Translational randomized phase II trial of cabozantinib in combination with nivolumab in advanced, recurrent, or metastatic endometrial cancer

BACKGROUND

Combining immunotherapy and antiangiogenic agents is a promising treatment strategy in endometrial cancer. To date, no biomarkers for response have been identified and data on post-immunotherapy progression are lacking. We explored the combination of a checkpoint inhibitor (nivolumab) and an antiangiogenic agent (cabozantinib) in immunotherapy-naïve endometrial cancer and in patients whose disease progressed on previous immunotherapy with baseline biopsy for immune profiling.

PATIENTS AND METHODS

In this phase II trial (ClinicalTrials.gov NCT03367741, registered December 11, 2017), women with recurrent endometrial cancer were randomized 2:1 to nivolumab with cabozantinib (Arm A) or nivolumab alone (Arm B). The primary endpoint was Response Evaluation Criteria in Solid Tumors-defined progression-free survival (PFS). Patients with carcinosarcoma or prior immune checkpoint inhibitor received combination treatment (Arm C). Baseline biopsy and serial peripheral blood mononuclear cell (PBMC) samples were analyzed and associations between patient outcome and immune data from cytometry by time of flight (CyTOF) and PBMCs were explored.

RESULTS

Median PFS was 5.3 (90% CI 3.5 to 9.2) months in Arm A (n=36) and 1.9 (90% CI 1.6 to 3.4) months in Arm B (n=18) (HR=0.59, 90% CI 0.35 to 0.98; log-rank p=0.09, meeting the prespecified statistical significance criteria). The most common treatment-related adverse events in Arm A were diarrhea (50%) and elevated liver enzymes (aspartate aminotransferase 47%, alanine aminotransferase 42%). In-depth baseline CyTOF analysis across treatment arms (n=40) identified 35 immune-cell subsets. Among immunotherapy-pretreated patients in Arm C, non-progressors had significantly higher proportions of activated tissue-resident (CD103+CD69+) ɣδ T cells than progressors (adjusted p=0.009).

CONCLUSIONS

Adding cabozantinib to nivolumab significantly improved outcomes in heavily pretreated endometrial cancer. A subgroup of immunotherapy-pretreated patients identified by baseline immune profile and potentially benefiting from combination with antiangiogenics requires further investigation.

A randomized phase II study of cabozantinib and nivolumab versus nivolumab in recurrent endometrial cancer

6010

Background: The efficacy of treatment for recurrent endometrial cancer (EC) remains limited. Vascular endothelial growth factor and inflammatory chemokines are proangiogenic factors and immune modulators involved in immune suppression. Reprogramming the tumor microenvironment by combining antiangiogenic and immunotherapy (IO) could enhance antitumor responses. Methods: A 2:1 randomized phase 2 trial compared the combination of cabozantinib and nivolumab (Arm A) versus nivolumab (Arm B) in recurrent EC. Primary endpoint was progression free survival (PFS) assessed by RECIST 1.1 (NCT03367741). Women with recurrent measurable EC were eligible. There were no limits on prior therapy, but at least one prior platinum-based chemotherapy was required. Patients (pts) were stratified according to MSI status and assessed by CT every 8 weeks. Cabozantinib was given at 40 mg daily (Arm A) and nivolumab at 240 mg, on D1 and D15 of a 28-day cycle for 4 cycles, followed by 480 mg every 4 weeks (Arms A & B). Pts with carcinosarcoma or prior IO were enrolled in an exploratory cohort and received combination treatment (Arm C). A baseline biopsy was required for all pts. CyTOF analysis was performed on fresh biopsies. Results: 76 evaluable pts were enrolled (Arm A: 36, Arm B: 18, Arm C: 9 carcinosarcoma, and 20 post IO including 7 pts crossed over from Arm B). 55% of pts had received ≥3 prior lines of therapy. Two pts were MSI high in Arm A and none in Arm B. The Kaplan-Meier estimated median PFS was 5.3 (95% CI: 3.5-9.5) months in Arm A and 1.9 (95% CI: 1.6-3.8) months in Arm B, with a log-rank p = 0.07, which met the significance level of 0.1 used for sample size calculation. Objective response rate (ORR) was 25% for Arm A and 16.7% for Arm B; stable disease (SD) was seen in 44.4% vs 11.1%, respectively. Clinical benefit (ORR+SD) was significantly higher in arm A vs B (p < 0.001). In Arm C-carcinosarcoma, one patient had a partial response (11.9 months duration) and four SD. In Arm C-prior IO, six pts responded and eight had SD. The most common related AEs in Arm A were diarrhea (47.2%), elevated liver enzymes (44.4%), fatigue (38.9%), anorexia, hypertension, and nausea (30.6%), mainly grade 1/2. Preliminary CyTOF analysis across treatment arms identified multiple immune subsets for further interrogation including activated CD8+ and CD4+ T cells. Conclusions: Cabozantinib plus nivolumab demonstrates improved PFS compared to nivolumab in heavily pre-treated women with recurrent EC. In-depth CyTOF analysis of the tumor microenvironment to identify predictive immune biomarkers of response is ongoing. Clinical trial information: NCT03367741.

Distant recurrence in a patient with polyp-confined stage IA serous endometrial carcinoma treated with adjuvant chemotherapy: A case report and review of literature

Uterine serous carcinoma is a rare, high-risk histological subtype of endometrial cancer, and use of adjuvant treatment in early stage IA disease is inconsistent, especially when the tumor is confined entirely within an endometrial polyp. We herein present a case of extrauterine recurrence in a 67-year-old female with polyp-confined, stage IA uterine serous endometrial cancer. She underwent comprehensive surgical staging with the pathology returning a 5 cm uterine serous carcinoma confined completely to a 7 cm polyp with negative margins, negative myometrial and lymphovascular space invasion, and twenty-nine negative para-aortic and pelvic lymph nodes. She went on to complete six cycles of adjuvant carboplatin and paclitaxel. She presented with a new pleural effusion approximately 20 months after receiving definitive treatment, and a diagnosis of recurrent, metastatic uterine serous carcinoma was confirmed through cytology. A review of the literature suggests practice patterns involving adjuvant treatment for polyp-confined stage IA uterine serous carcinoma are highly variable. Prospective studies clarifying the utility of adjuvant treatment for polyp-confined disease in comprehensively staged patients, especially pertaining to the impact this pathology has on recurrence risk, are needed for these patients.

Abstract GMM-031: CLINICAL PATHOLOGIC EXPRESSION OF CELL CYCLE REGULATORY COMPLEXES IN HIGH GRADE SEROUS OVARIAN CARCINOMA

INTRODUCTION: Cell cycle control is an important determinant of cancer progression and treatment response. Two key transcriptional regulatory complexes, DREAM and MMB, ensure coordinated cell cycle dependent gene expression. Though these complexes contain the same protein core called MuvB, they have opposing functions. The DREAM (DP, RB-like, E2F, and MuvB) complex represses over 800 cell cycle genes in G0/G1 and the MMB (Myb-MuvB) complex promotes mitotic gene expression. High expression of B-Myb, an oncogenic transcription factor involved in the MMB complex, is associated with cell cycle deregulation and poor prognosis in several cancers, including ovarian cancer. High B-Myb expression disrupts DREAM formation in human cell lines, resulting in increased proliferation. Previous analysis of TCGA data showed that MYBL2 (encoding B-Myb) undergoes gene copy number gain in 55% of high grade serous ovarian cancer (HGSOC) tumor samples and is associated with poor overall survival. We sought to validate these findings with clinical specimens and to investigate the role of DREAM- and MMB-regulated gene expression in HGSOC patient outcomes.

METHODS: We used expression levels of DREAM-and MMB-controlled genes as a functional readout for the status of these opposing transcriptional regulators. This retrospective study utilized tissue bank surgical pathology and cytology samples taken from 52 HGSOC lesions. RT-qPCR gene expression analysis was correlated to clinical and pathologic findings. Demographic information, follow-up, treatment, and outcomes data (age, Stage, optimal debulking, platinum sensitivity, survival) was obtained by chart review. Analyses of TCGA datasets were conducted in parallel.

RESULTS: RT-qPCR analysis of DREAM target genes (AURKA, KIF23, CCNB2, and FOXM1) revealed positive and significant correlations between MYBL2 and all genes tested: AURKA (ρ=0.4114, p&lt;0.01), KIF23 (ρ=0.4953, p&lt;0.001), CCNB2 (ρ=0.3278, p&lt;0.05), and FOXM1 (ρ=0.5033, p&lt;0.001). Stage at diagnosis, optimal debulking, platinum sensitivity and survival did not associate with high or low expression of target genes. High FOXM1 expression was associated with longer progression free survival (p&lt;0.01). High CCNB2 (encoding cyclin B2) showed a trend (p=0.0643) with decreased overall survival, with a median time difference of 20 months between high (26 months) and low (46 months) groups. Analysis of TCGA HGSOC datasets revealed that DREAM and MMB target genes were significantly upregulated in the presence of high B-Myb expression (Fisher's exact test, p&lt;0.01). The top 49 upregulated genes associated with high MYBL2 in HGSOC analysis have been previously annotated as DREAM target genes (χ2 with Yates correction p&lt;0.001).

CONCLUSIONS: Increased expression of selected cell cycle genes correlates to increased formation of MMB, and reduced DREAM assembly in HGSOC tissue. High expression of MYBL2 is associated with deregulated cell cycle gene expression programs in HGSOC. Larger scale studies would clarify the clinical prognostic value of the DREAM- and MMB-regulated gene expression.

Citation Format: Audra N. Iness, Lisa Rubinsak, Jessica Chaoul, Mikhail Dozmorov, Cora Uram-Tuculescu, Larisa Litovchick, Sarah Temkin. CLINICAL PATHOLOGIC EXPRESSION OF CELL CYCLE REGULATORY COMPLEXES IN HIGH GRADE SEROUS OVARIAN CARCINOMA [abstract]. In: Proceedings of the 12th Biennial Ovarian Cancer Research Symposium; Sep 13-15, 2018; Seattle, WA. Philadelphia (PA): AACR; Clin Cancer Res 2019;25(22 Suppl):Abstract nr GMM-031.

A final report of a phase I study of veliparib (ABT-888) in combination with low-dose fractionated whole abdominal radiation therapy (LDFWAR) in patients with advanced solid malignancies and peritoneal carcinomatosis with a dose escalation in ovarian and fallopian tube cancers

BACKGROUND

The combination of low-dose radiation therapy with PARP inhibition enhances anti-tumor efficacy through potentiating DNA damage. We combined low-dose fractionated whole abdominal radiation (LDFWAR) with ABT-888 in patients with peritoneal carcinomatosis with a dose escalation in ovarian and fallopian cancer patients (OV).

METHODS

Patients were treated with veliparib, 40-400mg orally BID on days 1-21 of 3 28-day cycles on 6 dose levels. Dose levels 5 and 6 included only OV patients. LDFWAR consisted of 21.6Gy in 36 fractions, 0.6Gy twice daily on days 1 and 5 for weeks 1-3 of each cycle. Circulating tumor material and quality of life were serially assessed.

RESULTS

32pts were treated. Median follow-up was 45months (10-50). The most common treatment-related grade 3 and 4 toxicities were lymphopenia (59%), anemia (9%), thrombocytopenia (12%), neutropenia (6%), leukopenia (6%), nausea (6%), diarrhea (6%), anorexia (6%), vomiting (6%) and fatigue (6%). The maximum tolerated dose was determined to be 250mg PO BID. Median PFS was 3.6months and median OS was 9.1months. In OV patients, OS was longer for platinum-sensitive patients (10.9mo) compared to platinum-resistant patients (5.8mo). QoL decreased for all groups during treatment. Germline BRCA status was known for 14/18 patients with OV cancers, 5 of whom were BRCA mutation carriers. One objective response (3%) was observed.

CONCLUSION

ABT-888 plus LDFWAR is tolerable with gastrointestinal symptoms, fatigue and myelosuppression as the most common toxicities. The single observed objective response was in a germline BRCA mutated, platinum-sensitive patient.

Advances and Concepts in Cervical Cancer Trials: A Road Map for the Future

OBJECTIVE

Cervical cancer is responsible for more than a quarter of a million deaths globally each year, mostly in developing countries, making therapeutic advances in all health care settings a top priority. The Gynecologic Cancer InterGroup (GCIG) is a worldwide collaboration of leading national research groups that develops and promotes multinational trials in gynecologic cancer. In recognition of the pressing need for action, the GCIG convened an international meeting with expert representation from the GCIG groups and selected large sites in low- and middle-income countries.

METHODS

The focus was to develop a consensus on several concepts for future clinical trials, which would be developed and promoted by the GCIG and launched with major international participation. The first half of the meeting was devoted to a resume of the current state of the knowledge and identifying the gaps in need of new evidence, validating control arms for present and future clinical trials and identifying national and international barriers for studies of cervix cancers. The second half of the meeting was concerned with achieving consensus on a path forward.

RESULTS AND CONCLUSIONS

There were 5 principal outcomes as follows: first, a proposal to expand fertility-preserving options with neoadjuvant chemotherapy; second, validation of the assessment of sentinel lymph nodes using minimally invasive surgery with an emphasis on identification and management of low-volume metastasis, such as isolated tumor cells and micrometastasis; third, evaluation of hypofractionation for palliative and curative radiation under the umbrella of the GCIG Cervix Cancer Research Network; fourth, adding to the advances in antiangiogenesis therapy in the setting of metastatic disease; and fifth, developing a maintenance study among women at high risk of relapse. The latter 2 systemic interventions could study PI3K (phosphatidylinositol-3-kinase) inhibitors, immunotherapy, anti-human papillomavirus approaches, or novel antiangiogenic agents/combinations.

A Phase I study of veliparib (ABT-888) in combination with low-dose fractionated whole abdominal radiation therapy in patients with advanced solid malignancies and peritoneal carcinomatosis

PURPOSE

The combination of low-dose radiotherapy with PARP inhibition has been shown to enhance antitumor efficacy through potentiating DNA damage. We combined low-dose fractionated whole abdominal radiation (LDFWAR) with escalating doses of veliparib (ABT-888), a small-molecule PARP inhibitor, in patients with peritoneal carcinomatosis from advanced solid tumor malignancies.

EXPERIMENTAL DESIGN

Patients were treated with veliparib (80-320 mg daily) for a total of 3 cycles. LDFWAR consisted of 21.6 Gy in 36 fractions, 0.6 Gy twice daily on days 1 and 5 for weeks 1-3 of each cycle. Circulating tumor cells (CTC) were collected and evaluated for γ-H2AX. Quality of life (QoL) was assessed using the EORTC-QLQ-C30 questionnaire.

RESULTS

Twenty-two patients were treated. Treatment-related grade 3 and 4 toxicities included lymphopenia (68%), anemia (9%), thrombocytopenia (14%), neutropenia (4%), leukopenia (9%), ascites (4%), vomiting (4%), and dyspnea (4%). No objective responses were observed. Disease stabilization (≥24 weeks) was observed in 7 patients (33%). Median progression-free survival (mPFS) was 4.47 months and median overall survival (mOS) was 13.04 months. In the subset of 8 ovarian and fallopian cancers, mPFS was 6.77 months and mOS was 17.54 months compared with mPFS 2.71 months and mOS 13.01 months in others. Patients with ovarian and fallopian cancers had better QoL over time than those with other cancers. An increased percentage of γ-H2AX-positive CTCs was observed in a subset of patients (3/6 with >2 CTCs at baseline).

CONCLUSIONS

Combined veliparib and LDFWAR is a well-tolerated regimen that resulted in prolonged disease stability for some patients with advanced solid tumors and carcinomatosis, particularly in the ovarian and fallopian cancer subpopulation.

Abstract B197: Phase II, single-arm study of tasisulam-sodium (LY573636-sodium) as 2nd–4th line therapy for platinum resistant ovarian cancer

Background: Tasisulam-sodium (tasisulam) is a novel anti-cancer agent that induces mitochondrial mediated apoptosis and anti-angiogenesis. The mechanism of action is being further evaluated. Phase I trials defined the dose and schedule for this agent and suggested activity in chemotherapy-resistant ovarian cancer (OvCa).

Methods: Patients (Pts) with no more than 2 prior systemic regimens for platinum-resistant OvCa received tasisulam by 2-hour intravenous infusion every 21 days, targeting a maximum concentration (Cmax) of 420 µg/mL. The primary endpoint was objective response rate (ORR). Secondary endpoints were clinical benefit rate [(CBR = complete response (CR) + partial response (PR) + stable disease (SD)], progression-free survival (PFS), overall survival (OS) and safety.

Results: From February 2007– May 2008, 55 pts were enrolled [median age of 55 years (range: 27–78); ECOG PS of 0–2]. Fifty pts had measurable disease by RECIST. A median of 3 cycles (range: 1–18) was administered. Hematologic adverse events (AEs) were the most common grade (G) 3/4 AEs, regardless of causality. G 3/4 thrombocytopenia or neutropenia occurred in 7.3%/20.0% and 12.7%/14.5% of pts, respectively. Febrile neutropenia occurred in 3.6% of pts, and G 3/4 anemia in 12.7%/1.8%. Other G 3/4 non-hematologic AEs in ≥ 2% of pts included infections (12.7%), pain (10.9%), metabolic abnormalities (14.5%), vomiting (7.3%), GI obstruction (5.6%) and dehydration and renal failure (3.6% each). Five deaths occurred on study (or within 30 days of discontinuation), 3 of which were confounded by complications of the underlying disease. A total of 8 investigator-assessed (RECIST) responses were reported in the 50 patients with measurable disease, and 6 were confirmed, for a response rate of 12.0% (90% CI: 4.4–19.6). Another 17 pts (34.0%) had SD for a CBR of 46% (90% CI: 34.4–57.6%). Median PFS was 1.9 months (90% CI: 1.5–3.0; 16.4% censored) and median OS was 12.9 months (90% CI: 8.6–17.7; 47.3% censored) in the 55 enrolled pts. Study is on-going with 3 pts still on treatment.

Conclusion: Tasisulam has encouraging activity in platinum-resistant OvCa. An alternative treatment schedule is currently being explored in this patient population to minimize the risk of serious myelosuppression while preserving efficacy.

Citation Information: Mol Cancer Ther 2009;8(12 Suppl):B197.

Does equal treatment yield equal outcomes? The impact of race on survival in epithelial ovarian cancer

OBJECTIVE

To determine if race impacts the survival of patients with epithelial ovarian cancer in a large academic medical center.

METHODS

Demographic and clinical-pathologic information from patients treated at the University of Chicago from 1992-2007 were analyzed. Continuous variables were analyzed with t tests and categorical variables with chi square tests. Survival curves were evaluated using Kaplan-Meier methods and Cox proportional hazard models were constructed for both overall and disease free survival.

RESULTS

209 women with epithelial ovarian cancer were included in the study, 163 (78%) white and 46 (22%) African American. The baseline demographic characteristics and clinico-pathologic factors such as disease stage, grading, CA-125 levels, rates of optimal debulking (<1 cm residual tumor), platinum sensitivity and American Society of Anesthesiologists score (ASA) were similar between the groups. The median overall survival for African American women was similar: 37.2 months (95% Confidence Interval (CI): 22.5, 52.9) while it was 34.1 months (95% CI: 27.4, 42.6) for white women.

CONCLUSIONS

There is no evidence of a racial disparity in either treatment or survival for ovarian cancer patients treated at a large academic center. Given that large epidemiologic studies suggested a difference in survival between African American and white women, other sources of disparities must be sought.

Type 2 11beta-hydroxysteroid dehydrogenase activity in human ovarian cancer

In the ovary cortisol-cortisone inter-conversion is catalyzed by the enzyme 11beta-hydroxysteroid dehydrogenase (11beta-HSD). Its role in carcinomas of human ovary is unknown. The majority of ovarian cancers are derived from ovarian surface epithelium and the inflammation caused by successive ovulation seems to a play a role in the development of cancer. Cortisol is known to act as anti-inflammatory agent and its metabolism by type 1 and type 11beta-HSD may control the inflammatory action by cortisol in ovary. We undertook this study to investigate type 2 11beta-HSD activity which functions exclusively oxidative direction, in normal ovarian tissue compared to ovarian epithelial cancer. Ovarian tissue was obtained from patients undergoing hysterectomy for both benign and malignant disease. Tissue was placed immediately on dry ice and subsequently transferred to a freezer where they were maintained at -70 degrees C. NAD dependent 11beta-HSD activity was then determined in this tissue. T-test was performed to determine statistical significance. Mean type 2 enzyme activity was 0.87 +/- 1.65 pmol/min g tissue in normal ovarian tissue versus a mean enzyme activity of 2.96 +/- 1.37 pmol/mim g tissue in from cancer specimens. This difference was statistically significant with a p-value of 0.03. Type 2 1beta-HSD activity in ovarian cancer specimens was significantly higher than enzyme activity measured in normal post-menopausal ovarian tissue. Decreased cortisol levels due type 2 1beta-HSD activity may play a role neoplastic transformation as well as tumor proliferation in ovarian cancer by eliminating anti-inflammatory action of cortisol.

Small bowel volvulus after uterine artery embolization requiring bowel resection: a case report

BACKGROUND

Previously described surgical complications following uterine artery embolization for leiomyomata include sequelae of uterine aberrant embolization (buttock and labial necrosis, vesicouterine fistula), prolapsed cervical myoma, uterine necrosis, ischemic uterine rupture and sepsis.

CASE

A 43-year-old woman presented with severe abdominal pain, nausea and vomiting 7 days after bilateral uterine artery embolization for symptomatic leiomyomata. Mechanical obstruction of the distal ileum was diagnosed and did not respond to conservative measures. At laparotomy, volvulus of the distal ileum, which adhered to omental and uterine adhesions, required resection and end-to-end anastomosis.

CONCLUSION

Volvulus may occur following uterine artery embolization for leiomyomata.

NAD Dependent 11β-Hydroxysteroid Dehydrogenase Activity in Human Endometrium and Endometrial Tumors

BACKGROUND

The isoforms of 11beta-hydroxysteroid dehydrogenase (11beta-HSD) types 1 and 2, regulated by ovarian steroids, catalyze the interconversion of glucocorticoids and their 11-keto metabolites. The role of these enzymes in malignancies of human endometrium is unknown. We compare NAD dependent 11beta-HSD (type 2) activity levels among normal human endometrium and endometrial carcinomas of differing grades and histologies.

METHODS

NAD dependent 11beta-HSD activity was determined in endometrial tissue obtained from patients undergoing hysterectomy for benign or malignant disease (endometroid, serous and carcinosarcomas). Student's t test was utilized with p < 0.05 considered significant. Data are presented as mean +/- SD.

RESULTS

NAD dependent 11beta-HSD activity was present in all endometrial samples. The activities were 0.61+/- 0.27 in normal (n = 9), 0.43 +/- 0.29 in endometrioid endometrial carcinoma (n = 14), 0.50 +/- 0.26 in uterine serous carcinoma (n = 6) and 0.25 +/- 0.37 in carcinosarcomas (n = 9). NAD dependent 11beta-HSD activity was lower in the carcinosarcoma group as compared to normal endometrial tissue (p = 0.03).

CONCLUSIONS

NAD dependent type 2 11beta-HSD activity was demonstrated in all normal and endometrial tumors. Enzyme activity in endometroid and uterine serious carcinoma tumors was similar to enzyme activity in normal endometrium. In contrast, carcinosarcomas show significantly lower enzyme activity compared to normal tissue.

11beta-Hydroxysteroid dehydrogenase activity in pregnancies complicated by hydatidiform mole

PROBLEM

11beta-Hydroxysteroid dehydrogenase (11beta-HSD) plays an important role in regulating active glucocorticoid reaching the fetus. In normal pregnancy, placental 11beta-HSD functions primarily in oxidative direction. Placental tissue of patients with pregnancies complicated by pre-eclampsia exhibit significantly lower type 1 and 2 11beta-HSD activities and significantly high cortisol level in cord blood suggesting fetal exposure to higher level of active glucocorticoids. The activity of 11beta-HSD in gestational trophoblastic disease has not been determined. The objective of this study was to assess 11beta-HSD activity in tissue from normal second trimester and pregnancies complicated by hydatidiform mole.

METHOD OF STUDY

Normal placental tissues were obtained from patients undergoing termination of pregnancy, and from patients undergoing uterine evacuation for hydatidiform mole. Both nicotinamide adenine dinucleotide (NAD)- and nicotinamide adenine dinucleotide phosphate (NADP)-dependent activities were assayed in central villous tissue. Comparison of groups was performed using Student's t-test. A P-value of 0.05 was considered significant. Data are presented as mean +/- S.D.

RESULTS

Tissue obtained from five patients with pathology-proven hydatidiform mole demonstrated significantly lower 11beta-HSD activities compared with placental tissue obtained from normal pregnancies. The mean NAD-dependent 11beta-HSD activity in normal placentas was 386 +/- 109 pmol/min/g placenta and in hydatidiform mole was 74 +/- 54 pmol/min/g placenta (P < 0.01). The mean NADP-dependent 11beta-HSD activity in normal placentas was 370 +/- 120 pmol/min/g placenta and in trophoblastic disease was 68 +/- 69 pmol/min/g placenta (P < 0.01).

CONCLUSION

Our data indicate significant impairment in the ability of hydatidiform mole tissue to inactivate glucocorticoids.

Peripartum disseminated extrapulmonary tuberculosis simulating ovarian carcinoma

Disseminated extrapulmonary tuberculosis is an uncommon complication of pregnancy. We present a 26-year-old multiparous immigrant from Haiti who was admitted following an extramural preterm delivery. Marked ascites was confirmed by computerized tomography, which also revealed a thickened greater omentum. These findings were considered suggestive of advanced ovarian carcinoma, although extrapulmonary tuberculosis was also considered despite negative tuberculin skin test screening. Image-guided omental biopsy demonstrated caseating granulomas substantiating the diagnosis of abdominal tuberculosis, which was later confirmed by cultures. The patient responded well to antituberculosis medications. This case describes the unusual peripartum presentation of abdominal tuberculosis simulating advanced ovarian carcinoma, and demonstrates the importance of considering extrapulmonary tuberculosis when encountering ascites and omental thickening during pregnancy despite negative tuberculin skin test screening.

Attenuation and dispersion of sound in dilute suspensions of spherical particles

This paper considers sound propagation in dilute suspensions of constant-mass particles that can translate and pulsate under the effects of a small amplitude sound wave. A new theory for sound attenuation and dispersion is developed on the basis of the changes of the suspension's compressibility produced by the relative motions between host fluid and particles. The approach, used earlier to treat propagation in rigid-particle suspensions, decouples the propagation problem from the more difficult problem of obtaining accurate descriptions for the fluid-particle interactions. In this work the role of the pulsational motion is included in the theoretical framework. The resulting theory is thus applicable to aerosols, bubbly liquids, emulsions, and hydrosols composed of elastic particles, and includes, as a special limit, rigid-particle suspensions. The results are expressed in terms of three complex quantities that describe, respectively, the particles' translational velocity, temperature, and pressure, relative to their counterparts in the fluid. Theoretical results for these quantities, applicable in wide frequency ranges, are available from previous studies [Temkin and Leung, J. Sound Vib. 49, 75-92 (1976), Temkin, J. Fluid. Mech. 380, 1-38 (1999)]. Together with the compressibility theory presented here, they provide a more general description of propagation in dilute suspensions than presently available. In the case of aerosols and hydrosols, the theory produces known results for the attenuation and the sound speed. For bubbly liquids and emulsions the new results presented here differ from those available in the literature. The differences are traced to the neglect in the existing theories of the acoustic pressure disturbance produced by the pulsations of the particles.