Improved therapeutic index of carboplatin plus cyclophosphamide versus cisplatin plus cyclophosphamide: final report by the Southwest Oncology Group of a phase III randomized trial in stages III and IV ovarian cancer.

PURPOSE: To compare cisplatin-cyclophosphamide versus carboplatin-cyclophosphamide as primary chemotherapy for stage III (suboptimal) and stage IV ovarian cancer. PATIENTS AND METHODS: Three hundred forty-two patients were randomly assigned to treatment with six courses of intravenous (i.v.) cisplatin 100 mg/m2 plus i.v. cyclophosphamide 600 mg/m2, or i.v. carboplatin 300 mg/m2 plus i.v. cyclophosphamide 600 mg/m2. RESULTS: The estimated median survivals were 17.4 and 20.0 months for the cisplatin and carboplatin study arms, respectively. The null hypothesis of a 30% survival superiority with the cisplatin arm was rejected at the P = .02 level. Clinical response rates were 52% for the cisplatin arm and 61% for the carboplatin arm. Pathologic complete response rates were similar for both study arms. There was less thrombocytopenia on the cisplatin arm (P less than .001); however, there was less nausea and emesis (P less than or equal to .001 for courses 1 to 5), renal toxicity (P less than .001), anemia (P = .01), hearing loss (P less than .001), tinnitus (P = .01), neuromuscular toxicities (P = .001), and alopecia (P less than .001) on the carboplatin arm. CONCLUSION: Carboplatin-cyclophosphamide proved to have a significantly better therapeutic index than cisplatin-cyclophosphamide in patients with stage III (suboptimal) and stage IV ovarian cancer.

Comparative efficacy of oral flurbiprofen, intramuscular morphine sulfate, and placebo in the treatment of gynecologic postoperative pain.

This single-dose, double-blind, randomized, placebo-controlled study compared the efficacy of 50 mg of oral flurbiprofen (Ansaid, Upjohn), 10 mg of intramuscular morphine sulfate, and placebo in 92 patients with moderate to severe postoperative gynecologic pain. According to pain intensity, pain relief, and pain intensity difference scores, the morphine-treated patients experienced significantly more pain reduction than the other patients by the first hour after treatment. The flurbiprofen group obtained the same level of significant pain relief as the morphine group by two hours after dosing, but relief persisted longer than in the morphine-treated patients. Evaluation of other efficacy variables revealed similar levels of significant pain reduction in both the flurbiprofen and morphine groups compared with the placebo group. Flurbiprofen was well tolerated and led to fewer side effects than either morphine or placebo.

Complications of extended-field therapy for cervical carcinoma without prior surgery.

This study is designed to analyze the complications of extended-field radiotherapy for carcinoma of the uterine cervix uncomplicated by recent prior surgery. Forty-two patients with carcinoma of the uterine cervix and lymph node metastases established by unequivocally positive bipedal lymphangiograms were treated with extended-field radiotherapy. External beam radiation to extended pelvic portals was limited to 4500 cGy using the linear accelerator and approximately 6000 mg-hr brachytherapy. Nodal boosts up to 500 cGy were generally limited to fields measuring less than 50 cm2. Higher doses were administered in 12 patients because of poor tumor regression. Eleven of these 12 patients experienced severe complications, and only three achieved control of their tumor. The type of treatment complication appeared to be directly related to specific modifications of the initial treatment plan. Treatment failures occurred within and outside of treatment portals with equal frequency.

Human DNA topoisomerase II-alpha.

DNA topoisomerase II-alpha (topo II-alpha) is the molecular target of several types of clinically useful anticancer drugs such as etoposide, teniposide, doxorubicin, and mitoxantrone. The enzyme is also a proliferation marker in normal cells and tissues. High levels of enzyme are present in the S and G2 phases of the cell cycle. New data are emerging which suggest that anticancer drugs which target the topoisomerases may be useful in the treatment of patients with ovarian neoplasms. However, there is relatively little data on the expression of these enzymes in human ovarian cancer. We have recently developed an in situ immunohistochemical stain which can detect the presence of topo II-alpha in formalin-fixed paraffin-embedded human tissue sections. In order to determine topo II-alpha levels in ovarian tumors, we immunostained for topo II-alpha, 30 ovarian neoplasms which ranged from benign to highly malignant. We correlated our results with expression of MIB1 in order to determine if topo II-alpha expression correlates with cell proliferation. Since the gene for topo II-alpha is closely linked to the gene for the c-erbB-2 oncogene, we also evaluated the cases for amplification of c-erbB-2. Our results indicate that topo II-alpha correlates well with MIB1 indicating that topo II-alpha may be useful in estimating cell proliferation in ovarian tumors. In addition, 1 of 15 patients with a malignant neoplasm had a carcinoma which expressed high levels of topo II-alpha. Since the sensitivity of cells to topo II targeted drugs is dependent on high topo II levels, this suggests that topo II-alpha immunostaining in ovarian cancer may also identify a subset of patients potentially treatable with topo II targeted drugs. None of the ovarian neoplasms showed amplification of c-erbB-2.

Progesterone production in adenocarcinoma of the colon metastatic to the ovaries.

A 59-year-old woman who presented with bowel obstruction, a large pelvic mass, and marked breast tenderness was found to have strikingly elevated preoperative serum concentrations of estrogen and progesterone. After resection of a primary adenocarcinoma of the colon and bilateral ovarian metastases, her serum progesterone and estradiol concentrations gradually declined. The unusual hormone production in the patient was confirmed by regression of clinical symptoms and by in vitro endocrine assays performed on cells from ovarian tumor grown in tissue culture. The tumor consumed pregnenolone and produced progesterone and estradiol in large quantity.

Pseudomyxoma peritonei associated with secondary infertility.

In summary, we report a case of secondary infertility attributed to pseudomyxoma peritonei caused by ruptured appendiceal mucocele. Resection of the tumor and visible mucinous ascites resulted in spontaneous conception. We hypothesize secondary infertility was caused by significant peritoneal inflammation and inhibition of sperm-oocyte interaction from the ascites.

Elevations of DNA topoisomerase I catalytic activity and immunoprotein in human malignancies.

DNA topoisomerase I (topo I) is the molecular target for the camptothecin group of anticancer drugs. These drugs are showing activity against a wide array of human tumors. Many data have indicated that the sensitivity of a tumor cell to the camptothecins is dependent on tumor topo I levels. Drug-sensitive cells have high levels of topo I. Unfortunately, there is still a relative lack of information on topo I levels in human malignancies. Because of this, we investigated topo I activity and immunoprotein levels in a variety of normal murine and human tissues, as well as tissues obtained from several carcinomas, lymphomas, and sarcomas. Flow cytometric analysis was also performed on the neoplastic specimens to determine the percentage of cycling cells. Topo I catalytic activity was detected in all normal tissues at a fairly constant level. The average topo I catalytic activity in normal mammalian tissues was 2.7 +/- 1.3 x 10(4) units/mg protein (range 1.1 to 5.0 x 10(4)). Topo I catalytic activity was much more variable in human malignancies and ranged from a low of 1.4 x 10(4) units/mg protein in a rhabdomyosarcoma to a high of 160 x 10(4) units/mg protein in a poorly differentiated ovarian carcinoma. Western blot analysis with either a mouse monoclonal antibody or scleroderma antibodies directed against topo I revealed that the elevated topo I catalytic activity levels in the malignant tissues are due to elevated amounts of topo I immunoprotein. It is possible that the high topo I levels that characterize several different types of human malignancies might indicate that these tumors would be sensitive to many of the new drugs that target topo I.

Systemic immunosuppression induced by photodynamic therapy (PDT) is adoptively transferred by macrophages.

Some derivatives of hematoporphyrins are strongly retained by tumor tissue as compared to normal tissue, and exposure of these photosensitizers to radiation in the visible spectrum can cause serious biological damage. These properties have been exploited in the development of a new treatment for cancer termed photodynamic therapy (PDT). However, recent studies have also demonstrated that PDT can also induce a state of systemic immunosuppression. The purpose of this study was to determine whether PDT-induced suppression of contact hypersensitivity (CHS) responses was an active phenomenon that could be adoptively transferred by viable splenocytes from PDT-treated mice. Although induction of adoptively transferable suppressor cells in PDT-treated mice required exposure to antigen, the suppressor cells were found to be antigen nonspecific in their function. Furthermore, splenocytes from PDT-treated mice were capable of generating levels of allospecific cytotoxic T lymphocyte (CTL) activity which were comparable to those generated by normal control mice, but the ability of irradiated spleen cells from PDT-treated mice to stimulate a mixed lymphocyte response (MLR) was dramatically impaired. Finally, chromatographic separation of T cells, B cells and macrophages showed that the cell type which mediates adoptively transferable suppression of CHS responsiveness is in the macrophage lineage.

Cystic ovarian necrosis complicating tamoxifen therapy for breast cancer in a premenopausal woman. A case report.

A premenopausal woman with recurrent stage II ductal breast carcinoma was treated with tamoxifen. After ten months of therapy her ovaries became acutely cystic and necrotic, but vascular torsion was not present. This case illustrates the special complications of tamoxifen therapy in premenopausal women.

Late complications of the Estes operation for tubal infertility. A case report.

The Estes procedure was designed to restore fertility in women with infertility related to tubal factors by transposition of an ovary into the uterine cavity with preservation of its vascular pedicle. This procedure was performed most commonly in the middle of this century in the United States. Many of these women are now perimenopausal and therefore entering the age of risk for ovarian neoplasia. We treated a patient who developed large intramyometrial cystic masses more than 20 years after undergoing an Estes procedure.

Ovarian cancer: histogenetic classification, histologic grading, diagnosis, staging, and epidemiology.

PIP: This paper presents an overview of the histogenic classification, histologic grading, diagnosis, staging, and epidemiology of ovarian cancer. The pathology of ovarian tumors is the most complex area of gynecologic pathology. The current staging system divides the ovarian cancers into major categories based on the 4 distinct cell populations that make up the ovary. Ovarian tumors have been further subclassified by enzyme production, cellular ultrastructure, genetic composition, and characterization of gene products. About 75-80% of ovarian tumors are of epithelial origin, 10% are stromal, 5% are germ cell, and the remainder fall under other categories. The histologic grade of a primary tumor is at least as important a determinant of a patient's clinical course as the stage at diagnosis. Low-grade epithelial ovarian cancers limited to the ovary with an intact capsule and no ascites are associated with a favorable prognosis, whereas poorly differentiated tumors are associated with a high likelihood of occult metastases and decreased survival. There is no effective screening method for the early detection of ovarian cancer, although there is the prospect that a tumor specific antigen can be identified to aid in early diagnosis. In the US, 18,000 new cases of ovarian carcinoma are diagnosed each year, with a fatality rate of 65%. The peak incidence occurs in the 8th decade of life, and the disease appears to be silghtly more common in blacks. Parous women have a 30-60% lower incidence of ovarian carcinoma than nulliparous women, and multiparas have a lower incidence than primiparas. There is some evidence that ovarian cancer is associated with a diet low in fiber and vitamin A. Oral contraceptive (OC) use seems to exert a protective effect, and the decreased risk correlated with increasing duration of OC use is long lasting.^ieng

[Progesterone, progestagens in premenstrual syndrome, the perimenopause and the menopause]. / Progestérone, progestatifs dans le syndrome prémenstruel, la périménopause et la ménopause.

Progesterone has been the first isolated gestagen. After a short review on the physiology of secretion of progesterone some pharmacologic actions are considered by the authors. Among gestagens, derivatives of pregnane are of special interest, particularly because of fewer, notably androgenic, side effects. After reviewing commercial French and Swiss products the authors focus on three applications: the premenstrual syndrome where progesterone is of interest for local and systemic administration the perimenopause in which several pathologies treatable by gestagens occur Finally the menopause in which progesterone is important in view of its physiologic role. Among the reasons to use progesterone combined with estrogens during menopause, prevention of endometrial cancer is the most important but other advantages are also noted. The authors discuss risk factors for breast cancer during treatment with gestagens in menopause. Finally the authors review compliance and underline the importance of new treatment schedules for the menopause: Continuous treatment, on-demand treatment or menstruation every 3 months.

Estrogen and progestogen therapy in advanced ovarian cancer: preliminary report.

Eleven women with advanced ovarian cancer were treated with a sequential and combined hormonal regimen designed to induce and bind tumor progesterone receptors. Two partial responses were seen, and two patients with a recent history of rapid tumor progression achieved disease stabilization. One patient experienced a transient ischemic cerebrovascular episode while on therapy, and a second patient discontinued therapy because of nausea. The regimen was able to induce progesterone receptors in vivo. One patient had no progesterone receptor in a pretreatment tumor biopsy, but did have a high titer of receptors after her first cycle of treatment.

Advanced ovarian dysgerminoma with cure of tumor persistent in meninges.

Isolated meningeal recurrence of ovarian cancer is uncommon. It is generally assumed that such cases are not accompanied by prolonged survival. We report the cure of a patient with advanced ovarian dysgerminoma who developed febrile carcinomatous meningitis 2 weeks after receiving her fifth course of combination chemotherapy (5 months after initiation of chemotherapy). No parenchymal brain disease was identified. The persistence of disease in the leptomeninges is related to the ability of the blood-brain barrier to exclude chemotherapeutic agents. The patient responded to craniospinal radiation and remains free of disease 2 years after completion of treatment.

Systemic immunosuppression induced by peritoneal photodynamic therapy.

Although photodynamic therapy is being used increasingly for the diagnosis and treatment of human cancer, its effect on immune responses has received little attention. This aspect was examined in a murine model. Mice given peritoneal photodynamic therapy had markedly decreased contact hypersensitivity responsiveness, not observed with cutaneous photodynamic therapy. The immunosuppression was systemic, because contact hypersensitivity was depressed at distal, unirradiated sites. Photodynamic therapy induced adoptively transferable cells that inhibited contact hypersensitivity responses in naive mice. The immunosuppression was reversible, but persisted for 3 weeks after photodynamic therapy. An acute-phase response characterized by leukocytosis and elevated serum amyloid P levels was observed in mice given photodynamic therapy but not in mice treated with either laser or dye alone. These data suggest a link between the acute-phase response and immunosuppression. Thus, although photodynamic therapy shows promise in cancer treatment, the induction of decreased systemic immunoresponsiveness is an important observation with potentially detrimental consequences.

Myonecrosis following deep pelvic hyperthermia.

A case report is presented in which severe myonecrosis of the inferior anterior abdominal wall followed treatment of a recurrent pelvic tumour with an annular phased array (AA) deep heating device. This unusual complication has not been observed at this institution in 107 patients previously treated with deep pelvic or abdominal hyperthermia, who had undergone a total of 368 hyperthermia sessions. The injury was confirmed radiographically and histopathologically, and was associated with serum enzymatic elevations characteristic of muscular injury. The implications for clinical trials employing the AA or similar devices are discussed.

Photodynamic therapy of human ovarian epithelial carcinoma, OVCAR-3, heterotransplanted in the nude mouse.

OBJECTIVE: Our objective was to develop an animal model for the study of photodynamic therapy in the treatment of human ovarian epithelial carcinoma. STUDY DESIGN: The human ovarian carcinoma OVCAR-3 was heterotransplanted into nude, athymic mice and treated with photodynamic therapy consisting of the hematoporphyrin derivative Photofrin II 10 ng/kg and argon-pumped dye laser light at 630 nm (200 J/cm2). Growth of tumors on one side of seven mice (treated tumors, n = 7) was compared with contralateral tumors (control tumors, n = 8) not exposed to laser. Hematoporphyrin derivative uptake was determined in tumor and other tissues. RESULTS: Photodynamically treated tumors were completely ablated, and all remained absent. Hematoporphyrin derivative uptake was nonselective for tumor compared with other tissues. CONCLUSION: This model provides reproducible parameters for the study of photodynamic therapy in the treatment of gynecologic malignancies and demonstrates the need for methods to increase selective uptake of hematoporphyrin derivatives.

Immunohistochemical detection of DNA topoisomerase I in formalin fixed, paraffin wax embedded normal tissues and in ovarian carcinomas.

AIMS: To determine, by in situ immunohistochemistry, whether ovarian carcinomas have increased expression of DNA topoisomerase I. METHODS: Paraffin wax blocks obtained from 15 samples of normal human tissues and from 14 cases of ovarian cancer were cut on to glass slides and immunohistochemically stained for topoisomerase I. The primary antibody was a mouse monoclonal that recognises topoisomerase I in western blots. Colour was detected using a peroxidase system with diaminobenzidine as the chromogen. The expression of topoisomerase I in the tissues and tumours was graded subjectively from 0 to 3+ based on the colour intensity of the immunostain. RESULTS: In normal tissues, topoisomerase I expression was strongest in the mucosal lymphocytes in the gastrointestinal tract and in the germinal centres of the tonsil. Weak topoisomerase I staining was found in the columnar epithelium of the gastrointestinal tract and in squamous mucosa. In the series of ovarian carcinomas, raised topoisomerase I was observed in 43% (6 of 14) of the tumours. Of the tumours with raised topoisomerase I, only three contained a population of rapidly cycling cells. Therefore, 21% of our series of ovarian carcinomas (3 of 14) had raised topoisomerase I expression and were proliferating rapidly. CONCLUSIONS: Topoisomerase I expression in formalin fixed, paraffin wax embedded human tissues can be evaluated by immunohistochemical staining. Increases in topoisomerase I occur in some cases of ovarian cancer.

Immunohistochemical staining for DNA topoisomerase II in frozen and formalin-fixed paraffin-embedded human tissues.

DNA topoisomerase II is the molecular target of several clinically useful chemotherapeutic drugs. The sensitivity of cells to drugs that target topoisomerase II is dependent on the cellular content of this enzyme. Drug-sensitive cells have elevated amounts of type II topoisomerase. To determine relative amounts of enzyme in malignant neoplasms, we developed an in situ immunohistochemical stain for topoisomerase II. The stain uses either polyclonal or monoclonal antibodies produced against the alpha isoform of the enzyme. Staining can be done on both frozen and formalin-fixed, paraffin-embedded tissues. By using this immunostain, we found marked differences in enzyme content in several human malignancies.