Final report on serial phase II trials of all-intraperitoneal chemotherapy with or without bevacizumab for women with newly diagnosed, optimally cytoreduced carcinoma of Müllerian origin.

BACKGROUND: Intraperitoneal (IP) chemotherapy can improve outcomes for women with optimally cytoreduced epithelial ovarian cancer but toxicities are a concern. We conducted 2 phase 2 trials of an IV/IP regimen using carboplatin and paclitaxel without (Trial A) and with bevacizumab (Trial B). METHODS: Both trials consisted of carboplatin AUC 6 day 1, and paclitaxel 60 mg/m2 on days 1,8, 15 of a 21-day cycle; in Trial B, patients received IV bevacizumab 15 mg/kg every cycle starting cycle 2. Chemotherapy was administered IV for cycle 1 and then IP for all subsequent cycles. Primary objectives included safety and tolerability, pathologic CR rate (Trial A), and the rate of completion of IP cycles of therapy (Trial B). Progression-free (PFS), overall survival (OS), and pharmacokinetic analysis were secondary endpoints. RESULTS: 81 patients were treated on both trials (n = 40 and 41 in trials A and B, respectively). Median age for trials A and B was 59 (range, 36-76) and 55 (range, 19-69) years, respectively. 68% and 85% of patients, respectively for A and B, completed at least 4 cycles of treatment in both trials. Treatment with bevacizumab resulted in higher rates of grade 3 fatigue (37 versus 33%) and grade 3-4 diarrhea (22 versus 8%). Median PFS was 23.5 (95%CI 16.2-35.3) and 25 (95%CI 16.4-42.7) months, respectively; median OS was 68 (95%CI 49.5-NR) and 79.7 (95%CI 59.0-79.7) months, respectively for Trial A and B. CONCLUSIONS: Weekly administered IP carboplatin and IP paclitaxel is tolerable and safe with similar activity with and without concommittant bevacizumab in these 2 trials.

Quality assessment and data analysis for microRNA expression arrays.

MicroRNAs are small (approximately 22 nt) RNAs that regulate gene expression and play important roles in both normal and disease physiology. The use of microarrays for global characterization of microRNA expression is becoming increasingly popular and has the potential to be a widely used and valuable research tool. However, microarray profiling of microRNA expression raises a number of data analytic challenges that must be addressed in order to obtain reliable results. We introduce here a universal reference microRNA reagent set as well as a series of nonhuman spiked-in synthetic microRNA controls, and demonstrate their use for quality control and between-array normalization of microRNA expression data. We also introduce diagnostic plots designed to assess and compare various normalization methods. We anticipate that the reagents and analytic approach presented here will be useful for improving the reliability of microRNA microarray experiments.

Collagen-induced proMMP-2 activation by MT1-MMP in human dermal fibroblasts and the possible role of alpha2beta1 integrins.

Culture of human dermal fibroblasts within a three-dimensional matrix composed of native type I collagen fibrils is widely used to study the cellular responses to the extracellular matrix. Upon contact with native type I collagen fibrils human skin fibroblasts activate latent 72-kDa type IV collagenase/ gelatinase (MMP-2) to its active 59- and 62-kDa forms. This activation did not occur when cells were cultured on plastic dishes coated with monomeric type I collagen or its denatured form, gelatin. Activation could be inhibited by antibodies against MT1-MMP, by the addition of TIMP-2 and by prevention of MT1-MMP processing. MT1-MMP protein was detected at low levels as active protein in fibroblasts cultured as monolayers. In collagen gel cultures, an increase of the active, 60-kDa MT1-MMP and an additional 63-kDa protein corresponding to inactive MT1-MMP was detected. Incubation of medium containing latent MMP-2 with cell membranes isolated from fibroblasts grown in collagen gels caused activation of the enzyme. Furthermore, regulation of MT1-MMP expression in collagen cultures seems to be mediated by alpha2beta1 integrins. These studies suggest that activation of the proMMP-2 is regulated at the cell surface by a mechanism which is sensitive to cell culture in contact with physiologically relevant matrices and which depends on the ratio of proenzyme and the specific inhibitor TIMP-2.

Preparation of uniform, intact DNA samples from resected tumor tissues for pulsed-field gel electrophoretic analyses.

Preparation of high molecular weight DNA from resected tumor tissues suitable for pulsed-field gel electrophoresis (PFGE) can be complicated by the presence of nonviable cells and lymphocytes. We have developed a simple procedure to reduce the level of degraded DNA in PFGE DNA samples prepared from resected tumor tissues. The procedure employs a single, three component Percoll step gradient centrifugation and can be performed on several tumor samples simultaneously. Analyses of DNAs from 15 tumor specimens (7 solid tumors and 8 aspirated fluids) demonstrate that the technique enriches the integrity of PFGE DNA samples. Morphologic evaluation of 9 specimens suggested that both cellular debris and contaminating normal lymphocytes are removed from starting cell populations during the enrichment procedure. Fractionation of cells also reduced cell clumping, allowing for the formation of more uniform PFGE DNA samples.

Vesicovaginal fistula revisited.

Vesicovaginal fistulas remain common and serious problems for women in West Africa. Thirty-six surgical repairs done during visiting professorships by American gynecologists between the years 1978-1987 are documented. The overall success rate was 70%. The management of large (greater than 4 cm) obstetric fistulas was especially difficult until the Latzko technique was abandoned for the technique of wide mobilization of vaginal flaps over the fistula site. This technique reduced the failure rate from 75% through 1986 to approximately 25% in 1987. Ongoing controversies and basic principles of surgical techniques in fistula repair are reviewed.

Contribution of endocervical curettage in evaluating abnormal cervical cytology.

A review of 540 patients evaluated by the Gynecologic Colposcopy Clinic for abnormal cervical cytology revealed that 372 (68.9%) had cervical intraepithelial neoplasia (CIN), microinvasive carcinoma, or frank invasive carcinoma. The repeat cytologic smear taken before biopsy was falsely negative in 26.4%. An endocervical curettage was obtained in 52.5% of patients with an adequate colposcopy who had a neo-plastic lesion and was positive in 17.9% of those sampled, including six patients with no lesion found on the ectocervix. An endocervical curettage was obtained in 88.5% of patients with an inadequate colposcopy who had a neoplastic lesion, and was positive in 48.7%. All patients with an inadequate colposcopy not having an endocervical curettage underwent conization of the cervix. Twelve patients (2.2%) were ultimately found to have invasive or microinvasive carcinoma. A positive endocervical curettage and an inadequate colposcopy were both correlated with a final diagnosis of invasion. The contribution of endocervical curettage to the outpatient work-up of abnormal cervical cytology is substantial and it should be performed in all patients in whom cone biopsy is not planned.

Reported ovarian cancer screening among a population-based sample in Washington state.

OBJECTIVE: To assess the prevalence of reported ovarian cancer screening among a population-based sample of women from Washington state and identify factors that influence the decision to be screened. METHODS: A population-based sample of 6749 women aged 54-84 years, living in 40 predominately rural communities in Washington state, was surveyed about their utilization of ultrasonography and CA 125 for ovarian cancer screening. We also assessed relevant demographic, family history, psychosocial, and health behavior variables. RESULTS: After exclusions, data from 4938 respondents were available. Two percent (n = 96) reported having been screened. Multiple logistic regression identified ovarian cancer worry, contact with an obstetrician-gynecologist, and family history of ovarian cancer as independently associated with screening. Based on self-reported family histories, 27 women had pedigrees consistent with high risk of ovarian cancer, but none of those women reported having been screened. CONCLUSION: Ovarian cancer screening is rare. Women at high risk of it might not be getting recommended screening.

Claudication as a rare symptom of recurrent cervical carcinoma.

Diagnosis of recurrent cervical cancer can be very difficult in the heavily irradiated pelvis. Sciatica and lymphedema are well-known symptoms of disease recurrent to the side wall. The isolated symptom of claudication is reported as an early sign of recurrence. Two patients are presented in whom claudication was the only early presenting symptom. This symptom in a patient with a history of a gynecologic malignancy should lead to an evaluation for recurrent cancer as well as the routine vascular studies.

The incidence of urogenital Chlamydia trachomatis infections among patients in Kumasi, Ghana.

The incidence of urogenital chlamydia infections among selected patients in Kumasi, Ghana was evaluated using an immunofluorescent monoclonal antibody technique. Chlamydia trachomatis was identified in 4 of 110 patients presenting for prenatal care, 2 of 55 female patients with infertility and 6 of 15 males with acute urethritis. The findings demonstrate that C. trachomatis is a frequently identified pathogen among male patients presenting with symptoms of acute urethritis; however, the incidence of chlamydia infections among asymptomatic patients is relatively low.

PIP: The incidence of urogenital chlamydia infections among selected patients in Kumasi, Ghana was evaluated using an immuno-florescent monoclonal antibody technique. Chlamydia trachomatis was identified in 4 of 110 patients presenting for prenatal care, 2 of 55 female patients with infertility and 6 of 15 males with acute urethritis. The findings demonstrate that C. trachomatis is a frequently identified pathogen among male patients presenting with symptoms of acute urethritis; however, the incidence of chlamydia infections among asymptomatic patients is relatively low. Sites for the study were the University of Science and Technology and the Komfo Anokye Teaching Hospital in Kumasi. These findings suggest that C. trachomatis is an important pathogen in sexually transmitted infection in Kumasi, Ghana; isolation rates from this area are consistent with those reported from western countries. An asymptomatic carriage rate of 3.6% is similar to that reported from nearby Accra. The present study did not demonstrate an increased incidence of C. trachomatis infections among patients with infertility, as has been noted in other studies. However, the etiology of infertility in these patients was not fully evaluated and prior chlamydial infections might have occurred.

Metastatic placental site trophoblastic tumor: long-term remission in a patient treated with EMA/CO chemotherapy.

OBJECTIVE: We document a case of long-term remission in a patient with metastatic placental site trophoblastic tumor (PSTT) and attempt to determine the response rate of metastatic PSTT to EMA/CO (etoposide, methotrexate, actinomycin-D, cyclophosphamide, and vincristine) combination chemotherapy based on available reports. METHODS: Medical records, histological slides, and radiological films were reviewed for a patient with metastatic PSTT diagnosed in 1991. Using Medline and cross-references, pertinent articles were reviewed. RESULTS: A 31-year-old patient with PSTT metastatic to the lungs and vagina is presently alive, without evidence of recurrent cancer, more than 6 years after treatment with EMA/CO chemotherapy and surgery. The total response rate for seven patients with metastatic PSTT treated with EMA/CO chemotherapy was 71% with a complete response rate of 28%. CONCLUSIONS: Metastatic PSTT is potentially curable. EMA/CO chemotherapy appears superior to older multiagent regimens used in treating PSTT.

Comparison of the pattern of metastatic spread of squamous cell cancer and adenocarcinoma of the uterine cervix.

Retrospective review of medical records and autopsy findings in patients dying of squamous cell cancer or adenocarcinoma of the uterine cervix was undertaken to evaluate for possible differences in biologic behavior between these tumor types. Twenty-one patients with each tumor type were evaluated. Patients with adenocarcinoma were found to have a higher incidence of tumor involvement of the paraaortic lymph nodes (13/21 vs 6/20, P less than 0.05), uterine corpus (17/17 vs 12/20, P less than 0.05), and adrenal gland (7/21 vs 0/21, P less than 0.005). Presence of ascites (9/21 vs 2/21, P less than 0.05) and hydrothorax (9/21 vs 3/21, P less than 0.05) was also significantly more frequent in patients with adenocarcinoma. These findings suggest that this tumor may behave differently in regard to pattern of metastatic spread or response to therapy. The therapeutic implications of these findings deserve further study.

Use of a stochastic simulation model to identify an efficient protocol for ovarian cancer screening.

The intervention protocol for an ovarian cancer screening trial should be efficient as well as effective, because it may become the standard of care if the trial demonstrates mortality reduction. To identify an efficient ovarian cancer screening protocol, the effectiveness and cost-effectiveness of selected single modality and multimodal screening strategies were estimated using a stochastic simulation model. Screening was simulated over a 30-year period in a hypothetical cohort of 1 million women aged 50 at the beginning of the period. The net present value of the cost per year of life saved was estimated for six protocols involving transvaginal sonography (TVS) and/or the tumor antigen CA 125. Internal and external validation was performed, and sensitivity analyses were conducted to assess the robustness of the ranking of the strategies. A multimodal strategy involving CA 125 with a threshold for positivity of either elevation above 35 U/ml or doubling since the previous screen, followed by TVS only if CA 125 is positive, was found to be efficient in the sense that no other strategies saved as many years of life at lower cost per year of life saved. Used annually, this strategy cost under $100,000 per year of life saved over a range of assumptions. The model's predictions are consistent with results reported in the literature regarding the performance of TVS and CA 125. The multimodal strategy used annually or every six months was efficient compared to either ultrasound or CA 125 used alone, over a range of assumptions. Simulation of screening may be useful in selecting a screening protocol to be tested in a randomized controlled trial.

Rectal prolapse in women with other defects of pelvic floor support.

OBJECTIVES: We describe a series of patients with rectal prolapse who had other pelvic floor defects. STUDY DESIGN: Patients with rectal prolapse that we examined between 1990 and 2000 were reviewed. RESULTS: During this time frame 55 patients with rectal prolapse were seen by one of us. Fifty-two of these patients had other defects of pelvic floor support and are the subject of this report. The diagnosis was established in all patients with video defecography. Thirty-nine of the patients had internal (occult) prolapse that simulated either a rectocele or an enterocele. The mean number of surgical procedures for pelvic floor support before the diagnosis of rectal prolapse was 1.5. Thirty-one patients underwent a sigmoid resection with rectopexy, 12 underwent a rectopexy alone, 3 underwent a Ripstein procedure, 2 elderly patients had physical therapy alone, and the other 4 patients had surgical correction of the rectal prolapse before being referred for repair of vaginal vault prolapse. Other procedures performed simultaneously included sacral colpopexy, sacrospinous suspension, rectopubic urethropexy, and abdominal fixation of the vagina to the uterosacral ligaments. CONCLUSIONS: Rectal prolapse frequently coexists with other pelvic floor defects. Internal rectal prolapse may simulate a rectocele or enterocele and requires defecography to establish the diagnosis. Rectopexy (with or without sigmoid resection) is a satisfactory technique for correction and may be combined with other reconstructive procedures on the pelvic floor.

Cisplatin, doxorubicin hydrochloride, and cyclophosphamide followed by radiotherapy in high-risk endometrial carcinoma.

OBJECTIVE: Our purpose was to assess the effect of adjuvant platinum-based, multiagent chemotherapy followed by conventional radiotherapy on the recurrence-free interval, patterns of recurrence, and survival of women with completely resected, poor-prognosis endometrial carcinoma. STUDY DESIGN: Surgical stage IC and II endometrial carcinomas involving the outer one third of myometrium and completely resected stage III and IV carcinomas were eligible for six cycles of cisplatin (Platinol), doxorubicin hydrochloride (Adriamycin), and cyclophosphamide (Cytoxan) (50, 50, 500 mg/m2), followed by external beam radiotherapy to pelvis, pelvis and periaortic chain, or whole abdomen, on the basis of documented disease. RESULTS: Forty-seven women were registered between April 1, 1984, and Oct. 10, 1992; 39 were eligible for review. Six were stage I, 28 were stage III, and five were stage IV. Two tumors were grade I, eight were grade 2, and 29 were grade 3. Twenty-three were endometrioid adenocarcinomas, eight papillary serous, six adenosquamous, and two clear cell. Thirty-seven patients (94.9%) completed six courses of chemotherapy, with no deaths ascribed to treatment. Grade 3 or 4 neutropenia was experienced by 17 (44%) and sepsis by three (8%). Current median follow-up is 27.3 months. Fifteen patients (38.5%) have recurrence, and 14 have died after a median interval of 26.9 months. The 2-year progression-free interval is 72.5% for nonpapillary serous histologic types and 22.5% for papillary serous cancers (p = 0.0074). CONCLUSION: Adjuvant chemotherapy with Platinol, Adriamycin, and Cytoxan followed by radiation therapy is well tolerated and seems to confer a survival advantage to women with nonpapillary serous endometrial carcinoma with a poor prognosis compared with historic controls treated by surgery or radiotherapy.

Prognostic significance of DNA content and nuclear morphology in borderline ovarian tumors.

We used the technique of image analysis to simultaneously measure DNA content and nuclear morphology of 21 borderline ovarian tumors. Aneuploidy was identified in 9 of 21 tumors and was unrelated to tumor stage or nuclear grade. Morphometric nuclear features that were measured included size, shape, texture, and average density. Nuclear size and shape were positively correlated (r = 0.507), and nuclear size and average density were negatively correlated (r = -0.772). Six tumors recurred and recurrence was significantly associated with tumor aneuploidy (P = 0.046), stage III tumors (P = 0.03), and increased nuclear texture (P = 0.07). These results suggest that measurement of DNA ploidy and nuclear morphology using image analysis can provide important prognostic information in patients with borderline ovarian tumors.

Malignant placental site trophoblastic tumor associated with placental abruption, fetal distress, and elevated CA-125.

The second pregnancy of 27-year-old woman, gravida 2, para 2 was complicated by a low alpha-fetoprotein and symptoms of chronic placental abruption. She delivered by cesarean section at 35 weeks for fetal distress at which time a biopsy of the uterus revealed a placental site trophoblastic tumor (PSTT). She rapidly developed intraabdominal spread of the neoplasm which did not respond to chemotherapy and she died 10 weeks later. Her CA-125 was elevated to 5360 mu/ml and this decreased after hysterectomy. This patient is reported to highlight a very malignant course of PSTT that was associated with a live-born male infant.

Genetic system for reversible integration of DNA constructs and lacZ gene fusions into the Escherichia coli chromosome.

A plasmid system for site-specific integration into and excision and recovery of gene constructs and lacZ gene fusions from the Escherichia coli chromosome was developed. Plasmid suicide vectors utilizing the origin of replication of R6K plasmids and containing the attP sequence of bacteriophage lambda, multiple cloning site, and antibiotic resistance markers facilitate reversible integration into the E. coli chromosome by site-specific recombination. Additional vectors permit construction of lacZ gene fusions in three possible reading frames for recombination with the bacterial chromosome. These suicide vectors can be propagated in newly constructed E. coli strains that harbor different pir alleles. Two helper plasmids that encode the necessary gene products for integration (Int) and excision (Int and Xis) were also constructed. This plasmid system was shown to be a reliable and efficient means to integrate and subsequently recover plasmids from the E. coli attB site.

Analysis of the Giemsa-banding patterns of the chromosomes from rats carrying the genes of the growth and reproduction complex (GRC).

Morphological studies of metaphase chromosomes were done with rats derived from the BIL/1 strain, which has genes affecting growth and reproduction linked to the major histocompatibility complex by conventional Giemsa-trypsin staining and the results were compared to rat strains not carrying these defects. A subterminal-terminal centromeric polymorphism was detected in chromosome 3 [del 3 (pter leads to cent)] among the strains studied. Comparison of the G-banded karotypes of the rats carrying the defects with the karotypes of the other strains did not reveal any gross chromosomal abnormalities.

Combining CA 125 and SMR serum markers for diagnosis and early detection of ovarian carcinoma.

OBJECTIVES: The serum tumor marker CA 125 is elevated in most clinically advanced ovarian carcinomas. Because these elevations may precede clinical detection by a year or more, CA 125 is potentially useful for early detection as part of an ovarian cancer screening program. However, CA 125 is often not elevated in clinically detected cancer and is frequently elevated in women with benign ovarian tumors. CA 125 may be more useful in conjunction with one or more other tumor biomarkers. Additional markers could play a role if, when used with CA 125, they identify some carcinomas missed by CA 125 (i.e., they improve sensitivity), rule out false positives (i.e., improve specificity), or are able to detect the same cancers earlier. METHODS: We have evaluated a composite marker (CM) that combines CA 125 and a previously described soluble mesothelin related (SMR) marker in sera from 52 ovarian cancer cases, 43 controls with benign ovarian tumors, and 220 normal risk controls who participated in a screening program, including 25 healthy women having two serum samples collected 1 year apart. CA 125, SMR, and CM were evaluated for their ability to identify clinical disease and for their temporal stability, which assesses their ability to obtain even greater sensitivity when used in a longitudinal screening program. RESULTS: CM has the best sensitivity, with specificity equal to CA 125. Importantly, CM has temporal stability at least as high as CA 125. CONCLUSION: The CM may outperform CA 125 alone in a longitudinal screening program as well as in a diagnostic setting.

Worry about ovarian cancer risk and use of ovarian cancer screening by women at risk for ovarian cancer.

OBJECTIVE: This study examined reports of perceived risk of ovarian cancer, worry, and screening use in a large sample of women. While screening for asymptomatic women is not generally recommended, in 1994 a consensus conference concluded that women with multiple affected relatives are at high risk for ovarian cancer and should be encouraged to participate in screening. The consensus report also suggested that women with a single affected first-degree relative are at elevated risk and while these women were not encouraged to get screening it was suggested that they may choose to pursue screening outside of a randomized trial [NIH Consensus Conference. JAMA 1995;273(6) 491-7]. METHODS: A total of 3257 women participated in this research by completing a mailed survey on ovarian cancer risk, worry, and use of screening. One hundred forty-two of these women were at high risk for this disease due to a strong family history. An additional 144 women were at elevated risk due to a single first-degree affected relative with ovarian cancer. RESULTS: Family history did predict perceived risk, difficulties due to worry, and use of ovarian cancer screening. However, the group of women most likely to report high levels of perceived risk and to have received screening for ovarian cancer were women with a single affected relative rather than those at high risk, for whom screening is recommended. CONCLUSIONS: These results suggest that many women need additional education about ovarian cancer risk. Most women overestimated their risk for this disease. Some average-risk women get screening although it is not recommended outside of randomized trials, and a significant percentage of women at high risk fail to get recommended screening.