Increased diversity of a cervical microbiome associates with cervical cancer

The cervical microbiome (CM) is a complex ecosystem that can change in response to gynecological cancers. We aimed to evaluate changes in the CM of patients who underwent chemoradiation (CRT) therapy for locally advanced cervical cancer. Before and after CRT, cervical swab samples were collected from 16 patients with squamous cell carcinoma of the cervix, and 30 healthy women. All samples were subjected to 16s rRNA-Seq analysis. In healthy premenopausal women the CM comprised mostly Lactobacillus (>90%); the CM community in samples from both pre- and postmenopausal pre-treatment cancer patients was heterogeneous, with a low proportion of Lactobacillus in younger cases. On the genus level, 27 and 11 taxa differentiated healthy controls from cancer patients in pre- and postmenopausal age groups, while 31 and 2 genera differentiated pre- and post-radiation samples and pre-radiation and the follow-up samples, respectively. Microbiome diversity was significantly higher in pre-treatment patients than in healthy controls. The results reveal significant alterations in the CM of cervical cancer patients relative to that in healthy controls; these changes were more striking after CRT. However, further research is needed to determine whether alteration of the CM offers new therapeutic options.

Recommendations of the Polish Society of Gynaecologists and Obstetricians, Polish Paediatric Society, Polish Society of Family Medicine, Polish Society of Vaccinology, Polish Society of Oncological Gynaecology and Polish Society of Colposcopy and Pathophysiology of the Uterine Cervix on prophylactic vaccinations against infections with human papillomaviruses in Poland

Several hundred million people are infected with genital genotypes of the human papillomavirus (HPV) annually in the world. The infections transmitted mainly through sexual routes are usually asymptomatic, but can lead to the development of cervical, vulvar, vaginal, anal, penile cancers, some head and neck cancers and genital warts (condylomas). The fraction HPV-related cancers range from nearly 100% in the case of cervical cancer to several/over a dozen percent in the case of other cancers and diseases. There are no effective drugs against HPV, but prophylactic HPV vaccines are available free of charge in immunization programmes in many countries around the world. In Poland, HPV vaccinations have so far been executed out on the pocket or in free-of-charge, local-governmental prevention programs, but the vaccination coverage of the target population does not exceed 10%. From November 2021, one of the vaccines is available with a 50% reimbursement, work is underway to reimburse the next ones, and the National Oncology Strategy assumes the implementation of the HPV immunization programmes and vaccination of 60% of the teen population by 2028. Three prophylactic HPV vaccines are registered. All of them are safe and their effectiveness in the prevention of diseases caused by vaccine genotypes reaches almost 100%, provided that full post-vaccination immunity is obtained before the contact with the virus. Girls aged 11-13 are the priority target cohort for HPV vaccination in Poland. The implementation of routine, free-of-charge HPV immunization in the Preventive Immunization Program (PIP) for all adolescents should be pursued. Persons over the age of 13 may also benefit from HPV vaccination and should be vaccinated according to product specifications. In addition to free access under the PIP, the key element for the success of the implementation of HPV vaccinations in Poland will be the education of medical personnel and parents of adolescents to be vaccinated.

Molecular classification of endometrial carcinoma, is it the new era of precision medicine?

For many years endometrial cancer has been subdivided into oestrogen - dependent (type I) and oestrogen - independent (type II), according to classical Bokhman classification. Histopathological evaluation including type and grade of tumour, along with clinical factors have been considered as very important prognostic factors that impact treatment decision. However, histologically similar tumours may have different outcomes. Recent molecular findings and new histopathological parameters have given new concept on risk stratification. The Cancer Genome Atlas Research Network (TCGA) of tumours have brought new insights into endometrial cancer management. Four molecular subgroups have been described: POLE ultramutated (POLE mut), p53 mutant (p53abn), mismatch repair deficient (MMRd) and non-specific molecular profile (NSMP). This new subdivision has been recently introduced in the European risk stratification system.

Nadir CA-125 has prognostic value for recurrence, but not for survival in patients with ovarian cancer

The objective of this study was to evaluate the nadir CA-125 in patients with epithelial ovarian cancer. A total of 168 patients who achieved complete remission (no clinical and radiological signs, CA-125 ≤ 35 U/ml) after first-line treatment were enrolled in the study. The relationship between CA-125 and survival was examined by applying generalized additive models to the Cox proportional hazards model. The median CA-125 concentration after the treatment was 10 U/ml (2.7–35 U/ml). The nadir CA-125 was related to progression-free survival but not to overall survival. The risk of recurrence in patients with 11–25 U/ml and 26–35 U/ml compared to patients with ≤ 10 U/ml was 1.87 (p < 0.0024) and 2.17 (p < 0.018), respectively. An increased risk of recurrence according to the nadir CA-125 (≤ 10 U/ml vs. 11–25 U/ml and ≤ 10 U/ml vs. 26–35 U/ml) was found in patients with high-grade tumours (hazard ratio, HR = 2.08 and 2.59, respectively), advanced disease (HR = 2.38 and 2.03, respectively), serous histology (HR = 2.08 and 2.43, respectively) and after complete cytoreduction (HR = 2.7 and 2.72, respectively). No correlation between the CA-125 nadir and recurrence risk was found in patients with early-stage disease or those receiving neoadjuvant chemotherapy or bevacizumab.

Prognosis of the patients suffered from uterine carcinosarcoma from rural and urban areas

OBJECTIVES

Uterine carcinosarcoma is a very aggressive neoplasm. Patients' median age at diagnosis ranges from 62 to 67 years. The aim of this study was to compare treatment results and prognostic factors for residents of urban and rural areas suffering from uterine carcinosarcoma.

MATERIAL AND METHODS

Clinical outcomes of 58 uterine carcinosarcoma patients treated in one institution were assessed: 25 residents of rural and 33 of urban areas. All the patients were treated by using surgery followed by chemotherapy (48 pts) or radiotherapy (10 pts). Standard chemotherapy regimen comprised of paclitaxel 175 mg/m² and carboplatin on day one at area under curve (AUC) six every 21 days. Radiotherapy was performed by combined treatment - tele and brachytherapy. External beam pelvic radiation therapy (EBRT) once a day, five days a week with a daily fraction size of 1.8 Gy over five weeks at cumulative dose 50.4 Gy was the first part of adjuvant treatment. High-dose-rate (HDR) brachytherapy at dose 22.5 Gy was the second part of radiotherapy.

RESULTS

A strong correlation between tumor diameter and the presence of lymph node metastasis was observed. Tumor size greater then 4.5 cm correlated with presence of node involvement and this parameter was statistically significant (p = 0.015). There was no significant correlation between other analyzed clinical factors and overall survival. In the period 2004 - 2010 43.5% (10/23) and 50% (14/28) of rural and urban residents, respectively, died due to carcinosarcoma progression.

CONCLUSION

Uterine carcinosarcoma patients in rural and urban areas seem to have similar outcomes.

Clinicopathological factors of pelvic lymph nodes involvement in advanced serous ovarian cancer

OBJECTIVES

Retroperitoneal lymph nodes metastases occur frequently in patients with ovarian cancer. Lymphadenectomy increases risk of perioperative complications. In clinical practice to reduce rate of complications aortocaval lymphadenectomy is omitted and solely resection of pelvic lymph nodes is performed. To establish factors affecting metastases to pelvic lymph nodes in advanced ovarian cancer.

MATERIAL AND METHODS

A retrospective study among patients with serous advanced ovarian cancer (FIGO IIIB-IVB) was conducted at the 1st Department of Obstetrics and Gynecology, Medical University of Warsaw and Department of Gynecologic Oncology, Maria Sklodowska-Curie National Research Institute of Oncology, Warsaw. All patients underwent surgical treatment including pelvic lymphadenectomy between 2014 and 2017. Data including age, body mass index (BMI), pretreatment CA125 serum level, tumor volume, grading, one-/both-sided tumor, menopausal status, ascites were analysed as possible factors influencing the pelvic lymph nodes involvement. The statistical analysis was performed with Python software.

RESULTS

87 consecutive patients were eligible for the study. Metastases to pelvic lymph nodes were found in 29 (33.33%) patients. Pretreatment serum CA-125 concentration (652 U/mL vs 360.9 U/mL, p < 0.05) and high grade histology corresponded with pelvic nodal involvement.

CONCLUSIONS

The knowledge of factors influencing metastases to pelvic lymph nodes may help clinicians in proper counselling and tailoring of therapy.

Contemporary principles of diagnostic and therapeutic management in cervical and ovarian neuroendocrine tumors

Enhancing knowledge about neuroendocrine neoplasms causes the need to improve management of these tumors. Although these tumors are rare in clinical practice, their biological diversity makes both diagnostics and therapy a challenge for contemporary oncology. The article discusses the latest developments in the diagnostic procedures and methods of treatment of the cervical and ovarian neuroendocrine tumors. Algorithms are presented to understand the differences in therapeutic management in these malignancies.

Sentinel lymph node in vulvar cancer

Lymph node removal as a part of surgical management is a standard of care in vulvar cancer patients. Due to patient morbidities and difficulties in treatment of inguinal healing after lymph nodes removal, lymphatic mapping has emerged as an increasingly popular option over the past few years. At this time several different techniques have been described and variety of different dyes were used. In addition, an important aspect of the use of the sentinel lymph node (SLN) technique is the removal of a limited number of lymph nodes, which allows more detailed pathological examination. Moreover, the interpretation of pathological ultra-staging of SLNs, which can identify low-volume metastases for which the clinical significance and the ideal management, remain uncertain. Despite differences in techniques and dyes used, this minimally invasive procedure is currently recommended as an alternative to full inguinofemoral lymph node dissection in selected cases by all major international societies. As for now SLN concept became a standard of care in vulvar cancer. This technique, though simple as a concept, requires a learning curve and should only be used in expert centers. This article provides a review on literature on SLN technique in vulvar cancer, current recommendations and future lines of investigation.

Rising serum CA-125 levels within the normal range is strongly associated recurrence risk and survival of ovarian cancer

BACKGROUND

In clinical practice alterations in CA-125 concentration within normal range in patients with ovarian cancer after first-line treatment are common. Even minor increase in CA-125 concentration is associated with patients' anxiety and difficult interpretation and counselling for clinicians. The aim of this study was to evaluate the significance of CA-125 fluctuations within reference level in patients who suffered from ovarian cancer with complete response after first-line treatment.

RESULTS

168 patients with epithelial ovarian cancer, who achieved complete remission after first line treatment were enrolled in the study. CA-125 concentration assessment was carried out during follow up visits. The recurrence of the disease was diagnosed on the first appearance of symptoms: clinical, radiological or histopathological/cytological. PFS and 5-year survival rate was calculated with Kaplan-Meier plots. Statistical analysis was performed with SAS / STAT® 9.4 / 14.4, SAS Institute Inc., Cary, NC, USA, 2017. Median concentration of CA-125 after first-line therapy was 10 U/ml. Increasing CA-125 concentration by > 5 U/ml, 3 and 6 months after the treatment was associated with higher risk of relapse (HR = 7.6, p < 0.0001 and HR = 5.29, p < 0.0001 respectively). 5-year survival rate was significantly lower in patients with increased CA-125 by 5 U/ml, 3 and 6 months after therapy (56.79% vs 0 and 50.62% vs 15.55%).

CONCLUSIONS

Increased concentration of CA-125 by > 5 U/ml within normal range, 3 and 6 months after treatment was unfavorable prognostic factor in ovarian cancer patients with complete response to primary therapy.

Retrospective analysis of the diagnostic effectiveness of the sentinel lymph node biopsy (SLNB) in vulvar cancer

OBJECTIVES

Inguinal lymphadenectomy used in the treatment of vulvar cancer often results in complications, such as lymphoedema or abnormal wound healing. Aim of this study was assessment of the diagnostic effectiveness of the sentinel lymph node biopsy (SLNB) procedure in patients treated due to vulvar cancer.

MATERIAL AND METHODS

Eighty-four patients diagnosed with squamous cell vulvar carcinoma (FIGO I-IV) underwent preoperative lymphoscintigraphy with technetium 99 to map sentinel lymph node. During surgery sentinel lymph nodes were identified and resected, followed by complete bilateral groin lymphadenectomy.

RESULTS

Sentinel lymph nodes were mapped with lymphoscintigraphy and biopsied in 84.3% and 90.1% of patients, respectively. False negative predictive value (FNPV) was 9.1% and false negative rate (FNR) was recorded in 16.7% of cases. Patients in advanced stages (FIGO III and IV) had significantly lower rate of lymphatic mapping compared to those in stage I and II (OR = 0.148, p = 0.022). Detection of sentinel lymph node in lymphoscintigraphy for tumor grade 2 and 3 was nearly eight times lower than for grade 1 cancers, however without statistical significance (OR = 0.126, p = 0.058).

CONCLUSIONS

The use of SLNB should be limited to vulvar cancer patients in early clinical stages.

Second-line lenvatinib in patients with recurrent endometrial cancer

OBJECTIVE

This study assessed the efficacy of lenvatinib, a multitargeted tyrosine kinase inhibitor, as second-line therapy in patients with unresectable endometrial cancer. The primary end point was the objective response rate (ORR) as assessed by independent radiologic review (IRR). Secondary end points included median progression-free survival (PFS), overall survival (OS), and clinical benefit rate. Exploratory end points examined the association of baseline levels of plasma biomarkers (50 circulating cytokine and/or angiogenic factors measured by immunoassays) with efficacy outcomes.

METHODS

An international, open-label, single-arm, multicenter, phase 2 trial was conducted. Eligible patients had histologically confirmed unresectable endometrial cancer that relapsed after 1 prior systemic platinum-based chemotherapy. Patients received once-daily oral lenvatinib 24 mg in a 28-day dosing cycle.

RESULTS

There were 133 patients in the study. By IRR, 19 patients had a confirmed objective response for an ORR of 14.3% (95% CI: 8.8-21.4). Durable stable disease (≥23 weeks) was observed in 31 patients (23.3%) and the clinical benefit rate was 37.6% (95% CI: 29.3-46.4). Median PFS was 5.6 months (95% CI: 3.7-6.3), and median OS was 10.6 months (95% CI: 8.9-14.9). The most common (any grade) treatment-related adverse events were fatigue/asthenia (48%), hypertension (49%), nausea/vomiting (32%), decreased appetite (32%), and diarrhea (31%). Lower baseline levels of angiopoietin-2 were associated with longer PFS, OS, and a higher ORR.

CONCLUSIONS

Patients with recurrent endometrial cancer treated with second-line lenvatinib experienced modest antitumor activity and treatment was generally well tolerated, with a safety profile consistent with previous studies.

Macrophage infiltration and genetic landscape of undifferentiated uterine sarcomas

Endometrial stromal tumors include translocation-associated low- and high-grade endometrial stromal sarcomas (ESS) and highly malignant undifferentiated uterine sarcomas (UUS). UUS is considered a poorly defined group of aggressive tumors and is often seen as a diagnosis of exclusion after ESS and leiomyosarcoma (LMS) have been ruled out. We performed a comprehensive analysis of gene expression, copy number variation, point mutations, and immune cell infiltrates in the largest series to date of all major types of uterine sarcomas to shed light on the biology of UUS and to identify potential novel therapeutic targets. We show that UUS tumors have a distinct molecular profile from LMS and ESS. Gene expression and immunohistochemical analyses revealed the presence of high numbers of tumor-associated macrophages (TAMs) in UUS, which makes UUS patients suitable candidates for therapies targeting TAMs. Our results show a high genomic instability of UUS and downregulation of several TP53-mediated tumor suppressor genes, such as NDN, CDH11, and NDRG4. Moreover, we demonstrate that UUS carry somatic mutations in several oncogenes and tumor suppressor genes implicated in RAS/PI3K/AKT/mTOR, ERBB3, and Hedgehog signaling.

Results of optimal debulking surgery with bowel resection in patients with advanced ovarian cancer

BACKGROUND

The surgical treatment of patients with advanced-stage ovarian cancer is based on maximal cytoreduction with widening the debulking on the extra-ovarian tissues and infiltrated organs. The purpose of the study was to assess the outcome after optimal cytoreduction with partial bowel resection and to find the risk factors of relapse. Another goal was the quantitative and qualitative assessment of intra- and postoperative complications in the studied group.

METHODS

The analysis of debulking procedures with intestinal resection and postoperative period in 33 ovarian cancer patients, The International Federation of Gynecology and Obstetrics (FIGO) stages III and IV, was performed.

RESULTS

The optimal cytoreduction defined as less than 1.0 cm residual disease was achieved in all patients including the following: 26 patients (78.8%) with no macroscopic residual disease, 4 patients (12.1%) with the largest residual tumor less than 0.5, and 3 patients (9.1%) with 0.5 cm to less than 1.0 cm residual disease. The rectosigmoid resection was the most common surgical procedure (n = 27). The risk of relapse was significantly higher in subjects who had the macroscopic residual tumor left during the primary operation (57.1 vs. 11.5%, P = 0.035). A primary bowel tumor size was another predictor of relapse. The maximum tumor diameter was significantly larger (14.9 ± 6.7 cm vs. 10.3 ± 4.7 cm, P = 0.047) in patients who developed the relapse.

CONCLUSIONS

As presented in the article, our outcomes and other authors' observations indicate that debulking surgery with bowel resection in patients with advanced ovarian cancer brings good results. Complications connected with bowel surgery are to be accepted. The interesting thing is that a primary bowel tumor size was a predictor of relapse.

The assessment of the prognostic value of tumor markers and cytokines as SCCAg, CYFRA 21.1, IL-6, VEGF and sTNF receptors in patients with squamous cell cervical cancer, particularly with early stage of the disease

The aim of this study is to determine the prognostic value of tumor markers, as squamous cell carcinoma antigen (SCCAg) and cytokeratin-19 fragment (CYFRA 21.1) and interleukin 6 (IL-6), vascular endothelial growth factor (VEGF), soluble tumor necrosis factor receptor I (sTNF RI), and sTNF RII in patients with squamous cell carcinoma of the cervix. The subjects of analysis were 138 patients with stage I–IVA according to the International Federation of Gynecology and Obstetrics (FIGO) classification. The collected research material comes from one oncology center. During the 10 years of follow-up, 56 relapses and 53 deaths were observed, and recurrent disease in early stage was confirmed in 45 % of patients. The pretreatment serum levels of SCCAg and CYFRA 21.1, and cytokines IL-6, VEGF, sTNF RI, and sTNF RII were determined in all patients. The probability of disease-free survival (DFS) and overall survival (OS) was evaluated using the log-rank test and the Cox regression model. Based on the ROC curve analysis for patients with recurrence, the largest area under the curve was demonstrated for SCCAg and IL-6 and for patients who died, for SCCAg and VEGF. Cox analysis demonstrated that independent prognostic factor for DFS was only SCCAg and for OS cytokine IL-6 and SCCAg, but in patients with early stage the prognostic value for DFS was VEGF, whereas IL-6 and CYFRA 21.1 for OS. Serum level of VEGF, CYFRA 21.1 and IL-6 before treatment in patients with early stage cervical cancer appears to be an important prognostic factor.

Abstract 4698: Gene expression profiling distinguishes between endometrial stromal tumors subtypes

Introduction

Endometrial stromal tumors (EST) are the second most prevalent uterine sarcomas. EST are divided into three histosubtypes: benign endometrial stromal nodules (ESN), low-grade endometrial stromal sarcomas (ESS) and the most malignant undifferentiated stromal sarcomas (UES). Moreover, due to clinicopathological features intermediate between classical low-grade ESS and UES, some tumors have been described in the literature as “high-grade ESS”. The histological distinction between these three subtypes has important prognostic implications. The molecular biology of these tumors remains poorly understood because of their low incidence.

Patients and Methods

In the present study, we performed gene expression profiling of 22 EST using microarray, RNA-Seq and qRT-PCR techniques. Our cohort included 10 classical low-grade ESS (8 with ESS-associated gene fusions), 8 UES and 4 tumors which were classified as high-grade ESS based on the presence of YWHAE-FAM22A/B fusion and histological features.

Results

Using gene expression microrarrays, we have identified 81 entities differentially expressed in analyzed samples (fold change &gt; 2, p &lt; 0.005). Hierarchical clustering analysis revealed that high-grade ESS formed a separate sub-cluster with a distinct molecular profile as compared with the low-grade ESS and UES cases. Low-grade ESS cases formed 2 distinct sub-clusters, each containing 5 cases, one of which presented gene expression profile partially corresponding to high-grade ESS cases. GO analysis of genes strongly up-regulated in UES specimens showed over-representation of immune response (GO:0006955) and immune system process (GO:0002376) pathways (MARCO, MYO1F, FCN1, GPR183, HLA-DPB1, FCGR2B, NCF1, CCL18, CD28, PTAFR, CCL13, STK4, CD14, NCF4 and CTLA4 genes) (p &lt; 0.05). UES cases were also characterized by significant down-regulation of WT1 tumor suppressor gene as compared to the low- and high-grade ESS. Moreover, both high-grade ESS and UES cases were characterized by significantly lower expression level of PEG3 gene, which has been reported as a tumor suppressor gene. All low-grade ESS cases presented significant over-expression of estrogen receptor ESR1 gene. Microarray results were validated by RNA-Seq and qRT-PCR experiments.

Conclusions

This study provides gene expression profiles that distinguish between EST subtypes and sheds light on the biology of these tumors. Our results point to immune system involvement in the pathogenesis of UES and support the notion that the current EST classification should discriminate high-grade ESS as a distinct subtype.

Citation Format: Joanna Przybyl, Magdalena Kowalewska, Anna Quattrone, Barbara Dewaele, Vanessa Vanspauwen, Julio Finalet-Ferreiro, Michal Swierniak, Elwira Bakula-Zalewska, Janusz A. Siedlecki, Mariusz Bidzinski, Jan Cools, Maria Debiec-Rychter. Gene expression profiling distinguishes between endometrial stromal tumors subtypes. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 4698. doi:10.1158/1538-7445.AM2014-4698

Adverse event profile by therapy cycle for vintafolide plus pegylated liposomal doxorubicin (PLD) versus PLD alone in platinum-resistant ovarian cancer

5572

Background: Vintafolide (EC145), a folic acid/desacetylvinblastine conjugate, binds with high affinity to folate receptors expressed in epithelial ovarian cancers. This analysis evaluated the incidence of adverse events (AEs) by treatment cycle and as a percent of total treatment cycles administered in the PRECEDENT trial, a randomized open-label study of subjects with platinum-resistant ovarian cancer receiving either vintafolide+PLD or PLD alone. Methods: Women ≥18 years old with ECOG status 0-2 and exposure to ≤2 prior systemic cytotoxic regimens were randomized 2:1 to vintafolide (2.5 mg IV tiw, weeks 1 and 3, q28 days)+PLD (50 mg/m2 IV day 1, q28 days) or PLD alone (same dose + schedule). AEs in the safety population (received at least 1 dose of study drug) were evaluated by cycle. Results: 157 patients received a total of 720 treatment cycles (518 vintafolide+PLD, 202 PLD alone). AEs (all grades, vintafolide+PLD vs PLD alone): 85.9% and 80.2% of cycles. Anemia, neutropenia, and thrombocytopenia were observed in 16.6% (vs 10.4% administered PLD alone), 19.1% (vs 10.4%), and 2.7% (vs 3.0%) of all cycles, respectively. Febrile neutropenia was observed in 0.2% (vs 0.5%) of cycles, respectively. Stomatitis and hand-foot syndrome (HFS) occurred in 16.6% (vs 22.8%) and 19.1% (vs 15.8%) of cycles, respectively. Peripheral sensory, motor, or sensorimotor neuropathy or polyneuropathy occurred in 10.1% (vs 2.5%) of cycles, and constipation and small intestinal obstruction/ileus were observed in 12.7% (vs 10.4%) and 2.9% (vs 4.0%) of cycles, respectively. Fatigue was similar between arms—15.8% of vintafolide+PLD vs 14.9% of PLD cycles. All AEs were noncumulative except for HFS, which for both arms increased in frequency through Cycle 6 compared with Cycles 1 and 2. Grade 3/4 AEs (vintafolide+PLD vs PLD alone): 29.3% vs 18.3% of cycles. Conclusions: After the number of treatment cycles was accounted for, anemia, neutropenia, and neuropathy were numerically greater in patients on vintafolide+PLD. Thrombocytopenia, constipation, small intestinal obstruction/ileus, fatigue, and HFS were similar. Stomatitis was numerically greater in patients administered PLD alone. Clinical trial information: NCT00722592.

A phase II trial of lenvatinib in patients with advanced or recurrent endometrial cancer: Angiopoietin-2 as a predictive marker for clinical outcomes

5520

Background: Lenvatinib is an oral receptor tyrosine kinase inhibitor targeting VEGFR1-3, FGFR1-4, RET, KIT, and PDGFRβ. The importance of angiogenesis in endometrial cancer (EC) highlights the need to understand clinical mechanisms of escape (eg, angiopoietin-2 [Ang-2]) from antiangiogenic therapy. Methods: Patients (pts) had metastatic/unresectable EC after 1 or 2 prior platinum-based treatments (Tx), ≤2 prior chemotherapies, and ECOG PS ≤2. Pts received lenvatinib 24 mg once daily until disease progression or development of unmanageable toxicities. Primary endpoint was objective response rate (ORR: complete + partial response [CR+PR]) by RECIST 1.1. Archival tumor tissue and baseline (BL) and post-Tx plasma samples were collected for molecular analyses (reported elsewhere). Results: 133 pts were treated (median age: 62 y) and evaluated for safety, efficacy, and molecular correlative analysis. Dose reduction (31%) or Tx discontinuation (31%) occurred for toxicity. Median Tx duration was 112 days. The most common adverse events were hypertension 55% (Gr 3/4: 33%), fatigue 42% (Gr 3: 12.8%), diarrhea 35% (Gr 3: 5.3%), decreased appetite 35% (Gr 3: 2.3%), and nausea 32% (Gr 3: 3%); 1 pt had Gr 5 asthenia. Bowel obstruction, fistula formation, and perforation occurred in 3.8%, 2.3%, and 1.5%, respectively. Confirmed CR+PRs were observed in 19 pts (14.3%) by independent review (IRR) and 29 pts (21.8%) by investigator assessment (Inv). mPFS was 5.4 mos and mOS was 10.6 mos. Among 50 serum factors tested, only BL plasma Ang-2 correlated with maximal tumor shrinkage, R = 0.36 (Spearman), p < 0.001; ORR; PFS; and OS. The 24 pts with low BL Ang-2 plasma levels (cut-off value <2082 pg/mL) were compared with the 98 pts with high BL Ang-2 (>2082 pg/mL) and improved ORR (61% vs 18%), mPFS (9.5 vs 3.7 mos), and mOS (23 vs 8.9 mos) were observed. Conclusions: Lenvatinib in this population was tolerable and resulted in a 14.3% (IRR) and 21.8% (Inv) ORR and mOS of 10.6 mos.Low BL Ang-2 level appears to predict clinical benefit in a subset of pts with advanced EC who may achieve high response rates and prolonged overall survival. Further assessment is warranted. Clinical trial information: NCT01111461.

microRNAs in uterine sarcomas and mixed epithelial-mesenchymal uterine tumors: a preliminary report

Uterine sarcomas and mixed epithelial–mesenchymal uterine tumors are a heterogeneous group of rare tumors for which there are very few diagnostic markers available. As aberrant microRNA (miRNA) expression patterns represent putative diagnostic cancer markers, we aimed to identify miRNA expression profiles of the major uterine sarcoma subtypes and mixed epithelial–mesenchymal tumors of the uterus. Eighty-eight miRNAs were assessed by quantitative RT-PCR in cancerous and non-cancerous tissue samples collected from 29 patients with endometrial sarcoma, leiomyosarcoma, and mixed epithelial–mesenchymal tumors. Tumor and control samples significantly (P < 0.05) differed in the expression of miR-23b, miR-1, let-7f, and let-7c in endometrial sarcomas, and miR-1, let-7c, miR-133b, let-7b, miR-143, let-7a, let-7d, let-7e, let-7g, miR-222, let-7i, and miR-214 in mixed epithelial–mesenchymal tumors. All the significantly changed miRNAs were down-regulated in the malignant tissues as compared to their normal counterparts. This may suggest their tumor suppressor role in these malignancies. No statistically significant changes in miRNA expression levels were found between leiomyosarcoma tumors and controls. The identified miRNAs warrant further studies as valuable candidate markers for the differential diagnosis of uterine sarcomas from benign uterine lesions and between uterine sarcoma subtypes.

Multiple independent variants at the TERT locus are associated with telomere length and risks of breast and ovarian cancer

TERT-locus SNPs and leukocyte telomere measures are reportedly associated with risks of multiple cancers. Using the Illumina custom genotyping array iCOGs, we analyzed ∼480 SNPs at the TERT locus in breast (n = 103,991), ovarian (n = 39,774) and BRCA1 mutation carrier (n = 11,705) cancer cases and controls. Leukocyte telomere measurements were also available for 53,724 participants. Most associations cluster into three independent peaks. The minor allele at the peak 1 SNP rs2736108 associates with longer telomeres (P = 5.8 × 10(-7)), lower risks for estrogen receptor (ER)-negative (P = 1.0 × 10(-8)) and BRCA1 mutation carrier (P = 1.1 × 10(-5)) breast cancers and altered promoter assay signal. The minor allele at the peak 2 SNP rs7705526 associates with longer telomeres (P = 2.3 × 10(-14)), higher risk of low-malignant-potential ovarian cancer (P = 1.3 × 10(-15)) and greater promoter activity. The minor alleles at the peak 3 SNPs rs10069690 and rs2242652 increase ER-negative (P = 1.2 × 10(-12)) and BRCA1 mutation carrier (P = 1.6 × 10(-14)) breast and invasive ovarian (P = 1.3 × 10(-11)) cancer risks but not via altered telomere length. The cancer risk alleles of rs2242652 and rs10069690, respectively, increase silencing and generate a truncated TERT splice variant.

Abagovomab as maintenance therapy in patients with epithelial ovarian cancer: a phase III trial of the AGO OVAR, COGI, GINECO, and GEICO--the MIMOSA study

PURPOSE

To determine whether abagovomab maintenance therapy prolongs recurrence-free (RFS) and overall survival (OS) in patients with ovarian cancer in first clinical remission.

PATIENTS AND METHODS

Patients with International Federation of Gynecology and Obstetrics stage III to IV ovarian cancer in complete clinical remission after primary surgery and platinum- and taxane-based chemotherapy were randomly assigned at a ratio of 2:1 in a phase III, double-blind, placebo-controlled, multicenter study. Abagovomab 2 mg or placebo was administered as 1-mL suspension once every 2 weeks for 6 weeks (induction phase) and then once every 4 weeks (maintenance phase) until recurrence or up to 21 months after random assignment of the last patient. The primary end point was RFS; secondary end points were OS and immunologic response.

RESULTS

Characteristics of the 888 patients included: mean age, 56.3 years; Eastern Cooperative Oncology Group performance status, ≤ 1 in > 99% of patients; serous papillary subtype, 81.5%; stage III, 85.9%; and cancer antigen 125 ≤ 35 U/mL after third cycle, 80.9%. Mean exposure to study treatment (± standard deviation) was 449.7 ± 333.08 days. Hazard ratio (HR) of RFS for the treatment group using tumor size categorization (≤ 1 cm, > 1 cm) was 1.099 (95% CI, 0.919 to 1.315; P = .301). HR of OS using tumor size categorization (≤ 1 cm, > 1 cm) was 1.150 (95% CI, 0.872 to 1.518; P = .322). The most frequently reported type of adverse event was an injection site reaction in 445 patients (50.2%), followed by injection site erythema and fatigue in 227 (25.6%) and 212 patients (23.9%), respectively. By the final visit, median anti-anti-idiotypic antibody level was 493,000.0 ng/mL, indicating a robust response.

CONCLUSION

Abagovomab administered as repeated monthly injections is safe and induces a measurable immune response. Administration as maintenance therapy for patients with ovarian cancer in first remission does not prolong RFS or OS.

Randomized, open-label, phase III study comparing patupilone (EPO906) with pegylated liposomal doxorubicin in platinum-refractory or -resistant patients with recurrent epithelial ovarian, primary fallopian tube, or primary peritoneal cancer

PURPOSE

This study compared the efficacy and safety of patupilone with those of pegylated liposomal doxorubicin (PLD) in patients with platinum-refractory or -resistant epithelial ovarian, primary fallopian tube, or primary peritoneal cancer.

PATIENTS AND METHODS

Patients with three or fewer prior regimens were eligible if they had received first-line taxane/platinum-based combination chemotherapy and were platinum refractory or resistant. Patients were randomly assigned to receive patupilone (10 mg/m(2) intravenously every 3 weeks) or PLD (50 mg/m(2) intravenously every 4 weeks).

RESULTS

A total of 829 patients were randomly assigned (patupilone, n = 412; PLD, n = 417). There was no statistically significant difference in overall survival (OS), the primary end point, between the patupilone and PLD arms (P = .195; hazard ratio, 0.93; 95% CI, 0.79 to 1.09), with median OS rates of 13.2 and 12.7 months, respectively. Median progression-free survival was 3.7 months for both arms. The overall response rate (all partial responses) was higher in the patupilone arm than in the PLD arm (15.5% v 7.9%; odds ratio, 2.11; 95% CI, 1.36 to 3.29), although disease control rates were similar (59.5% v 56.3%, respectively). Frequently observed adverse events (AEs) of any grade included diarrhea (85.3%) and peripheral neuropathy (39.3%) in the patupilone arm and mucositis/stomatitis (43%) and hand-foot syndrome (41.8%) in the PLD arm.

CONCLUSION

Patupilone did not demonstrate significant improvement in OS compared with the active control, PLD. No new or unexpected serious AEs were identified.

The promoter methylation and expression of the O6-methylguanine-DNA methyltransferase gene in uterine sarcoma and carcinosarcoma

O6-methylguanine-DNA methyltransferase (MGMT) gene promoter hypermethylation is observed in a number of solid tumors and is correlated with the silencing of MGMT expression. In glioblastoma patients treated with the alkylating agent temozolomide, MGMT gene methylation status was shown to have predictive value in terms of prolonged overall survival. Recently, temozolomide has demonstrated promising activity in the treatment of soft tissue sarcomas, including those of the uterus. The tissue specimens involving tumor samples and normal uterine fragments were obtained from nine patients with smooth muscle uterine sarcoma, 11 with stromal uterine sarcoma and 17 with mixed uterine tumors. MGMT gene promoter methylation was analyzed by combined bisulfite restriction analysis (COBRA) while its expression levels were assessed using the real-time reverse transcription polymerase chain reaction (qRT-PCR). MGMT promoter methylation was observed in 27% of all tumor samples analyzed. When stratified by the disease type, 55.5% (5/9) of smooth muscle sarcomas, 23.5% (4/17) of mixed uterine tumor tissues and 9% (1/11) of stromal sarcomas showed MGMT methylation. The MGMT promoter methylation was associated with lower levels of gene expression in tumors when compared with those with an unmethylated promoter (P=0.0232) or normal tissues (P=0.0141). To conclude, MGMT promoter methylation and downregulation of gene expression is observed in a fraction of carcinosarcomas and non-epithelial malignant tumors of corpus uteri. The assessment of MGMT promoter methylation status may potentially identify patients who would benefit from temozolomide treatment.

Estimation of groin recurrence risk in patients with squamous cell vulvar carcinoma by the assessment of marker gene expression in the lymph nodes

Background

Regional lymph node (LN) status is a well-known prognostic factor for vulvar carcinoma (VC) patients. Although the reliable LN assessment in VC is crucial, it presents significant diagnostic problems. We aimed to identify specific mRNA markers of VC dissemination in the LN and to address the feasibility of predicting the risk of nodal recurrence by the patterns of gene expression.

Methods

Sentinel and inguinal LN samples from 20 patients who had undergone surgery for stage T_1-3, N_0-2, M₀ primary vulvar squamous cell carcinoma were analyzed. Gene expression profiles were assessed in four metastatic [LN(+)] and four histologically negative [LN(−)] lymph node samples obtained from four VC patients, by the Affymetrix U133 Plus 2.0 gene expression microarrays. Of the set of genes of the highest expression in the metastatic LNs compared to LN(−), seven candidate marker genes were selected: PERP, S100A8, FABP5, SFN, CA12, JUP and CSTA, and the expression levels of these genes were further analyzed by the real-time reverse transcription polymerase chain reaction (qRT-PCR) in 71 LN samples.

Results

All of the seven genes in question were significantly increased in LN(+) compared to LN(−) samples. In the initial validation of the seven putative markers of metastatic LN, the Cox proportional hazard model pointed to SFN, CA12 and JUP expression to significantly relate to the time to groin recurrence in VC patients.

Conclusions

Our findings first provided evidence that SFN, CA12 and JUP have a potential of marker genes for the prediction of the groin recurrence LN in VC patients.

Identification of suitable reference genes for gene expression measurement in uterine sarcoma and carcinosarcoma tumors

OBJECTIVE

To date no suitable reference genes have been identified in carcinosarcomas and non-epithelial malignant tumors of corpus uteri for normalizing real-time RT-PCR (qRT-PCR) assays. The purpose of this study was to select appropriate references for gene expression studies in these tumors.

MATERIALS AND METHODS

We used RNA extracts from 75 tissue samples, representing 50 tumors and 25 fragments of normal uterine tissues obtained from 50 patients treated for mixed tumors, smooth muscle sarcoma and stromal sarcoma of the uterus. qRT-PCR for five potential reference (housekeeping) genes, namely B2M, HMBS, HPRT1, TBP and UBC, was performed. The expression stability of these genes was assayed using geNorm software application.

RESULTS

The analysis of gene expression data with geNorm identified HPRT1 as the most stable reference gene, followed by UBC and HMBS, for all the investigated tissues. When stratified by disease, the results still pointed at HPRT1 as the gene that retained the greatest robustness in mixed tumors as well as in smooth muscle and stromal sarcomas.

CONCLUSIONS

Our work is the first report on reference gene selection for qRT-PCR applications in mixed tumors, smooth muscle sarcoma and stromal sarcoma of the uterus. A ranking of candidate genes' stability values for the three types of tumors is provided and might serve as a valuable guide for future gene expression studies of these rare entities.

Polypectomy followed by adjuvant chemotherapy in a patient with sarcoma botryoides of the uterine cervix--case report and review of the literature

BACKGROUND

Embryonal rhabdomyosarcoma in a form of a polyp of the uterine cervix occurs mainly in young women in their second decade of life. The characteristic microscopic features are: the submucosal cambium layer and the presence of rhabdomyoblasts in the stroma. So far the treatment has not been well defined and ranges from conservative to radical surgery

CASE

The presented case is a 22-year old woman with cervical polyp. Polypectomy with D&C was performed in 2005 and the microscopic examination revealed rhabdomyosarcoma botryoides. Detailed examination diagnosed stage 1a of the disease. The patient received 6 cycles of chemotherapy (Vincristine and Actinomycin).

CONCLUSION

Conservative treatment may be considered in young women with favorable prognostic factors who wish to preserve their fertility Polypectomy followed by chemotherapy is a possible option for such patients.

Evaluation of intraoperative and postoperative complications related to lymphadenectomy in ovarian cancer patients

Assessment of the regional lymph node status is an integral part of diagnostics for ovarian cancer patients. Due to the risk of complications, lymphadenectomy for ovarian cancer patients, as a routine treatment procedure, is still a subject of controversy. Therefore, the present study aimed to evaluate the frequency and nature of intraoperative and postoperative complications in ovarian cancer patients treated with surgery. In addition, a comparison of the frequency and nature of surgical complications between patients who underwent lymphadenectomy and those who did not was carried out. A retrospective analysis of 211 consecutive ovarian cancer patients treated with surgery with pelvic and aortic lymphadenectomy (group I), and 258 ovarian cancer patients treated with surgery but without lymphadenectomy (group II) was carried out. All of the patients were treated with complementary chemotherapy. The frequency and nature of the intraoperative and postoperative complications were determined. The most frequent intraoperative complications in the two groups were haemorrhage, urinary system damage and digestive tract damage. The difference in the frequency and nature between the groups was not statistically significant (p=0.683). The most frequent postoperative complications were haemorrhage, intestinal junction dehiscence, eventrations, wound dehiscence, anaemia, wound healing complications and intestinal fistulas. Haemorrhage, eventrations and wound healing complications were more frequent in group I. The difference was statistically significant (p=0.002). Due to postoperative complications, reoperative procedures were necessary in two women in group II (0.78) and in 15 women (7.11%) in group I. The difference was statistically significant (p=0.000). In conclusion, the most frequent intraoperative complications were haemorrhage, urinary system damage and digestive tract damage. The frequency of complication was found to be similar in the two groups. A statistically significant higher rate of postoperative complications, such as haemorrhage, eventrations and wound healing complications was confirmed in the lymphadenectomy group.

Clinical significance of serum CA-125 and soluble tumor necrosis factor receptor type I in cervical adenocarcinoma patients

HYPOTHESIS

The purpose of this study was to answer the question whether the measurement of the pretreatment tumor markers and cytokine levels would be of clinical use in patients with cervical adenocarcinoma.

METHODS

CA-125, carcinoembryonic antigen (CEA), and squamous cell carcinoma (SCC), as well as interleukin 6 (IL-6), IL-8, vascular endothelial growth factor, IL-1 receptor antagonist, soluble tumor necrosis factor receptor type I (sTNF RI), and sTNF RII, were assessed in the sera of 120 cervical adenocarcinoma patients.

RESULTS

CA-125 presented a better diagnostic sensitivity than did CEA and SCC, whereas the concentration of most cytokines, except for sTNF RII, revealed higher sensitivity, than did the standard tumor markers. The highest sensitivity was found for sTNF RI. The concentrations of the examined parameters were found to be significantly higher in patients with advanced stage (IIB-IV) as compared with patients with I-IIA stage. [Float1]Serum concentration of IL-6 was the only one that differs significantly, depending on the histological grade. During the 3-year follow-up, 25 patients relapsed, and 73 patients were disease-free. Significantly higher pretreatment serum concentrations of the examined parameters (except for SCC and IL-1 receptor antagonist) were found in patients who developed recurrences. Soluble tumor necrosis factor receptor type I and CA-125 were found to present the highest sensitivity, with areas under the receiver operating characteristic curve of 0.833 and 0.809, respectively. As the result of univariate analysis, CA-125, CEA, sTNF RII, IL-6, sTNF RI, and clinical stage were considered factors of poor prognosis. Multivariate analysis has proven that CA-125 and clinical stage were the only significant independent prognostic factors of the disease-free survival.

CONCLUSION

CA-125 is an independent prognostic factor for disease-free survival. Our results have also demonstrated that sTNF RI is probably the most useful marker in cervical adenocarcinoma patients, especially in the early stages of disease.

The frequency of human papillomavirus infection in polish patients with vulvar squamous cell carcinoma

INTRODUCTION

Vulvar cancer is a rare condition representing about 4% of all female genital tract tumors. In contrast to the established relationship of virtually all cervical cancer cases with the human papillomavirus (HPV) infection, the reported HPV positivity in vulvar carcinoma ranges widely.

METHODS

Using the Linear Array HPV Genotyping Test, we investigated the HPV incidence in a group of 46 Polish patients with vulvar squamous cell carcinoma (age range, 37-93 years; median age, 70.2 years) in clinical stages T1-2, N0-2, and M0.

RESULTS

The presence of HPV DNA was confirmed in 7 of 46 (15%) primary tumor samples. HPV 16 was found in 5 tumors (71%). HPVs 6 and 58 were detected in the remaining 2 cases of virus-associated tumors.

CONCLUSIONS

We conclude that a fraction of cancers of vulva associated with HPV is insignificant, given the HPV prevalence of 8.6% in the Polish population aged 55 to 59 years (the oldest cohort of Polish women studied to date).

Trabectedin Plus Pegylated Liposomal Doxorubicin in Recurrent Ovarian Cancer

Purpose

The objective of this study was to compare the efficacy and safety of trabectedin plus pegylated liposomal doxorubicin (PLD) with that of PLD alone in women with recurrent ovarian cancer after failure of first-line, platinum-based chemotherapy.

Patients and Methods

Women ≥ 18 years, stratified by performance status (0 to 1 v 2) and platinum sensitivity, were randomly assigned to receive an intravenous infusion of PLD 30 mg/m2followed by a 3-hour infusion of trabectedin 1.1 mg/m2every 3 weeks or PLD 50 mg/m2every 4 weeks. The primary end point was progression-free survival (PFS) by independent radiology assessment.

Results

Patients (N = 672) were randomly assigned to trabectedin/PLD (n = 337) or PLD (n = 335). Median PFS was 7.3 months with trabectedin/PLD v 5.8 months with PLD (hazard ratio, 0.79; 95% CI, 0.65 to 0.96; P = .0190). For platinum-sensitive patients, median PFS was 9.2 months v 7.5 months, respectively (hazard ratio, 0.73; 95% CI, 0.56 to 0.95; P = .0170). Overall response rate (ORR) was 27.6% for trabectedin/PLD v 18.8% for PLD (P = .0080); for platinum-sensitive patients, it was 35.3% v 22.6% (P = .0042), respectively. ORR, PFS, and overall survival among platinum-resistant patients were not statistically different. Neutropenia was more common with trabectedin/PLD. Grade 3 to 4 transaminase elevations were also more common with the combination but were transient and noncumulative. Hand-foot syndrome and mucositis were less frequent with trabectedin/PLD than with PLD alone.

Conclusion

When combined with PLD, trabectedin improves PFS and ORR over PLD alone with acceptable tolerance in the second-line treatment of recurrent ovarian cancer.

Early cervical cancer managed by laparoscopy and conventional surgery: comparison of treatment results

INTRODUCTION

The goal of this retrospective analysis was to compare the results of treatment in patients with early cervical cancer managed by laparoscopy with those for patients observed after laparotomy.

METHODS

The retrospective analysis was carried out with 22 patients operated on with total laparoscopic hysterectomy and 58 patients treated by abdominal hysterectomy. Patients with clinical tumor stage IA, IB1, or IIA were eligible for surgery. The main efficacy end point was disease-free survival evaluated by the Kaplan-Meier method. The survival curves were compared using log-rank tests. In addition, length of hospitalization, duration of surgery, and complication rate were compared. P < 0.05 was set as statistically significant.

RESULTS

Predicted 3-year disease-free survival rates in the "open surgery" and "laparoscopy" groups were 0.86 (standard deviation [SD], 0.049) and 0.82 (SD, 0.098), respectively (P = 0.53). Recurrence rate was 13.6% after laparoscopy and 12% in open surgery. In 2 patients, intraperitoneal spread occurred after laparoscopy. The operation time was longer and hospitalization shorter after laparoscopy.

CONCLUSIONS

The 3-year disease-free survival was similar in both groups. Total laparoscopic radical hysterectomy may be an option in early cervical cancer; however, the intraperitoneal spread in 2 patients compels a search for possible risk factors in patients managed by laparoscopy.

The accuracy of the sentinel lymph node concept in early stage squamous cell vulvar carcinoma

OBJECTIVE

The purpose of the study was to determine the feasibility and accuracy of the sentinel lymph node (SLN) identification in vulvar carcinoma patients.

METHODS

Sixty-two patients with clinical early stage vulvar cancer underwent SLN detection procedure, followed by a complete inguinofemoral lymphadenectomy. The SLN was identified intraoperatively using lymphoscintigraphy with technetium-99m as well as patent blue V staining. The resected lymph nodes (LN) were submitted for histological examination by hematoxylin-eosin staining (H-E) and cytokeratin immunohistochemistry (IHC) and examined by the reverse transcriptase-polymerase chain reaction (RT-PCR) assay.

RESULTS

A total of 109 inguinal LN were dissected in 56 patients. SLNs were identified in 76% groins with patent blue V and in 99% with the use of Tc-99m. The accuracy differed significantly (p<0.0001). An H-E examination combined with IHC revealed 7 false-negative SLNs. The sensitivity of this method was 73% (95% CI, 64% to 81%) and the negative predictive value for a negative SLN finding was 92% (95% CI, 87% to 97%). The RT-PCR assay showed 8 false-negative SLNs. The sensitivity of the RT-PCR-based assay was 83% (95% CI, 75% to 90%) and the negative predictive value for a negative SLN was 88% (95% CI, 82% to 94%). The two diagnostic methods were found not to differ significantly.

CONCLUSIONS

In SLN mapping, the Tc-99m colloid lymphoscintigraphy is superior to the blue dye staining. Our data do not support the concept of the SLN identification as a highly accurate procedure in predicting the inguinofemoral LN status in patients with early stage vulvar cancer.

[Analysis of risk factors for recurrence after treatment of endometrial uterine cancer]

OBJECTIVE

The aim of this study was to evaluate selected clinical, histological and diagnostic factors as prognostics of time and location of endometrial cancer recurrence. We also attempted to design a more efficient follow-up protocols for patients with recurrent endometrial cancer.

METHODS

A retrospective review of 196 patients with recurrent endometrial cancer treated at the Department of Gynecologic Oncology, Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, was done. Recurrence was analyzed by site, presence or absence of symptoms and methods of detection. We focused our attention on the impact of specific disease characteristics on pattern and risk of recurrence.

RESULTS

Vast majority of recurrences (88%) occurred within the first 3 years after the primary treatment, whereas 71% within the first two years after the completion of the treatment. More than half of the patients (55%) were symptomatic when relapse occurred, while no statistically significant differences were found in time to relapse between the symptomatic and the asymptomatic group. Disease-free time observed when vaginal relapse occurred was significantly shorter compared to distant sites (p = 0.049). Histological maturity of primary tumor seems to be a prognostic of disease-free time (p = 0.039). Also patients with histological type I and II seem to have different courses of the disease (p = 0.064). Among recurrent endometrial cancer cases, pelvic examination, abdominal or pelvic ultrasound and chest x-ray could detect 95% of relapses.

CONCLUSIONS

A follow-up program in the first three years after the primary treatment of endometrial cancer is useful in detecting recurrent disease. There is no reason to use an intensive program of follow-up in patients with low risk primary disease. Pelvic examination, vaginal and abdominal ultrasound, chest x-ray are good and not expensive methods in relapse detection. There is no clinical justification for the routine use of the Pap smear in the follow-up of patients with endometrial cancer.

Randomized phase 3 trial of interferon gamma-1b plus standard carboplatin/paclitaxel versus carboplatin/paclitaxel alone for first-line treatment of advanced ovarian and primary peritoneal carcinomas: results from a prospectively designed analysis of progression-free survival

OBJECTIVES

Interferon gamma (IFN-gamma) is a pleiotropic cytokine with antiproliferative, immunostimulatory, and chemosensitization properties. This trial was designed to evaluate IFN-gamma 1b plus carboplatin and paclitaxel in treatment-naive ovarian cancer (OC) and primary peritoneal carcinoma (PPC) patients.

METHODS

Eligible patients were randomized to 6 cycles of carboplatin/paclitaxel every 3 weeks or the same in combination with IFN-gamma 1b (100 microg 3x/wk subcutaneously). The primary endpoint was overall survival (OS) time (target hazard ratio (HR)=0.77). Secondary endpoints included progression-free survival (target HR=0.7), based on blinded review of serial imaging scans, physical exams, and CA-125 levels.

RESULTS

847 patients were enrolled (OC 774, PPC 73) in Europe (n=539) and North/South America (n=308) from January 29, 2002 to March 31, 2004 and stratified according to: optimal debulking (n=271) versus suboptimal debulking with plans for interval debulking (PID) (n=238) or no PID (n=338). The study stopped early following a protocol-defined second interim analysis which revealed significantly shorter OS time in patients receiving IFN-gamma 1b plus chemotherapy compared to chemotherapy alone (1138 days vs. not estimable, HR=1.45, 95% CI=1.15-1.83). At the time of the analysis, 169 of 426 (39.7%) patients in the IFN-gamma 1b plus chemotherapy group had died compared to 128 of 421 (30.4%) in the chemotherapy alone group. Serious adverse events were more common in the IFN-gamma 1b plus chemotherapy group (48.5% vs. 35.4%), primarily due to a higher incidence of serious hematological toxicities (34.5% vs. 22.7%).

CONCLUSIONS

Treatment with IFN-gamma 1b in combination with carboplatin/paclitaxel does not have a role in the first-line treatment of advanced ovarian cancer.

TP53 status and taxane-platinum versus platinum-based therapy in ovarian cancer patients: a non-randomized retrospective study

Background

Taxane-platinum therapy (TP) has replaced platinum-based therapy (PC or PAC, DNA damaging chemotherapy) in the postoperative treatment of ovarian cancer patients; however, it is not always effective. TP53 protein plays a differential role in response to DNA-damaging agents and taxanes. We sought to define profiles of patients who benefit the most from TP and also of those who can be treated with PC.

Methods

We compared the effectiveness of PC/PAC (n = 253) and TP (n = 199) with respect to tumor TP53 accumulation in ovarian cancer patients with FIGO stage IIB-IV disease; this was a non-randomized retrospective study. Immunohistochemical analysis was performed on 452 archival tumors; univariate and multivariate analysis by the Cox's and logistic regression models was performed in all patients and in subgroups with [TP53(+)] and without TP53 accumulation [TP53(-)].

Results

The advantage of taxane-platinum therapy over platinum-based therapy was seen in the TP53(+), and not in the TP53(-) group. In the TP53(+) group taxane-platinum therapy enhanced the probability of complete remission (p = .018), platinum sensitivity (p = .014), platinum highly sensitive response (p = .038) and longer survival (OS, p = .008). Poor tumor differentiation diminished the advantage from taxane-platinum therapy in the TP53(+) group. In the TP53(-) group PC/PAC was at least equally efficient as taxane-platinum therapy and it enhanced the chance of platinum highly sensitive response (p = .010). However, in the TP53(-) group taxane-platinum therapy possibly diminished the risk of death in patients over 53 yrs (p = .077). Among factors that positively interacted with taxane-platinum therapy in some analyses were endometrioid and clear cell type, FIGO III stage, bulky residual tumor, more advanced age of patient and moderate tumor differentiation.

Conclusion

Our results suggest that taxane-platinum therapy is particularly justified in patients with TP53(+) tumors or older than 53 years. In the group of patients ≤53 yrs and with TP53(-) tumors platinum-based therapy is possibly equally efficient. We provide hints for planning randomized trials to verify these observations.

The value of tumor marker and cytokine analysis for the assessment of regional lymph node status in cervical cancer patients

The aim of the study was to evaluate the utility of the measurements of the circulating tumor markers, squamous cell carcinoma antigen (SCCA), CA125, carcinoembryonic antigen (CEA), cytokeratin fragment 19 (CYFRA 21.1), and the cytokines, interleukin-6 and vascular endothelial growth factor (VEGF), to estimate regional lymph node involvement in patients with cervical cancer. The study comprised 182 untreated patients with cervical cancer. The regional lymph node status was assessed either by the postsurgical histopathologic examination or by the computed tomography (CT). Concentrations of SCCA, CEA, and CA125 were determined using the Abbott Instruments system, of CYFRA 21.1 by the Roche kits, and of IL-6 and VEGF by the ELISA of R&D Systems (Minneapolis, MN). For the statistical analyses, Mann-Whitney U test and chi(2) test were applied. Serum levels of SCCA, CEA, CA125, CYFRA 21.1, IL-6, and VEGF were measured in patients with specified pelvic and para-aortic lymph node status. SCCA, CA125, and IL-6 levels were found to be significantly higher in patients with lymph node metastases than in those with no lymph node involvement. Also, the percentage of patients with simultaneously elevated concentrations of SCCA and CA125 or SCCA and IL-6 differed depending on the lymph node status and was significantly higher in the series of patients with lymph node metastases. Simultaneous assessment of serum levels of SCCA and CA125 or SCCA and IL-6 in patients with cervical cancer may be useful for the regional lymph node evaluation, especially in patients with advanced stages, when the lymph nodes are examined only by CT, with no histologic confirmation.

CHFR gene is neither mutated nor hypermethylated in ovarian cancer

BACKGROUND

CHFR is a mitotic checkpoint protein that under mitotic stress (caused also by taxanes) delays progression into mitosis.

METHODS

We looked for CHFR gene (605,209) alterations and its promoter hypermethylation in 48 ovarian carcinomas either sensitive or resistant to taxane treatment. We used single-strand conformation polymorphism analysis, sequencing and methylation-specific polymerase chain reaction.

RESULTS

Neither mutations in the CHFR gene nor hypermethylation of its promoter region were found. A novel single nucleotide polymorphism (Val154Val) was identified in exon 5 of alternatively spliced transcript.

CONCLUSIONS

Our results indicate that CHFR gene status cannot serve as a molecular predictor of ovarian cancer sensitivity to taxanes.

Results of chemotherapy for pulmonary metastases of carcinoma of the cervix in patients after primary surgical and radiotherapeutic management

The purpose of this study was to evaluate the results of chemotherapy of pulmonary metastases from invasive carcinoma of the cervix, which were detected after a disease-free period after initial treatment with surgery or radiotherapy. Fifty patients with radiologically proven pulmonary metastases were treated with chemotherapy. All patients received a platinum-5-fluorouracil (PF) program: cisplatin 75 mg/m(2) and 5-fluorouracil 800 mg/m(2) every 4 weeks. The overall 1- and 3-year survival after PF chemotherapy was 62% and 17.6%, respectively. The progression-free survival at 1 and 3 years was 36.7% and 14.3%, respectively. There were 6 (12%) complete responses and 17 (34%) partial responses. Hematologic tolerance was acceptable. Third degree and fourth degree leukopenia was diagnosed in four (8%) and six (12%) patients, respectively. Three individuals had third degree thrombocytopenia. In the multivariate analysis, the following prognostic factors were associated with poor survival: time to recurrence after primary treatment (P= 0.002), number of lung metastases (P= 0.016), and progression during chemotherapy (P= 0.001). We conclude that PF regimen is a safe and reasonably effective chemotherapy in the management of patients with pulmonary metastases after primary treatment for invasive carcinoma of the cervix who do not qualify for surgical metastasectomy.

The evaluation of intra- and postoperative complications related to debulking surgery with bowel resection in patients with FIGO stage III-IV ovarian cancer

The surgical treatment of advanced ovarian cancer is based on the maximal debulking with widening the operation range to the infiltrated organs. The aims are as follows: (1) the assessment of the quantity and quality of intra- and postoperative complications in patients with advanced ovarian cancer in which partial bowel resection was performed and (2) the evaluation of intra- and postoperative complications related to surgery with bowel resection and anastomosis, compared to Hartmann's procedure. The analysis of debulking procedures with intestinal resection and postoperative period in 39 ovarian cancer patients, FIGO stage III-IV, was performed. During 39 operations, the most frequent type of resection was the sigmoidectomy or proctosigmoidectomy (29 patients). In the remaining patients, left- and right-side hemicolectomy or partial enterectomy was done. Twenty-four anastomosis and 15 Hartmann's procedures were performed. There were no differences between surgery with anastomosis and Hartmann's procedure in aspect of quantity of complications, blood loss, and the time of surgery. There were no statistically significant differences in overall survival and progression-free survival in both groups. We conclude that the percentage of complications related to debulking surgery with intestinal resection in advanced ovarian cancer patients might be accepted. The quantity of complications related to surgery with anastomosis and to Hartmann's procedure is similar. If possible, the surgery with anastomosis should be performed.

Nadroparine activated fibrinolysis and improvement of glomerular filtration rate in patients with FIGO IIB–IIIB cervical cancer treated with radiochemotherapy

OBJECTIVES

(1) Evaluation of the influence of hemostatic disorders on renal function in patients with FIGO stage IIB-IIIB cervical cancer treated with radiochemotherapy. (2) Identifying methods of improving renal function in this patients group.

METHODS

Treatment design assumes the administration of a total radiation dose of 46-65 Gy and, additionally, cisplatin 40 mg/m2 every 7 days in patients with normal plasma creatinine level. Renal function was assessed with the aid of dynamic scintigraphy with glomerular filtration rate (GFR) evaluation. Analysis of serum hemostatic system covered D-dimers, PAP, PAI-1, tPA, FDP, F1+2 and TAT. The same hemostatic parameters were also evaluated in urine. The patients were divided into two groups: the study group - i.e. patients with affected GFR and the control group - with normal GFR. Half of study group patients, throughout the entire treatment, receive nadroparine 2850 units aXa/0.3 ml every 24 h during and 6 weeks after the treatment.

RESULTS

There are significant decreases of GFR in control (median -9.7%) and study group without nadroparine (median -9.9%) and increase in the GFR (median 22.3%) in study group with nadroparine (p=0.0001). Plasma and urine hemostatic parameter analysis showed activation of fibrinolysis in patients treated with nadroparine and fibrinolysis inhibition in remaining groups.

CONCLUSIONS

(1) Inhibition of fibrinolysis may cause subclinical renal insufficiency in patients with advanced cervical cancer. (2) Insufficiency increases after the end of radiochemotherapy in patients, as well with normal GFR as, with primary decreased GFR. (3) Application of nadroparine causes fibrinolysis activation, and increase in the GFR.

Phase II open label randomized study of trabectedin (T) given as two different dosing schedules in women with platinum-sensitive, recurrent ovarian carcinoma: Preliminary results

5031

Background: Trabectedin (Yondelis, ET-743) is a marine derived compound which binds to the minor groove of DNA distorting the DNA structure and induces apoptosis and cell cycle arrest. It has shown clinical activity in soft tissue sarcoma, ovarian, prostate and breast cancer. Methods: Patients (pts) with recurrent platinum sensitive ovarian carcinoma were randomized in a multicenter, open label study to receive T as 1.5 mg/m2 over 24 h infusion (schedule A) or 1.3 mg/m2 over 3 h infusion (schedule B) both every 3 weeks. All pts received dexamethasone premedication. Primary objective is to evaluate the response rate (RECIST) and secondary objectives are response duration, CA-125 response, time to progression and safety. Results: 107 pts were enrolled in 23 centers. Demographic and disease characteristics were well balanced. Toxicity and response data on the first 99 pts are available: median age 57 (25–78) years; ECOG PS=0: 72% and =1: 28%; pts received a median of 4 cycles (range:1–19 in A, 1–13 in B). Relative dose intensity was 84% and 93% respectively. Objective responses due to investigator’s assessment were 29% (8% CR, 21% PR) with 52% SD in A and 28% (11% CR, 17% PR) with 45% SD in B, with 11 pts not yet evaluable for response. CA 125 responses ≥ 50% occurred in 23% in A and 26% in B. TTP data will be presented. Safety: 501cycles were delivered; the most common any grade drug-related AEs per patient were (A and B) fatigue (56% and 47%), nausea (63% and 70%), vomiting (56% and 45%) and constipation (25% and 30%). Consistent with previous experience, alopecia, stomatitis and neurotoxicity were uncommon and mild/moderate. Grade 3/4 fatigue occurred in 15% in A and 4% in B. Grade 3/4 lab abnormalities were non-cumulative neutropenia (50% and 32%) and reversible ALT increase (58% and 53%). G-CSF support was not routinely given. There were 4 deaths <30 days last infusion date (3 in A unrelated to study drug, one in B due to related multiorgan failure). Conclusions: This analysis suggests that both T schedules appear active with manageable toxicity. There was a trend for less neutropenia and fatigue with schedule B. On the basis of these efficacy results, no additional phase III comparisons between these 2 schedules seem warranted

[Table: see text]

Comparison of the results of surgical treatment using laparoscopy and laparotomy in patients with endometrial cancer

The objective of the current study was to compare the results of surgical treatment in endometrial cancer with the use of laparoscopy and the traditional approach of laparotomy. Our goal was to evaluate and compare the morbidity, recurrence rate, and disease-free survival in both groups. This article is a retrospective study. A chart review of 45 patients treated by laparoscopy between 1994 and 2002 and 136 patients treated by laparotomy between 2001 and 2002 was performed. Disease-free survival in both groups was evaluated with the Kaplan-Meier method and was compared using the log-rank test. The rate of recidive was 6% in the laparoscopy group and 13% in the laparotomy group. There was no statistically significant difference in disease-free survival and recidive rate between the laparoscopy and laparotomy groups. Laparoscopic management in endometrial cancer does not worsen the prognosis, and the disease-free survival is similar to that resulting from the traditional approach. The benefits of minimal invasive surgery are quicker postoperative recovery, shorter hospital stay, and no wound complications.