Estrogen receptor and peroxidase activity in epithelial ovarian carcinomas.

The endocrine biology of cancers originating from the ovarian epithelium was examined with respect to three sequential indicators for estrogen action: available estrogen receptor in the cytosol, total extractable estrogen receptor from the nucleus, and endogenous tissue peroxidase--a putative postnuclear marker for estrogen-induced growth in uteri of laboratory animals and in some mammary tumor models. Cancers of human ovarian epithelium were distinguished from other ovarian tumors by a higher incidence of detectable (greater than 50 fmol/g tissue wet wt) estrogen receptor in the cytosol (P less than 0.001). Approximately one-half (14/29) of the ovarian adenocarcinoma specimens had greater than 500 fmol available estrogen receptor/g tissue wet weight in their cytosols when assayed by a 2-hour incubation with 17 beta-[2,4,6,7-3H(N)]estradiol followed by treatment with dextran-coated charcoal. With a single exception, ovarian adenomas and nondiseased specimens of premenopausal and postmenopausal ovaries (n = 24) contained less than 500 fmol available estrogen receptor/g tissue wet weight in their cytosols. With respect to extractable estrogen receptor in the nucleus, 11/14 primary and 3/9 metastatic ovarian adenocarcinomas had greater than 50 fmol/g wet weight, as assayed by exchange at 30 degrees C for 5 hours after adsorption of the extracted receptor to hydroxylapatite. Endogenous peroxidase activity, measured in vitro by guaiacol oxidation, occurred in substantially higher amounts in the primary ovarian adenocarcinomas than in benign tumors and control ovaries and could be demonstrated within ovarian adenocarcinoma cells by electron microscopy.

Cancer risk in men exposed in utero to diethylstilbestrol.

BACKGROUND: An association between prenatal diethylstilbestrol (DES) exposure and cancer in men, especially testicular cancer, has been suspected, but findings from case-control studies have been inconsistent. This study was conducted to investigate the association between prenatal DES exposure and cancer risk in men via prospective follow-up. METHODS: A total of 3613 men whose prenatal DES exposure status was known were followed from 1978 through 1994. The overall and site-specific cancer incidence rates among the DES-exposed men were compared with those of the unexposed men in the study and with population-based rates. The relative rate (RR) was used to assess the strength of the association between prenatal DES exposure and cancer development. All statistical tests were two-sided. RESULTS: Overall cancer rates among DES-exposed men were similar to those among unexposed men (RR = 1.07; 95% confidence interval [CI] = 0.58 to 1.96) and to national rates (RR = 0.99; 95% CI = 0.65 to 1.44). Testicular cancer may be elevated among DES-exposed men, since the RRs for testicular cancer were 3.05 (95% CI = 0.65 to 22.0) times those of unexposed men in the study and 2.04 (95% CI = 0.82 to 4.20) times those of males in the population-based rates. The higher rate of testicular cancer in the DES-exposed men is, however, also compatible with a chance observation. CONCLUSIONS: To date, men exposed to DES in utero do not appear to have an increased risk of most cancers. It remains uncertain, however, whether prenatal DES exposure is associated with testicular cancer.

Prediction of survival in gynecological cancer based on immunological tests.

Patients with advanced cancer have a depressed immunological function. We performed a battery of tests on peripheral blood samples from 42 patients with gynecological cancer to determine the extent to which this depression was due to abnormal lymphocyte function, as compared to changes in the number of lymphoid cells in the peripheral blood or in the efficiency of purification of cells in Ficoll:Hypaque gradients in preparation for testing. The percentage of lymphocytes in the gradient-derived cell suspension (% LG) and the absolute lymphocyte count were more informative than mitogen stimulation, mixed leukocyte culture, and T- and B-cell measurements. Both values decreased significantly with the advancing stage of cancer, and we were able to predict survival of patients with uniform stage of disease. The % LG correlated with survival better than did any other test when multivariate analyses of all test combinations were performed. Low values of % LG reflected both the depressed lymphocyte counts and the altered buoyant density of the leukocytes of many patients with advanced cancer. A large portion of the depression in other immune function tests was statistically attributed to changes in % LG and the lymphocyte counts. We concluded that these two simple measurements provide valuable information about patients with gynecological cancer.

Self-reported allergy, infection, and autoimmune diseases among men and women exposed in utero to diethylstilbestrol.

Immunotoxicology studies of prenatal or neonatal exposure to diethylstilbestrol (DES) show effects on immune function of the adult animal. Prenatally exposed humans are known to be at increased risk of vaginal adenocarcinoma, but little research has been done to assess immunologic function. A placebo-controlled clinical trial of DES was conducted in the early 1950s. The sons and daughters born to participants of this clinical trial were traced and interviewed about immune-related health problems. Symptom and disease rates for the DES exposed (253 sons and 296 daughters) were compared with rates for the unexposed (241 men and 246 women). DES-exposed men and women reported rates of allergy, infection, and autoimmune disease similar to the unexposed. However, because autoimmune diseases are rare, a larger sample is needed to evaluate further DES-associated risk of autoimmunity.

Diethylstilbestrol and other sex hormones during pregnancy.

Intrauterine exposure to diethylstilbestrol (DES) has been associated with ths subsequent rare development of clear cell adenocarcinoma of the vagina and cervix in exposed female progeny. These tumors have been seen thus far in patients between the ages of 7 and 29 years. In addition, nonmalignant epithelial and structural genital alterations have been frequently observed. The epithelial changes of adenosis, ectropion, metaplasia, and potential neoplasia are considered. Thus far, no increased risk of squamous cell neoplasia has been demonstrated in DES-exposed subjects. However, increased pregnancy wastage, including premature birth, does appear to be more common among DES-exposed women; this increase may be related to the structural uterine and cervical changes that have occurred. DES-exposed men have been demonstrated to have anatomic genital changes, but the effects of these changes, if any, on male infertility are not known. Masculinization of the female external genitalia, including phallic enlargement and labioscrotal fusion, has been reported following intrauterine exposure to certain progestational agents and androgens.

Medical treatment of urethral prolapse in children.

Urethral prolapse denotes the complete circular eversion of the urethral mucosa through the external meatus. Two different entities exist: premenarcheal and menopausal urethral prolapse. Premenarcheal prolapse is predominantly asymptomatic and is usually brought to medical attention by vaginal bleeding. Trauma and medical conditions predisposing a patient to increased abdominal pressure are associated with prolapse in children. The menopausal group seeks medical attention primary because of the severity of urinary symptoms, ie, nocturia, urgency, tenesmus, dysuria, and frequency. Therapy for both groups has been traditionally accomplished by surgical manipulation-excision, surgical ligation, cautery, fulguration, and cryosurgery. The authors treated 5 premenarcheal female children with antibiotics, estrogen cream, and sitz baths for 2 weeks. In all the patients prolapse was resolved. The results, with follow-up for 4 to 12 months without recurrence, suggest that urethral prolapse in children can be managed without surgical intervention.

Risk factors for diethylstilbestrol-associated clear cell adenocarcinoma.

OBJECTIVE: To assess the influence of postnatal factors on the development of clear cell adenocarcinoma in women exposed to diethylstilbesterol (DES), particularly factors related to exogenous or endogenous hormone exposures, and to reassess the relation of season of birth. METHODS: For the analysis of postnatal factors, 244 cases were compared with 244 age-matched DES-exposed women. Information was obtained from telephone interviews, with questions asked in reference to an index age, the age at which clear cell adenocarcinoma was diagnosed. For the analysis of season of birth, 604 cases, living or deceased, were compared with 1749 DES-exposed women. RESULTS: Neither oral contraceptive (OC) use nor pregnancy was associated with risk of clear cell adenocarcinoma: the odds ratios (OR) were 1.1 (95% confidence interval [CI] 0.7, 1.8) for OC use and 1.3 (95% CI 0.7, 2.3) for pregnancy. The OR for fall season of birth relative to all other seasons was 1.2 (95% CI 0.9, 1.4). CONCLUSION: Pregnancy and OCs do not increase risk of DES-associated clear cell adenocarcinoma. In addition, season of birth does not appear to be a material factor; the previous finding of an increased risk for fall season of birth is most likely not valid and probably a chance finding due to small sample size.

The management of ASCUS cervical cytologic abnormalities and HPV testing: a cautionary note.

A recently published study of the management of low-grade cytologic smears compared immediate colposcopy to human papillomavirus (HPV) triage and entry cytology smears (conservative management) as three triage techniques for managing atypical squamous cells of undetermined significance (ASCUS) smears (Atypical Squamous Cells of Undetermined Significance/Low-grade Squamous Intraepithelial Lesion Triage Study [ALTS]). The study reported a high sensitivity (96.3%) for HPV testing using hybrid capture 2 to detect cervical intraepithelial neoplasia (CIN) III. The authors concluded that HPV testing is a viable option for managing ASCUS smears. We have reviewed the published data from the ALTS trial and have found a large excess of colposcopies and biopsies in the HPV arm in comparison with the conservative management (cytology) arm. In addition, the ALTS trial quality control and pathology review results raise doubts about the diagnostic validity of the study to establish standards of clinical practice. Furthermore, until the 2-year follow-up analysis of the conservative management arm is completed to detect CIN III, a valid comparison between HPV triage and conservative management is not possible. We conclude that, based on published data, HPV testing for routine clinical management of low-grade cytologic abnormalities (ASCUS smears) is not warranted, and that HPV testing is currently an investigational tool.

Persistence and distribution of estrogen receptor in advanced epithelial ovarian carcinoma after chemotherapy.

Estrogen receptor in tumor cytosol extracts from primary ovarian adenocarcinomas and/or from their metastatic foci was measured for determination of whether or not estrogen receptor content is preserved after chemotherapy. Tumor tissue was analyzed from 36 patients who had not received chemotherapy and from 16 patients after varying periods of chemotherapy. The percentages of relatively estrogen receptor-rich tumors (with more than 35 fmol estrogen receptor per milligram soluble protein, or with more than 1200 fmol estrogen receptor per gram tissue wet weight) were similar in the two groups (31 and 37%). In three of four patients who had specimens analyzed both before and after chemotherapy, there was little difference between the levels of estrogen receptor in the initial sample and in samples taken after ten to 32 months of chemotherapy. In one patient, a decrease in the amount of receptor after chemotherapy appeared to be related to the sampling technique used. There was no discernible effect of treatment on the prevalence or amount of estrogen receptor in metastases. No correlation was observed between estrogen receptor levels and the histologic type or grade of the tumor or the patients' survival. The data suggest that chemotherapy has little effect on measurable receptor levels in ovarian epithelial carcinomas. When present in one tumor site, receptor can be expected to be present in a majority of other sites in the same patient.

Comparison of histologic and colposcopic findings in DES-exposed females.

A study was undertaken to evaluate the histologic alterations associated with two of the most abnormal colposcopic findings, mosaicism and punctation, that are commonly found in the vaginas and cervices of young women who have been exposed prenatally to diethylstilbestrol (DES). Four-fifths of 215 biopsy specimens from 171 exposed subjects with mosaicism or punctation disclosed metaplastic squamous epithelium, the presence of which is thought to reflect the repair of vaginal adenosis and cervical ectropion. Hyperkeratosis was observed in one-fifth of the specimens and was more frequent in lesions colposcopically graded I than II. Mild dysplasia was encountered in only one specimen. The findings indicate that the presence of squamous cell dysplasia cannot be predicted by the finding of Grade I or II mosaicism or punctation in the DES-exposed female despite the fact that these abnormal colposcopic patterns are associated with dysplasia in about 10% of cases when encountered in the cervix of the unexposed woman.

Human papillomavirus detection and p53 expression in clear-cell adenocarcinoma of the vagina and cervix.

OBJECTIVE: To determine whether infection with oncogenic human papillomavirus (HPV) and/or altered expression of the tumor suppressor protein p53 is associated with clear-cell adenocarcinoma of the vagina or cervix. METHODS: Paraffin-embedded tissue specimens were studied from 14 women with clear-cell adenocarcinoma of the vagina or cervix. Nine women had a history of intrauterine diethylstilbestrol exposure. Human papillomavirus DNA was amplified via the polymerase chain reaction using consensus L1 primers and was detected by dot blot hybridization with a generic HPV probe and type-specific oligonucleotide probes. P53 protein was detected by immunohistochemical analysis with a mouse monoclonal antibody, DO-7. RESULTS: Three tumors contained HPV 31 DNA sequences. Eight tumors were HPV DNA-negative and three were indeterminate for HPV. P53 was detected in ten tumors; it was undetectable in the three tumors containing HPV 31 and in one tumor indeterminate for HPV. Three patients presented with or later developed metastatic disease. In each case, the tumor, including sites of metastasis, was HPV-negative and p53-positive. CONCLUSIONS: These findings suggest that infections with oncogenic HPVs may be a cofactor in the development of clear-cell adenocarcinoma of the vagina or cervix, though this association is less than that reported for squamous or non-clear-cell adenocarcinomas. Prior studies have shown that detection of the p53 protein by immunohistochemistry correlates with mutations in the p53 tumor suppressor gene. The detection of p53 in HPV-negative clear-cell adenocarcinoma suggests a second mechanism in the etiology of these rare tumors.

Continued follow-up of pregnancy outcomes in diethylstilbestrol-exposed offspring.

OBJECTIVE: To evaluate long-term pregnancy experiences of women exposed to diethylstilbestrol (DES) in utero compared with unexposed women. METHODS: This study was based on diethylstilbestrol-exposed daughters, the National Collaborative Diethylstylbistrol Adenosis cohort and the Chicago cohort, and their respective nonexposed comparison groups. Subjects who could be traced were sent a detailed questionnaire in 1994 that contained questions on health history, including information on pregnancies and their outcomes. We reviewed 3373 questionnaires from exposed daughters and 1036 questionnaires from unexposed women. RESULTS: The response rate was 88% among exposed and unexposed women. Diethylstilbestrol-exposed women were less likely than unexposed women to have had full-term live births and more likely to have had premature births, spontaneous pregnancy losses, or ectopic pregnancies. Full-term infants were delivered in the first pregnancies of 84.5% of unexposed women compared with 64. 1% of exposed women identified by record review (relative risk [RR] 0.76, confidence interval [CI] 0.72, 0.80). Preterm delivery of first births occurred in 4.1% of unexposed compared with 11.5% of exposed women, and ectopic pregnancies in 0.77% of unexposed compared with 4.2% of exposed women. Spontaneous abortion was reported in 19.2% of DES-exposed women compared with 10.3% in control women (RR 2.00, CI 1.54, 2.60). According to complete pregnancy histories (many women had more than one pregnancy), preterm births were more common in DES-exposed women (19.4% exposed versus 7.5% unexposed (RR 2.93 CI 2.23, 3.86). Second-trimester spontaneous pregnancy losses were more common in DES-exposed women (6.3% versus 1.6%; RR 4.25, CI 2.36, 7.66). More first-trimester spontaneous abortions occurred in DES-exposed women than in controls (RR 1.31, CI 1.13, 1.53), and DES-exposed women had at least one ectopic pregnancy more often than unexposed women (RR 3.84, CI 2.26, 6.54). CONCLUSION: Pregnancy outcomes in DES-exposed women were worse than those in unexposed women.

Topographic relation of cervical ectropion and vaginal adenosis to clear cell adenocarcinoma.

Twenty specimens of uterus and vagina removed because of clear cell adenocarcinoma of the cervix or vagina in women exposed prenatally to diethylstilbestrol were serially blocked and sectioned to study the topographic relation between the carcinoma and the cervical ectropion and vaginal adenosis. Three tumors were cervical; 17 were vaginal. Iodine staining performed on 8 specimens indicated that the carcinoma developed consistently just above the distal limit of the cervical or vaginal surface that failed to stain with iodine, a location that usually corresponds to the distal limit of abnormality visible by colposcopic examination. Microscopic examination disclosed the presence of both cervical ectropion and vaginal adenosis in all the specimens. Mucinous glands were abundant above the tumor. In 18 of the 20 cases, tuboendometrial glands were intimately related to the carcinoma, either surrounding it or abutting its inferior border. These data, in addition to other evidence, suggest that tuboendometrial epithelium, whether in the ectocervix or vagina, provides the bed from which clear cell adenocarcinoma develops.

Cytology of 575 young women with prenatal exposure to diethylstilbestrol.

The vaginal and cervical cellular changes encountered in 575 postpubertal females exposed prenatally to diethylstilbestrol (DES) were compared with those of an unexposed population with particular reference to the role of cytology in the detection of vaginal adenosis and cervical ectropion (erosion). Several methods of obtaining specimens were utilized, the most effcacious of which was scraping of the vagina, especially the fornices, and the portio vaginalis of the cervix. With this technic, columnar cells of the mucinous type and metaplastic squamous cells were observed in 34% of the vaginal scrapes and 54% of the scrapes of the cervical portio. A higher incidence was apparent among those patients in whom iodine staining of the vaginal mucosa was abnormal or vaginal adenosis was proven by biopsy. Moderate to severe dysplasia of the squamous cells or atypical glandular cells were found in 1% of the exposed subjects. This study indicates that the presence of mucinous columnar or metaplastic squamous cells in vaginal scrapes is suggestive of vaginal adenosis but that vaginal cytology cannot be considered a uniformly reliable screening technic for detecting the presence of this disorder.

Design and preliminary observations of National Cooperative Diethylstilbestrol Adenosis (DESAD) Project.

The National Cooperative Diethylstilbestrol Adenosis (DESAD) Project has completed the major portion of its enrollment phase with the examination of more than 3000 daughters of women taking synthetic nonsteroidal estrogens (denoted DES) during pregnancies occurring from the early 1940s to the mid-1960s. The aims of the Project are to fill urgent needs for information on the prevalence and incidence of structural and epithelial abnormalities or neoplastic changes and their complications in these young women. Participants are grouped by mode of entry as identified by prenatal record review (40.1%), documented as DES-exposed but walking in (25.1%), or referred (22.8%) to the DESAD Project for examination, and not documented as exposed but having gynecologic abnormalities typical of those associated with DES exposure (12.0%). This study cohort, in part having paired controls, will be examined annually for at least 5 years. Details of the design and selected preliminary findings are reported.

DES-associated clear cell adenocarcinoma of the vagina and cervix.

PIP: Epidemiologic, clinical and pathologic data on all cases of clear cell adenocarcinoma of the genital tract in women born in 1940 and later are collected by the Registry for Research on Hormonal Transplacental Carcinogenesis. Other cases of genital cancer are also recorded if there is a history of prenatal hormone exposure. Evidence strongly suggest a mullerian nature for clear cell adenocarcinomas. Of the 333 cases accessioned between 1970 and 1976, about 2/3 of the completely investigated cases had histories of prenatal exposure to stilbestrol (DES) or similar compounds. Estimated risk of clear cell adenocarcinoma ranges from 0.14 to 1.4 per 1000 DES-exposed, with age-incidence peaking at age 19. Cytology and a thorough pelvic examination are important tools for accurate diagnosis. Surgery and radiation are used to treat these tumors, but follow up in most cases has been limited to 5 years. Several cases of small or superficial tumors have been observed to spread to regional pelvic nodes, with recurrences in the lungs or supraclavicular areas. For inquiries, contact the Registry for Research on Hormonal Transplacental Carcinogenesis, 5841 S. Maryland Ave., Chicago, Ill 60637. Analysis of pathologic specimens should be directed to Robert E. Scully, MD, Dept of Pathology, Massachusetts General Hospital, Boston, Mass 02114.^ieng

A correlative nuclear DNA and histologic study of genital squamous lesions in DES exposed progeny.

PIP: 72 vaginal and cervical squamous lesions from 55 DES-exposed young women were analyzed using the technique of Feulgen microspectrophotometry to correlate the nuclear DNA content with histologic changes and follow-up data. A euploid pattern was observed in 23 specimens (14 cervical and 9 vaginal) histologically classified as immature squamous metaplasia. Of the 49 significant squamous abnormalities, 17 (9 cervical and 8 vaginal) were polyploid, and 32 (26 cervical, 5 vaginal, and 1 pericervical collar) were aneuploid. Most of the lesions with polyploid patterns were histologically classified as atypical metaplasia or slight dysplasia, while most of the aneuploid lesions were moderate and severe dysplasias. Conservative therapy usually eradicates polyploid lesions with no recurrence; in contrast, a high recurrence rate is seen in patients with aneuploid lesions managed with biopsy and/or therapy. The presence of abnormal mitotic figures in aneuploid lesions is the most significant histologic feature which differentiates aneuploids from polyploids. The biologic behavior of lesions can be better appreciated if histologic findings are supplemented with nuclear DNA data.^ieng

Does early exposure to maternal smoking affect future fertility in adult males?

Animal data suggest that prenatal exposure to certain tobacco smoke components such as nicotine may affect the development of the male gonadal axis, which may in turn affect future adult fertility. There are no previous epidemiologic studies on the potential effects of early (prenatal and childhood) exposure to maternal smoking on the reproductive system in adult male offspring. To investigate this question, we used data from a follow-up study of reproductive function and fertility among young adult sons of mothers who had participated in a randomized clinical trial of diethylstilbestrol use during pregnancy. We observed no significant effects of early exposure to maternal smoking on conventional semen characteristics, hormone levels (follicle stimulating hormone [FSH], luteinizing hormone [LH] and testosterone), urogenital abnormalities and diseases, or perceived infertility problems. Current active smoking by the men was, however, associated with a significant decrease in the percentage of sperm with normal morphology.

Vaginal and cervical abnormalities, including clear-cell adenocarcinoma, related to prenatal exposure to stilbestrol.

A variety of vaginal and cervical abnormalities have been encountered in the offspring of women who have taken stilbestrol or chemically related nonsteroidal estrogens during pregnancy. Cervical erosion has been noted most often, but vaginal adenosis has been proven by biopsy in over 30 percent, and transverse vaginal and cervical ridges have been seen in approximately 10 percent of the exposed population. Although the use of these drugs had been widespread during the last two decades, the Registry of Clear-Cell Adenocarcinoma of the Genital Tract in Young Females has been able to collect only 170 cases of vaginal and cervical cancers of this type from all over the world. It is important that cytologists and pathologists become familiar with the various non-enoplastic and neoplastic disorders related to these hormones in order that additional epidemiologic, clinical and pathological information be acquired without delay.

Intrauterine diethylstilbestrol exposure and its consequences: pathologic characteristics of vaginal adenosis, clear cell adenocarcinoma, and related lesions.

In 1971, the development of clear cell adenocarcinoma of the vagina in young females was first linked to a history of intrauterine exposure to diethylstilbestrol (DES). This communication reviews data on cases accessioned in the Registry of Clear Cell Adenocarcinoma of the Genital Tract in Young Females, findings in exposed female and male subjects without cancer, and discusses current concepts of the pathogenesis of the DES-related anomalies of the lower genital tract.