Lymphatic spread of cervical cancer: an anatomical and pathological study based on 225 radical hysterectomies with systematic pelvic and aortic lymphadenectomy

To assess the patterns of lymphatic spread in cervical carcinoma, radical hysterectomy with systematic lymphadenectomy was performed in 66 patients FIGO stage IB-IIA <4 cm, and 159 patients stage IB-IIA >4 cm to stage IV. The latter patients were treated with neoadjuvant chemotherapy (NACT). Parametria were evaluated by the giant section technique in 109 patients. In 40 of these, the superficial and deep layers of the vesicouterine ligament, the sacrouterine ligament, and the distal part of the cardinal ligament were separately evaluated. The median number of nodes removed was 48 pelvic (range 20-107) and 22 aortic (range 7-64). Positive nodes were found in 14 (21%) stage IB-IIA <4 cm and in 38 (23%) NACT-treated patients, all having pelvic node metastasis. Aortic nodes were involved in 2 (3%) and 5 (3%) patients, respectively. Solitary metastases were found in the superficial obturator (21% of stage IB-IIA <4 cm and 31% of NACT-treated positive node patients, respectively), external iliac (7 and 3%, respectively), and common iliac nodes (7 and 3%, respectively). Parametrial nodes were found in 59% of giant sections (8% metastatic). The superficial and deep layers of the vesicouterine ligament, the uterosacral ligament, and the distal part of the lateral parametrium revealed the presence of nodes in 33% (no metastatic nodes), 26% (3% metastatic), 5% (no metastatic nodes), and 70% (5% metastatic) of patients, respectively. Overall, parametrial nodes were positive in 12% of stage IB-IIA <4 cm and 7% of NACT-treated patients. The diameter of node metastasis was <10 mm in more than 80% of positive nodes. In conclusion, parametrial nodes were mainly located in the cardinal and vesicouterine ligaments, both being a potential site of metastasis. The superficial obturator, external iliac, common iliac, paracaval, intercavoaortic, and paraaortic nodes were the groups more frequently involved. These data may be useful for tailoring radical hysterectomy and lymphadenectomy according to the primary tumor and the surgeon's intent.

Prognostic significance of epidermal growth factor receptor in laryngeal squamous cell carcinoma

Epidermal growth factor receptor (EGFR) content was determined by a radioligand receptor assay in 140 primary laryngeal squamous cell carcinomas (median value of 8.4 fmol mg-1 protein, range 0-169.9 fmol mg-1 protein). Cox univariate regression analysis using EGFR as a continuous variable showed that EGFR levels are directly associated with the risk of death (chi 2 = 14.56, P-value = 0.0001) and relapse (chi 2 = 7.77, P-value = 0.0053). A significant relationship between EGFR status and survival was observed at the different arbitrary cut-off values chosen (8, 16 and 20 fmol mg-1 protein). The cut-off value of 20 fmol mg-1 protein was the best prognostic discriminator. In fact, the 5 year survival was 81% for patients with EGFR- tumours compared with 25% for patients with EGFR+ tumours (P < 0.0001). The 5 year relapse-free survival was 77% for patients with EGFR- tumours compared with 24% for patients with EGFR+ tumours (P < 0.010). When clinicopathological parameters and EGFR status were examined in the multivariate analysis, T classification and EGFR status retained an independent prognostic value. In this study we demonstrated that high EGFR levels single out patients with poor prognosis in laryngeal cancer.

Oxaliplatin or paclitaxel in patients with platinum-pretreated advanced ovarian cancer: A randomized phase II study of the European Organization for Research and Treatment of Cancer Gynecology Group

PURPOSE

This was a multicentric, open, randomized, phase II study of single-agent paclitaxel and oxaliplatin to evaluate the efficacy of oxaliplatin in a relapsing progressive ovarian cancer patient population and to analyze the safety profile and impact of both agents on quality of life, time to progression, and survival.

PATIENTS AND METHODS

Eighty-six patients with platinum-pretreated advanced ovarian cancer were randomly assigned to two arms: 41 received paclitaxel at 175 mg/m(2) over 3 hours every 3 weeks, and 45 received oxaliplatin at 130 mg/m(2) over 2 hours every 3 weeks. For inclusion, patients had to have a performance status of 0 to 2 and to have received at least one and no more than two prior cisplatin- and/or carboplatin-containing chemotherapy regimens within the last 12 months.

RESULTS

Seven confirmed responses were observed in each arm, for an overall response rate in the total treated population of 17% (95% confidence interval [CI], 7% to 32%) in the paclitaxel arm and 16% (95% CI, 7% to 29%) in the oxaliplatin arm. Median time to progression was 14 weeks and 12 weeks, and overall survival was 37 weeks and 42 weeks in the paclitaxel and oxaliplatin arms, respectively. Among 63 patients with a 0- to 6-month progression-free, platinum-free interval, there were five objective responses with paclitaxel in 31 patients and two objective responses with oxaliplatin in 32 patients. Nine patients (22%) in the paclitaxel arm had grade 3 or 4 neutropenia (National Cancer Institute of Canada [NCIC] Common Toxicity Criteria). Two patients (4%) experienced grade 3 thrombocytopenia in the oxaliplatin arm. Maximum grade (grade 3) NCIC neurosensory toxicity was experienced by three patients (7%) in the paclitaxel arm and by four patients (9%) in the oxaliplatin arm.

CONCLUSION

Single-agent oxaliplatin at 130 mg/m(2) every 3 weeks is active with moderate toxicity in patients with cisplatin-/carboplatin-pretreated advanced ovarian cancer.

Growth-inhibitory effect of quercetin and presence of type-II estrogen-binding sites in human colon-cancer cell lines and primary colorectal tumors

We studied the effect of quercetin (Q) on the proliferation of HT-29, WiDr, COLO 201, and LS-174T human colon cancer cell lines. Q, between 10 nM and 10 microM, exerted a dose-dependent, reversible inhibition of cell proliferation. Cell-cycle analysis revealed that the growth-inhibitory effect of Q was due to a blocking action in the G0/G1 phase. Using a whole-cell assay with 17 beta-[3H]-estradiol as tracer, we demonstrated that all these cell lines contain type-II estrogen-binding sites (type-II EBS). By using Q and other chemically related flavonols (3,7-4'-trimethoxyquercetin, 3,7,3',4'-tetramethoxyquercetin, kaempferol, morin, and rutin), we observed that the affinities of these compounds for type-II EBS are correlated with their growth-inhibitory potential. Furthermore, the Q sensitivity of the colon cancer cell lines was correlated with the number of type-II EBS/cell. Then Q could regulate colon cancer cell growth through a binding interaction with type-II EBS. This mechanism could also be active in vivo as we have observed that cytosolic type-II EBS are present in primary colorectal cancers and that Q is effective in inhibiting the in vitro bromodeoxyuridine incorporated by neoplastic cells in these cancers.

Anatomical and pathological study of retroperitoneal nodes in epithelial ovarian cancer

The pattern of lymphatic spread was evaluated in 81 previously untreated ovarian cancer patients (Stage I, 35; Stage II, 2; Stage III, 44) undergoing systematic aortic and pelvic lymphadenectomy. Positive nodes were found in 14% Stage I and 68% Stage III patients. Either pre- and paraaortic, or pre- and paracaval nodes were the only aortic node metastasis in 14% of patients. Common iliac nodes were the sole metastasis in pelvic area in 11%, external iliac in 14%, and obturator in 6% of patients. Therefore, the above node groups, which overall were the most frequently involved, may be considered those primarily invaded by the tumor. When data were analyzed according to stage, aortic nodes were the site of metastasis in 6% Stage I and 14% Stage III patients and pelvic nodes in 8% Stage I and 11% Stage III patients. Both aortic and pelvic areas were positive in 43% Stage III patients. The median number of positive nodes/patient was 2 (range, 1-3) and 4 (range 2-46) in Stages I and III, respectively. Lymphatic spread was ipsilateral to the tumor in all Stage I and in 40% Stage III patients. In Stage III metastases were also observed in intercavoaortic, retrocaval, retroaortic, internal iliac, and presacral nodes. In apparent Stage I, lymphatic metastasis seemed to be limited to one ipsilateral group, and the removal of the primary nodes ipsilateral to the tumor may be considered an adequate procedure. In Stage III, the presence of metastasis beyond the primary nodes and the frequent bilateral involvement suggest that all lymphatic tissue surround the aorta, the cava, and the pelvic vessels should be removed if a cytoreductive intent is pursued.

Analysis of cyclin E and CDK2 in ovarian cancer: gene amplification and RNA overexpression

Cyclins and their associated kinases (cdks) play a key role in controlling the cell cycle, a process whose disregulation can potentially lead to uncontrolled cell growth and hence to cancer. We have studied the role of both cyclin E and its associated kinase cdk2 in ovarian cancer. Primary, metastatic, recurrent and benign ovarian tumors were screened for cyclin E and cdk2 gene amplification. Cyclin E was shown to be amplified in 21% and cdk2 in 6.4% of the cases analyzed. Cyclin E and cdk2 RNA expression levels were determined by semi-quantitative RT-PCR analysis in a partially overlapping series of samples and compared to the expression levels of normal ovarian surface epithelial cells. Cyclin E RNA was overexpressed in 29.5% and cdk2 in 6.5% of ovarian tumors tested. We determined that in most cases gene amplification leads to higher RNA levels for cyclin E and that the overall levels of cyclin E and cdk2 RNA were correlated. We hypothesize that cyclin E and cdk2 are, in part co-regulated and that they may concur to ovarian tumor development.

A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies

OBJECTIVE

To evaluate the clinical effectiveness of retroperitoneal drainage following lymphadenectomy in gynecologic surgery.

METHODS

One hundred thirty-seven consecutive patients undergoing systematic lymphadenectomy for gynecologic malignancies were randomized to receive (Group A, 68) or not (Group B, 69) retroperitoneal drainage. The pelvic peritoneum and the paracolic gutters were not sutured after node dissection. Perioperative data and complications were recorded.

RESULTS

Clinical and surgical parameters were comparable in the two groups. Postoperative hospital stay was significantly shorter in Group B (P < 0.001), whereas the complication rate was significantly higher in Group A (P = 0.01). This was mainly due to a significant increase in lymphocyst and lymphocyst-related morbidity. Sonographic monitoring for lymphocyst showed free abdominal fluid in 18% of drained and 36% of not-drained patients (P = 0.03). Symptomatic ascites developed in 2 drained (3%) and 3 not-drained (4%) patients (NS), respectively.

CONCLUSIONS

Prophylactic drainage of the retroperitoneum seems to increase lymphadenectomy-related morbidity and postoperative stay. Therefore, routine drainage following lymphadenectomy seems to be no longer indicated when the retroperitoneum is left open.

Epidermal growth factor, oestrogen and progesterone receptor expression in primary ovarian cancer: correlation with clinical outcome and response to chemotherapy

The expression of epidermal growth factor receptor (EGFR), oestrogen receptor (ER) and progesterone receptor (PR) was assayed by a radioreceptor method in 117 primary ovarian cancers. EGFR was not significantly related to any of the clinicopathological parameters examined. In patients with stage II-IV disease who underwent second-look surgery after primary chemotherapy, a significant correlation between high EGFR levels and poor response to chemotherapy was demonstrated (P = 0.031). Moreover, post-operative residual tumour showed an independent role in predicting chemotherapy response (P = 0.0007) and EGFR status showed a borderline significance (P = 0.052) in the multivariate analysis. No correlation between steroid hormone receptors and clinicopathological parameters was observed. Whereas a significant relationship was shown between EGFR positivity and a shorter overall survival (OS) (P = 0.0022) and progression-free survival (PFS) (P = 0.0033), patient survival was not related to steroid hormone receptor status. Among the parameters tested only stage, ascites and EGFR status retained an independent prognostic value in the multivariate analysis.

Long-term survival following neoadjuvant chemotherapy and radical surgery in locally advanced cervical cancer

The aim of this study was to analyse the long-term survival and the relationships between prognostic factors at presentation, chemoresponsiveness and disease outcome in patients with locally advanced cervical cancer treated by neoadjuvant chemotherapy and radical surgery (RS). Two consecutive studies of neoadjuvant chemotherapy containing cisplatin, bleomycin plus/minus methotrexate followed by radical hysterectomy and systematic aortic and pelvic lymphadenectomy were carried out between January 1986 and September 1990 on 130 patients with > or = 4 cm stage IB2-III cervical cancer. Survival analysis was performed using the Kaplan and Meier test and Cox's multivariate regression analysis. 128 (98%) of the patients enrolled were evaluable for clinical response and survival, 83% (106) of the patients responded to chemotherapy, with a 15% complete response rate. Logistic regression analysis demonstrated that International Federation of Gynecology and Obstetrics (FIGO) stage, cervical tumour size, parametrial involvement and histotype are highly predictive of response. Responding patients underwent laparotomy, but 8% were not amenable for radical surgery. The 10-year survival estimates were 91%, 80% and 34.5% for stage IB2-IIA bulky, IIB and III, respectively (P < 0.001). After Cox's regression analysis, the parameters significantly associated with survival were the same factors predicting response to neoadjuvant chemotherapy. No stage IB2-IIA bulky patient has so far relapsed, while 12% stage IIB and 56% stage III patients recurred. The 10-year disease-free survival estimates are 91% and 44% for stage IB2-IIB and III, respectively (P < 0.001). Metastatic nodes and persistent tumour in the parametria were the only two independent factors for disease-free survival after multiple regression analysis. After a long-term follow-up (median follow-up 98 months (20-129+)), our results give new evidence of the prognostic value of response to neoadjuvant chemotherapy and of a possible therapeutic benefit of the sequential treatment adopted which, however, must be verified in a randomised setting.

BRCA1 gene promoter methylation status in high-grade serous ovarian cancer patients--a study of the tumour Bank ovarian cancer (TOC) and ovarian cancer diagnosis consortium (OVCAD)

BACKGROUND

Mutations in BRCA1/2 genes are involved in the pathogenesis of breast and ovarian cancer. Inactivation of these genes can also be mediated by hypermethylation of CpGs in the promoter regions. Aim of this study was to analyse the clinical impact of BRCA1 promoter gene methylation status in a homogenous cohort of high-grade serous ovarian cancer (HGSOC) patients.

METHODS

The cohort included 257 primary HGSOC patients treated by cytoreduction and platinum-based chemotherapy. DNA was extracted from fresh frozen tissue samples. BRCA1 gene promoter methylation rate was assessed using polymerase chain reaction (PCR).

RESULTS

14.8% of patients presented hypermethylation within a selected region of the BRCA1 promoter. The rate of hypermethylation was significantly higher in younger patients (20.8% hypermethylation in the age group ⩽ 58 years versus 8.7% hypermethylation in the age group >58 years; p = 0.008). Optimal tumour debulking could be reached in 63% of patients, without significant differences in the extent of residual disease with respect to the methylation status. No impact of BRCA1 gene promoter methylation status on progression free- and overall-survival rates was found. No significant differences within BRCA1 promoter methylation status between primary and metastatic tissue could be observed. These results on BRCA1 promoter methylation status were also confirmed in a subgroup of 107 patients found negative for BRCA1 exon 11 mutations.

CONCLUSIONS

Our data suggest that BRCA1 methylation determines the earlier onset of HGSOC. Furthermore our study supports the idea that BRCAness is not only due to mutations but also to epigenetic changes in BRCA1 promoter gene.

Mutations of the D310 mitochondrial mononucleotide repeat in primary tumors and cytological specimens

A mononucleotide repeat (D310) in mitochondrial DNA has been recently identified as a mutational hot spot in primary tumors. We analyzed 56 tumors for insertion/deletion mutations in the D310 repeat. A total of 13 mutations were detected. The highest frequency of mutations was found for cervical cancer, followed by bladder tumors, breast cancer and endometrial neoplasia. No alterations were observed in four patients suspected of malignancy but without evidence of malignant tumor. We detected identical changes in four of four urine sediments from patients with bladder cancer and in three of three fine needle aspirates of patients with breast cancer. Our results indicate that D310 abnormalities are detectable in cytology specimens from patients with cancer and support the notion that D310 analysis may represent a new molecular tool for cancer detection.

Early feeding compared with nasogastric decompression after major oncologic gynecologic surgery: a randomized study

OBJECTIVE

To evaluate the feasibility, safety, and tolerance of early feeding in patients undergoing surgery for gynecologic malignancies.

METHODS

Patients were stratified according to operative time and type of tumor and were randomized into two arms: A) early oral feeding and B) nasogastric decompression followed by feeding at the first passage of flatus. Variables assessed included nausea, vomiting, time to first passage of flatus and stool, time elapsed before adequate tolerance of a regular diet, postoperative stay, and complications.

RESULTS

Sixty-one patients were randomized into each arm. The types of tumor, the surgical procedures performed, and the operative times were similar in both groups. Early oral feeding in patients in arm A was associated with a significantly faster resolution of postoperative ileus (P < .01), with a more rapid return to a regular diet (P < .01), with an earlier first passage of stool (P < .01), and with a shorter postoperative stay (P < .05) than patients in arm B. Rates of nausea and vomiting were similar in both arms. Hindered deglutition and nasal soreness caused by the nasogastric tube were observed in 88% of patients in arm B. Insertion of a nasogastric tube was necessary in six patients in arm A (10%), and three of these had postoperative complications. Thus, early feeding was feasible in 95% of patients and did not seem to be related to preoperative chemotherapy, tumor type, or lymphadenectomy.

CONCLUSION

Early feeding is feasible and well tolerated and is associated with reduced postoperative discomfort and a more rapid recovery in patients undergoing major surgery for gynecologic malignancies.

Cisplatin (P), bleomycin (B), and methotrexate (M) preoperative chemotherapy in locally advanced vulvar carcinoma

Based on the encouraging results of neoadjuvant chemotherapy (NACT) and radical surgery (RS) observed in locally advanced cervical cancer, 21 patients with advanced squamous cell carcinoma of the vulva (FIGO stages, IVa, 21; TNM stages, T2N2M0, 6, T3N2M0, 11, T4N2M0, 4) were submitted to two to three cycles of cisplatin (P, 100 mg/m2, Day 1), bleomycin (B, 15 mg, Days 1, 8), and methotrexate (M, 300 mg/m2 + cfr, Day 8) NACT followed by RS in operable patients. Two patients (10%) had a partial response in the primary tumor (T) and 14 (67% CR+PR) in the inguinal nodes (N). The operability rate following NACT was 90% (pathological downstaging rate, 33%) but surgery was really radical in 79% of cases. Pathological N response was significantly related to the pathological T downstaging, and a persistently high N positivity rate was detected (inguinal, 81%; pelvic, 47%). NACT+RS had an acceptable morbidity but the therapeutic results were less encouraging than expected with a 3-year survival of 24% and stage, pathological T downstaging, and N status all significantly affected survival. Sixty-eight percent of the operated patients recurred 3-17 months from the end of treatment and 50% of them had a distant relapse. PBM NACT did not seem to add any substantial benefit to the surgery alone in this subset of patients with extremely advanced disease. Studies on a chemoradiotherapeutic approach are currently in progress in order to confirm the promising preliminary results.

Radical hysterectomy: a randomized study comparing two techniques for resection of the cardinal ligament

To compare two different surgical techniques for the resection of the cardinal ligaments during radical operation for cervical cancer, 84 patients with locally advanced cervical cancer (FIGO stages IB-IIA > or = 4 cm, IIB-III) primarily treated with chemotherapy and then eligible for radical surgery underwent radical hysterectomy. Lateral parametria were resected by using the Meigs technique or a modified Magara technique. The procedure to be performed on the right hand side was randomly chosen, consequently the left cardinal ligament was resected with the other technique. Evaluation of the first 35 cases showed that the median size of the parametria resected with the modified Magara technique (52 mm) was significantly greater than that removed with the Meigs technique (34 mm) (P < 0.05). Therefore hemoclips were routinely adopted in the following 49 cases. In 11% of cases hemoclips could not be used due to a deep and narrow pelvis or varicosities of the hypogastric plexus, therefore clamps were necessary. Bleeding complicating parametrial dissection occurred independently of the adopted technique. Five-years DFS is 100, 80, and 52% for stage IB-IIA > 4 cm, IIB and III, respectively. The study showed that the modified Magara technique is feasible and safe and allows for a more radical resection of the parametrial tissue. Furthermore, this approach seems to improve the local control of disease.

The combination of quercetin and cytosine arabinoside synergistically inhibits leukemic cell growth

It has been demonstrated that quercetin (3,3',4',5,7-pentahydroxyflavone) inhibits the growth of several cancer cell lines and that the antiproliferative activity of this substance is probably mediated through a binding interaction with type II estrogen binding sites (type II EBS). The effect of quercetin and cytosine arabinoside (Ara-C) alone or in combination, was tested on HL-60 cell growth. Quercetin significantly synergized the inhibitory activity of Ara-C on HL-60 cell growth while rutin, the 3-rhamnosylglucoside of quercetin, neither competed with [3H]estradiol for type II EBS nor was effective alone or in combination with Ara-C. Based on these results, we studied by a clonogenic assay the effect of quercetin and Ara-C alone and in combination on colony formation by human leukemic cells (CFU-L). In all cases both drugs exhibited a dose-related inhibition of CFU-L in a range of concentrations between 10 nM and 10 microM and 0.01 nM and 10 microM for quercetin and Ara-C, respectively. The combination of the two drugs resulted in a synergistic inhibitory activity on CFU-L. Considering that plasma concentrations of quercetin effective in vitro were obtained in vivo without any apparent side effects, we conclude that this report represents further experimental evidence that quercetin could be used in the treatment of acute leukemias.

Epidermal growth factor receptor (EGFR) is not related to the prognosis of cervical cancer

We analyzed the prognostic significance of epidermal growth factor receptor (EGFR) in a large prospective series of 90 cervical cancer patients observed for a long follow-up period. EGFR levels ranged from 0 to 52.1 fmol/mg protein, with a median value of 6.0 fmol/mg protein. Patients with an advanced stage of disease expressed lower EGFR levels than those with an early stage of disease (median values were 7.8 fmol/mg protein for patients with stage I-II and 4.2 fmol/mg protein for patients with stage III-IV, P = 0.013). There was no correlation between EGFR expression and other clinicopathological parameters analyzed. No significant relationship was shown between EGFR positivity and overall survival. No significant relationship between EGFR status and disease-free survival was observed. Cox univariate regression analysis using EGFR as a continuous variable showed that EGFR levels are not associated with the risk of disease recurrence after treatment or death (P-value not significant). Our data didn't seem to indicate a prognostic role of EGFR in cervical cancer.

Modified type IV-V radical hysterectomy with systematic pelvic and aortic lymphadenectomy in the treatment of patients with stage III cervical carcinoma. Feasibility, technique, and clinical results

BACKGROUND

Due to the high prevalence of perioperative major morbidity and the difficulties in achieving surgical disease free margins, surgery has had no role in the treatment of patients with Stage III cervical carcinoma.

METHODS

Forty-two women with International Federation of Gynecology and Obstetrics (FIGO) Stage III cervical carcinoma responding to platinum-based neoadjuvant chemotherapy underwent the maximum surgical effort, comprised of a modified type IV-V radical hysterectomy (37 patients) or anterior pelvectomy (5 patients) with systematic pelvic and aortic lymphadenectomy. Feasibility, modifications of surgical technique, and pathologic and clinical data were analyzed.

RESULTS

Surgery was feasible in all 42 patients intraoperatively selected. Disease free margins were achieved in all but one patient. The median operating time was 390 minutes, and the median estimated blood loss was 800 mL. In the last series of patients, these figures declined to 320 minutes and 600 mL, respectively. Major morbidity consisted of severe intraoperative hemorrhage in two patients, pulmonary embolism in four, ureteral fistula in three, and laparocele in three. The number of lymph nodes removed ranged from 30 to 117 with a median of 56. The mean lengths of vagina and lateral parametrium resected were 55 and 48 mm, respectively. Despite perioperative chemotherapy, lymph node metastasis was present in 36% of patients, parametrial disease in 38%, and vaginal disease in 45%. After a median follow-up of 53 months, the 5-year overall and disease-free survival rates of radically operated patients were 70% and 58%, respectively.

CONCLUSIONS

Thanks to improved surgical technique and perioperative care, extended radical surgery appears to be feasible with acceptable morbidity in chemosensitive women with Stage III cervical carcinoma and may constitute a valid alternative to radiotherapy in these patients.

A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision

BACKGROUND

Although studies in animals demonstrated a better wound healing after abdominal incision with cold scalpel than with electrocautery, clinical experiences did not confirm these findings. The purpose of this study was to compare early and late wound complications between diathermy and scalpel in gynecologic oncologic patients undergoing midline abdominal incision.

METHODS

Patients undergoing midline abdominal incision for uterine malignancies were divided into two groups according to the method used to perform the abdominal midline incision: cold scalpel and diathermy in coagulation mode. Early and late complications were compared. Logistic regressions were used for statistical analysis.

RESULTS

Nine hundred sixty-four patients were included, of whom 531 were in the scalpel group and 433 in the electrocautery group. Both groups were similar with respect to demographic, operative, and postoperative characteristics. Univariate analysis revealed a higher incidence of severe wound complications in the scalpel group than in the electrocautery group (8 of 531 versus 1 of 433, P <0.05). After adjustment for confounding variables (eg, age, body mass index) no differences were found between groups.

CONCLUSIONS

Scalpel and diathermy are similar in terms of early and late wound complications when used to perform midline abdominal incisions. Therefore the choice of which method to use remains only a matter of surgeon preference.

Nm23 expression in endometrial and cervical cancer: inverse correlation with lymph node involvement and myometrial invasion

The expression of nm23 has been shown to correlate in some solid tumours with their metastatic potential and to be associated with a favourable prognosis in human breast cancer and melanoma. In breast and ovarian cancer nm23 expression is also correlated with lymph node involvement. We analysed the expression of nm23-H1 and -H2 in normal endometrium and in endometrial and cervical cancer by both Northern and Western blotting. Cellular localisation of Nm23-H1 was visualised by immunohistochemistry mostly in the cytoplasm. Both isoforms of Nm23 were present in all the samples analysed, and a clear direct correlation between Nm23-H1 and -H2 levels was evident. Median nm23-H2 levels were higher than than -H1 levels in both tissues. Cervical cancer patients with lymph node involvement were shown to have significantly lower protein levels of Nm23 (P < 0.007 for H1 and P < 0.009 for H2), and a similar trend was also evident in endometrial cancer. Furthermore, the degree of myometrial invasion in endometrial cancer patients was also inversely correlated with Nm23-H1 levels of expression (P < 0.003). Nm23 level may therefore be taken into consideration as a new marker in the prognostic characterisation and in the treatment planning of uterine tumour patients.

p53 overexpression is associated with cytoreduction and response to chemotherapy in ovarian cancer

The aim of this study was to assess the association of p53 status with primary cytoreduction, response to chemotherapy and outcome in stage III-IV primary ovarian cancer patients. Immunohistochemical analysis of p53 was performed on formalin-fixed, paraffin-embedded specimens from 168 primary ovarian carcinomas by using the DO-7 monoclonal antibody. p53 nuclear positivity was found in 84 out of 162 (52%) malignant tumours. A higher percentage of p53 nuclear positivity was observed in patients with advanced stage of disease than in stage I-II (57% vs 23% respectively; P = 0.0022) and in poorly differentiated versus well/moderately differentiated tumours (59% vs 32% respectively; P = 0.0038). The multivariate analysis aimed to investigate the association of FIGO stage, grade and p53 status with primary cytoreduction in 136 stage III-IV patients showed that stage IV disease may influence the possibility to perform primary cytoreduction in ovarian cancer patients. p53-positivity also maintained a trend to be associated with poor chance of cytoreduction. In patients who underwent pathologic assessment of response, cases who did not respond to chemotherapy were much more frequently p53-positive than p53-negative (86% vs 14% respectively; P = 0.012). Moreover, patients with stage III disease and < 2-cm residual tumour were more likely to respond to treatment. In multivariate analysis, FIGO stage and p53 expression were independently correlated with pathologic response to chemotherapy. Time to progression and survival rates were shown not to be different in p53-positive versus p53-negative patients.

Analysis of 138 consecutive ovarian cancer patients: incidence and characteristics of familial cases

Eight families with two or more first-degree relatives affected with ovarian carcinoma were identified among a series of 138 consecutive ovarian cancer patients. History of breast cancer was reported in six of the eight families. Five of 19 patients with familial cancer developed ovarian cancer as a second primary tumor following breast carcinoma, whereas only 6/130 sporadic cases had a previous history of breast cancer. No significant difference was detected in clinical and pathological features between sporadic and familial cases. However, in three high-risk families ovarian cancer tended to develop at a younger age compared with other familial cases and with sporadic occurrences, and nulliparity was less frequent in the familial group. These observations emphasize the need to take into account multiple factors-in addition to positive family history-for the evaluation of genetic predisposition to ovarian carcinoma.

The pelvic retroperitoneal approach in the treatment of advanced ovarian carcinoma

OBJECTIVE

To evaluate the feasibility, complications, and clinical role of pelvic cytoreduction using the retroperitoneal approach in the treatment of advanced ovarian cancer.

METHODS

We studied 66 women with previously untreated advanced ovarian cancer who underwent pelvic retroperitoneal surgery. The possibility of achieving extrapelvic cytoreduction (residual disease less than 2 cm), involvement of the Douglas cul-de-sac or vesicouterine fold, or the presence of a frozen pelvis were indications for the retroperitoneal approach. Operative time, blood loss and transfusions, perioperative complications, and postoperative stay were analyzed prospectively. The performance status of each patient was assessed preoperatively and postoperatively.

RESULTS

The pelvic retroperitoneal approach was used in 66 of 147 (45%) consecutive patients who underwent primary surgery with intent of cytoreduction. This approach was necessary in 60 of 94 (64%) patients with residual tumor less than 0.5 cm and contributed to achieving such a minimal residual disease in 36 of 38 (95%) stage IIB-IIIB and 58 of 109 (53%) IIIC-IV patients. Severe morbidity, but with no long-term sequelae, occurred in six (9%) patients. Before surgery, only ten (15%) of these patients had a performance status grade 0-1, 21 (32%) had grade 2, and 35 (53%) grade 3-4. After surgery, these figures were 52 (79%), 14 (21%), and 0, respectively. The 5-year survival rate was 37%, with a median survival and follow up time of 27 months (range 4-98) and 43 months, respectively.

CONCLUSION

If the proper technique is used, complete pelvic cytoreduction is always feasible and morbidity is acceptable. In our series, it was necessary to approach the pelvis retroperitoneally in 64% of optimally cytoreduced patients, which suggests that this technique has an important clinical role in the treatment of patients with advanced ovarian cancer.

Immunogenicity of allo-vesicle carrying ERBB2 tumor antigen for dendritic cell-based anti-tumor immunotherapy

Dendritic cells (DCs) are able to orchestrate innate and acquired immunity and can activate and sustain a long-lasting anti-tumor immune response in vivo when used as anti-tumor cell therapy. The selection of the antigen and the choice of its formulation are key points in designing anti-cancer DC-based vaccines. Cell released vesicles/exosomes have been shown to transfer antigens, HLAI/peptide complexes and co-stimulatory molecules to recipient cells. In this study we describe the generation of an allogenic microvesicle cell factory in which the expression of a specific tumor antigen was combined to the expression of co-stimulatory and allogeneic molecules. The DG75 lymphoblastoid cell line was selected as microvesicle producer and transfected with ErbB2, as tumor antigen prototype. The shed microvesicles transferred antigenic components to recipient DCs, increasing their immunogenicity. DC pulsing resulted in cross-presentation of ErbB2 both in HLAI and HLAII compartments, and ErbB2-specific CD8+ T cells from cancer patients were activated by DCs pulsed with vesicle-bound ErbB2. The microvesicle cell factory proposed may represent a source of cell free immunogen to be used for DC-based cancer therapy.

Pelvic and aortic lymphadenectomy

Pelvic and aortic lymphadenectomy for gynecologic malignancies has changed from a random "picking" of some pelvic and aortic lymph nodes to a well-established technique based on adequate knowledge of the patterns of spread of the primary tumor. The identification of the node groups to remove, the number of nodes to count, and the border of dissection in the different clinical situations make pelvic and aortic lymphadenectomy a reproducible surgical intervention. The large experience accumulated over the years has greatly improved the technique and perioperative and complication management. The improved knowledge of the natural history of gynecologic tumors has refined the indications for lymph node dissection. Today, pelvic and aortic lymphadenectomy is primarily a staging procedure. The therapeutic value of lymphadenectomy is recognized in the surgical treatment of cervical cancer, but it is still under evaluation in ovarian and endometrial tumors.

Menstrual and hormone patterns in women treated with high-dose cisplatin and bleomycin

Menstrual and hormone patterns were investigated in 10 fertile women (median age 37, range 25-43 years) with locally advanced cervical cancer treated with neoadjuvant chemotherapy (CT). CT consisted of two cycles of high-dose cisplatin (CDDP, 40 mg/m2, Days 1 to 4) and bleomycin (B, 15 mg/m2, Days 1 and 8) separated by an interval of 21 days. Menstrual patterns before and during CT were recorded. FSH, LH, estradiol, and progesterone were assayed on the day that treatment was begun, after 2 and 4 days of CDDP administration, and weekly between and after the two cycles. Hormone assays during the first week of CT showed no significant change in hormone levels. After the first course of CT, five patients showed hypergonadotrophic amenorrhea and five patients maintained menses, two showing ovulatory and three showing follicular phase hormone patterns. After the second course of CT, one more patient become amenorrheic, and endocrine follow-up showed that two patients maintained hypergonadotrophic amenorrhea, four with hypergonadotrophic amenorrhea had a return of hormone levels to the follicular range of 7-9 weeks after, three maintained follicular phase hormone patterns until operation, and one ovulated. Gonadal dysfunction should be included among the side effects of high-dose CDDP and B regimens.