovarian cancer cells may enhance the cytotoxic effects, thus improving the therapeutic efficacy of tumor necrosis factor-alpha.

Comparison of leuprolide acetate and human chorionic gonadotropin for the induction of ovulation in clomiphene citrate-stimulated cycles

OBJECTIVE

To examine the relative efficacies of leuprolide acetate (LA) and hCG in inducing ovulation and a normal luteal phase during clomiphene citrate (CC)-stimulated superovulation cycles.

DESIGN

Prospective, randomized, blinded, and cross-controlled in consecutive cycles.

SETTING

Large military tertiary care center.

PATIENTS

Twenty-one ovulatory patients undergoing superovulation with CC and IUIs for the treatment of unexplained or male factor infertility.

INTERVENTIONS

Clomiphene citrate (100 mg/d) on cycle days 5 through 9 in both of the study cycles. Administration of 2 mg SC LA in one cycle and 10,000 IU IM hCG in another cycle for induction of the midcycle surge.

MAIN OUTCOME MEASURES

Serum LH, FSH, E2, and P levels every 12 hours for 36 hours after administration of either LA or hCG to characterize the midcycle hormonal dynamics. Luteal phase duration and serum P levels during the midluteal phase were used to estimate the adequacy of the luteal phase. Serial ultrasounds also were done to determine the incidence of luteinized unruptured follicle syndrome.

RESULTS

Serum FSH levels in the periovulatory interval were significantly higher after the administration of LA. There were no differences in the periovulatory E2 or P levels or the incidence of sonographic evidence of ovulation after administration of either LA or hCG. Although midluteal serum P levels were higher in the cycles in which hCG was administered, all 42 treatment cycles had adequate luteal phases as assessed by luteal phase duration and three midluteal P levels. Ongoing pregnancies occurred after both LA- and hCG-stimulated cycles.

CONCLUSION

Leuprolide acetate and hCG were equivalent in their abilities to induce ovulation. Further evaluation of the adequacy of the luteal phase and the ensuing pregnancy rates after LA induction of an endogenous gonadotropin surge are indicated.

Evaluation of the significance of the estradiol response during the clomiphene citrate challenge test

OBJECTIVE

To evaluate the relationship between the E2 response during the clomiphene citrate (CC) challenge test and ovarian responsiveness to exogenous gonadotropins.

DESIGN

Performance of a CC challenge test followed by ovulation induction with exogenous gonadotropins as part of participation in an assisted reproduction program.

SETTING

Assisted reproduction program in a large military tertiary care center.

PATIENTS

Two hundred forty-seven women between the ages of 24 and 39 years with normal CC challenge tests within 1 year of their assisted reproduction cycle.

INTERVENTIONS

Performance of CC challenge tests and ovulation induction with exogenous gonadotropins as a component of an assisted reproduction cycle.

MAIN OUTCOME MEASURES

Correlation of the E2 response during the CC challenge test and peak E2, the duration of stimulation, number of ampules of exogenous gonadotropins, number of mature follicles, number of mature oocytes recovered, and fertilization and pregnancy rates in an assisted reproduction program.

RESULTS

No correlation exists between the E2 response during the CC challenge test and any of the parameters evaluated.

CONCLUSION

Monitoring of the E2 response during the CC challenge test did not predict ovarian responsiveness or pregnancy rates in patients participating in an assisted reproduction program and one may choose not to include it in routine testing.

The "less than optimal" cytology: importance in obstetric patients and in a routine gynecologic population

OBJECTIVE

To determine whether patients with less than optimal Papanicolaou tests constitute a low-risk group for developing subsequent abnormalities and thus do not need early repeat screening.

METHODS

For the 10-month period October 1989 to August 1990, all screening Papanicolaou tests were classified by the 1988 Bethesda System. Tests designated as less than optimal solely on the basis of lack of an endocervical component were the subject of the study. Prenatal patients with less than optimal tests had repeat tests at the postpartum visit (delayed-repeat group), whereas gynecologic less than optimal tests were repeated within 4 weeks (early-repeat group). The frequency of cytologic abnormalities in our routine gynecologic population was compared with that for both the delayed- and early-repeat testing groups.

RESULTS

The less than optimal rate in obstetric patients was 10.2% (153 of 1492), which was significantly higher than the 5.6% rate (473 of 8411) in the routine gynecologic population (P < .0001). The rates of dysplasia or combined abnormalities (dysplasia, human papillomavirus, or atypia) in the delayed-repeat group did not differ significantly from those in the routine gynecologic population (P = .69 and P = .33, respectively). However, the rates of dysplasia or combined abnormalities were significantly lower in the early-repeat group than in the routine gynecologic population (P = .02 and P = .003, respectively).

CONCLUSIONS

Less than optimal cervical cytologies occurred almost twice as often in obstetric as in gynecologic patients. Prenatal less than optimal test results were not associated with important cervical pathology, and repeat testing may safely be deferred until postpartum. In addition, early repeat testing in gynecologic patients is a low-yield procedure.