P-glycoprotein, HER-2/neu, and mutant p53 expression in human gynecologic tumors.

BACKGROUND: Overexpression of P-glycoprotein has been associated with a worse prognosis for some groups of patients not receiving chemotherapy. Recently, it has been demonstrated that in vitro both c-Ha-Ras overexpression and mutant p53 overexpression do activate the MDR1 gene (also known as PGY1) in murine NIH 3T3 cells. This direct connection between oncogenic activation, antioncogenic malfunctioning (presence of mutant instead of wild-type p53 protein), and MDR1 gene expression constitutes a fundamental conceptual model that could provide an explanation for the obscure prognostic role, in the absence of chemotherapy, of the MDR1 gene. PURPOSE: Our goal was to test whether the relationship between MDR1 (P-glycoprotein) expression, oncogenic activation, and mutant p53 protein expression demonstrated in vitro is also reproducible in vivo for two groups of human gynecologic tumors. METHODS: Fifty tumor specimens (31 mammary, 11 endometrial, and eight cervical) were analyzed. They had been obtained from previously untreated patients. Aliquots of these specimens had been frozen and stored at -70 degrees C since surgical collection or routinely fixed in formalin and embedded in paraffin. DNA was extracted from routinely fixed specimens for single-strand conformation polymorphism (SSCP) analysis. Immunohistochemical techniques were used on frozen material to determine: 1) P-glycoprotein expression using two different monoclonal antibodies (c219 and JSB1); 2) HER-2/neu (c-erb-B2; also known as ERBB2) expression using the NCL-CB11 monoclonal antibody; and 3) mutant p53 protein expression using the PAb 1801 monoclonal antibody. Polymerase chain reaction (PCR)-SSCP was used to confirm recognition of the mutated isoform of p53. Endometrial and cervical carcinomas were studied by both PCR-SSCP DNA analysis and immunohistochemical analysis. Only when there was full concordance between both methods were endometrial and cervical tumors considered to express mutant p53. RESULTS: A statistically significant (P = .009; Fisher's exact test) association between HER-2/neu and MDR1 expression was found for the more aggressive form of inoperable, locally advanced mammary carcinoma. Expression of HER-2/neu or mutant p53 was similar in both tumor groups studied--mammary carcinoma with a low basal expression of P-glycoprotein compared with endometrial and cervical carcinomas with significantly (P = .0002; chi-square test) higher levels of expression. CONCLUSIONS: The highly statistically significant coexpression of P-glycoprotein and HER-2/neu took place only in the subgroup of aggressive, locally advanced, inoperable mammary carcinomas, whereas no statistically significant association could be found for operable tumors. No association between mutant p53 expression and MDR1 activation was found in the human tumors analyzed.

Identification of p53 mutations by means of single strand conformation polymorphism analysis in gynaecological tumours: comparison with the results of immunohistochemistry.

The tumour-suppressing gene p53 may undergo mutation by a variety of mechanisms, thus losing its tumour-suppressing activity, and ultimately behaving like an oncogene. The PAb 1801 monoclonal antibody is known to recognise both wild type and mutated p53, although in practice it seems to show a higher reactivity with the mutated gene product in several human tumours. We studied p53 overexpression in a series of 36 human tumours (17 mammary ductal infiltrating carcinomas, 11 endometrial carcinomas and 8 uterine cervical carcinomas) by means of immunohistochemistry using the PAb 1801 antibody and the streptavidin-biotin peroxidase technique. Furthermore, all tumours were screened for mutations in the "hot spot" regions of the p53 gene (exons 5 to 8) by means of SSCP (single strand conformation polymorphism) DNA analysis following amplification of the target exons using the polymerase chain reaction. A good correlation (75-100%) between positive immunohistochemistry and p53 mutations was observed in mammary and endometrial cancer, whereas mutations were detected in only two out of seven immunoreactive cervical carcinomas. Following these results, immunohistochemistry with the PAb monoclonal antibody may be safely used as a screening tool for the detection of mutated p53 in clinical samples of mammary and endometrial cancer, whereas it should be complemented with DNA analysis in cervix carcinoma.

High rate of expression of multidrug resistance-associated P-glycoprotein in human endometrial carcinoma and normal endometrial tissue.

The overexpression of P-glycoprotein was studied in 10 normal endometrial controls (five from the proliferative and five from the secretory phase of the menstrual cycle) and in 23 endometrial carcinomas of different histological varieties, using the C219 and JSB-1 monoclonal antibodies. Three of the tumours had been previously treated with combination chemotherapy containing doxorubicin. All endometrial carcinomas, whether treated or untreated, as well as the normal endometrial controls from both the proliferative and the secretory phase of the menstrual cycle, overexpressed P-glycoprotein. This puts endometrial carcinoma into the same category as other tumours arising in organs which normally overexpress P-glycoprotein, all of which tend to be intrinsically resistant to chemotherapy.

Chemotherapy-induced emesis: management of early and delayed emesis in milder emetogenic regimens.

The objective of the present study was to examine the problem of the control of nausea and vomiting induced by non-cisplatin containing cyclophosphamide-based chemotherapy regimens in breast cancer patients. This was randomized, double-blind, parallel-group and placebo-controlled study comparing the efficacy of three antiemetic therapeutic regimens (ondansetron for 3 days, ondasetron plus metoclopramide, and ondansetron given in a single dose) in breast cancer patients receiving cyclophosphamide-based chemotherapy regimens on an outpatient basis. Both the primary and the secondary efficacy were measured. The primary efficacy variable was the number of emetic episodes (considering early and delayed emesis). The secondary efficacy variable measured was the quality of life. Two-by-two tables using the chi-square test and relative-risk concept were elaborated for statistical analysis. There was no difference between high-dose ondansetron and ondansetron plus metoclopramide among patients given CMF (cyclophosphamide, methotrexate, 5-fluorouracil). The single-dose ondansetron regimen showed the worst results. In patients given an FEC regimen (cyclophosphamide, epirubicin, 5-fluorouracil) the antiemetic efficacy was best for the high-dose ondansetron regimen, followed by the ondansetron plus metoclopramide regimen, and was worst for single-dose ondansetron administration. Despite the use of different antiemetic schedules, nausea and emesis are significant problems in patients receiving cyclophosphamide-based chemotherapy. Their adequate control should be the aim of any antiemetic approach.

Sperm morphology analysis (strict criteria) in male infertility is not a prognostic factor in intrauterine insemination with husband's sperm.

OBJECTIVE: To assess the prognostic value of strict sperm morphology analysis in intrauterine insemination with husband's sperm (IUI) cycles performed because of male infertility. DESIGN: Prospective study. SETTING: Academic tertiary hospital. PATIENTS: Seventy-four consecutive couples subjected to 271 IUI cycles because of male infertility. MAIN OUTCOME MEASURE: Strict morphology analysis 1 month before the beginning of IUI following the criteria of Kruger et al. RESULTS: Pregnancy and no pregnancy couples were similar regarding strict normal forms (2.85% +/- 2.07% versus 3.13% +/- 2.63%), slightly amorphous forms, and the morphology index (11.79 +/- 6.06 versus 12.04 +/- 7.13). Pregnancy rates (PRs) were similar when normal forms were <4% (39.1%) or > 4% (35.7%). The PR, although higher in the group with morphology index > 10% (41.4%) than in the group < 10% (33.3%), lacked statistical significance. In pure male infertility group, mean values of morphology were similar in pregnancy and nonpregnancy group. A not significant trend was detected toward higher PRs in morphology index > 10% (50.0%) than in the group < 10% (33.3%). CONCLUSION: Strict morphology analysis 1 month before the beginning of IUI is not a useful prognostic factor in IUI performed because of male infertility.

Selective embryo reduction in a sextuplet pregnancy.

The treatment course of a 29-year-old infertile woman using hMG and TDI was the cause of a sextuplet pregnancy in which a successful embryo reduction was carried out during the first trimester. The reduction was performed twice: the first around the 9th week of pregnancy transvaginally, and the second during the 12th week by transabdominal puncture. The perinatal outcome was favorable, and the patient spontaneously delivered a healthy infant on the 39th week of pregnancy.

Does minimal endometriosis reduce fecundity?

Twenty-one patients with minimal endometriosis treated with artificial insemination with donor semen (AID) because of male sterility were compared with 40 patients with the same degree of endometriosis treated by "expectant management" (EM). The conception response of both groups was analyzed with the life-table method calculating the monthly fecundity rate (MFR), and the cumulative pregnancy rate (CPR). Both groups were similar in terms of woman's age and length of infertility before diagnosis. The results obtained after the 12th month showed that the group treated with AID had a CPR of 80.9% and an MFR of 0.201, much higher than the group treated with EM, in which the CPR was 47.5% and the MFR 0.060. The results of the fecundity rate of the AID-treated group was comparable to that of normal population.

Levels of CA-19.9, CA-125, and CA-195 in seminal plasma and in vitro fertilization rates.

OBJECTIVE: To assess the relationship between carbohydrate tumor markers in seminal plasma and fertilization rates in IVF cycles. DESIGN: Prospective study. SETTING: Academic tertiary hospital. PATIENTS: Forty-six consecutive couples subjected to IVF in which at least one oocyte was obtained. MAIN OUTCOME MEASURES: Determination of CA-19.9, CA-125, and CA-195 in seminal plasma 1 week before IVF. RESULTS: CA-125 was higher in the group without fertilization (321 +/- 198 U/mL, mean +/- SD) than in the group in which at least one oocyte was fertilized (155 +/- 165 U/mL), whereas CA-19.9 and CA-195 were similar in both groups. However, at the cutoff 66%, lower values of CA-19.9 were found in the fertilization group rate < 66% (707 +/- 1,217 versus 1,069 +/- 1,084) and of CA-195 (67 +/- 44 versus 218 +/- 274). No correlation was found between tumor marker levels and fertilization rates. CONCLUSION: CA-125 seems to be an indicator of sperm fertilization capacity, whereas the importance of CA-195 and CA-19.9 will require further studies.

Intrauterine insemination with frozen sperm increases pregnancy rates in donor insemination cycles under gonadotropin stimulation.

OBJECTIVE: To compare the efficacy of IUI donor and pericervical insemination donor in frozen sperm insemination cycles under gonadotropin stimulation. DESIGN: Couples where infertility was caused by male conditions were randomized into two groups: IUI and pericervical insemination. Semen samples, gonadotropin stimulation, and ovarian monitoring were the same in both groups. One IUI was performed per cycle as against two pericervical inseminations. SETTING: The donor insemination program at the Human Reproduction Unit at the Hospital of Cruces, Pais Vasco University. PATIENTS: Eighty-eight women (47 IUI and 41 pericervical insemination) with at least one patent fallopian tube and < 40 years of age. MAIN OUTCOME MEASURE: Intrauterine gestational sac observed by transvaginal ultrasound. RESULTS: Per woman pregnancy rate (PR) was higher in IUI than in pericervical insemination (65.96% versus 41.46%, odds ratio [OR] = 2.73, confidence interval [CI] = 1.06 to 7.2). Pregnancy rates were always higher in IUI irrespective of woman and husband's status, but statistical significance was not reached in any subgroups analyzed independently. Per cycle PR was also significantly higher in IUI than in pericervical insemination: 24.03% (31/129) versus 11.89% (17/143) (OR = 2.34, CI = 1.17 to 4.71). Moreover, cumulative PR was higher in IUI (86% versus 49.5%) (OR = 6, CI = 1.98 to 18.80). CONCLUSION: Per woman and per cycle PRs were significantly higher in IUI.

Women who are not exposed to spermatozoa and infertile women have similar rates of stage I endometriosis.

OBJECTIVE: To compare the prevalence of endometriosis and its different stages in infertile women and women not exposed to spermatozoa. DESIGN: Prospective study. SETTING: Artificial insemination donor program at a university hospital. PATIENT(S): One hundred fifty women unable to conceive because they had not been exposed to spermatozoa (134 with azoospermic partner, 10 with an HIV-positive partner, and 6 without a male partner). Controls were 750 women in infertile couples in which the male partner had normal sperm. INTERVENTION(S): Laparoscopy was systematically performed in a blinded manner in both groups as part of the infertility work-up. MAIN OUTCOME MEASURE(S): Diagnosis of endometriosis. RESULT(S): In unexposed women and controls, the prevalence of endometriosis was similar (32% and 34.5%). Rates of stage I disease were also similar in both groups (26% and 19.3%). There was a significant trend toward higher stages of endometriosis in infertile women (stage II disease, 3.3% vs. 5.7%; stage III disease, 1.3% vs. 3.1%; stage IV disease, 1.3% vs. 6.4%). Endometriosis was not associated with the few demographic characteristics that differed between groups. CONCLUSION(S): From an epidemiologic point of view, stage I endometriosis is not more common in infertile women than in unselected women. However, stage II to IV endometriosis was more frequent in infertile women. Whereas a relation between stage I endometriosis and infertility seems unlikely, the relation between stages II to IV endometriosis and infertility seems possible.

Correlation of MDR1 expression and oncogenic activation in human epithelial ovarian carcinoma.

The expression of the MDR1 gene has been shown to correlate with tumor aggressiveness and oncogenic activation both in experimental tumor models and in human clinical specimens In order to verify whether this association also takes place in ovarian carcinoma, we studied tumor samples from 39 patients by means of immunohistochemistry for the overexpression of P-glycoprotein (MDR1), nm23, c-erb-B2 and p53. MDR1 (p = 0.023), nm 23 (p = 0.037) and c-erb-B2 (p = 0.015) were expressed significantly more in specimens from patients with advanced stage of disease. There were no differences in p53 expression between both groups of patients. Furthermore, we found a significant coexpression of MDR1 and nm23 (p = 0.028), and of MDR1 and c-erb-B2 (p = 0.0077). There was no association between the expression of the MDR1 gene and p53. These results parallel those previously reported by us for mammary carcinoma, and seem to indicate that expression of the multidrug resistance gene (MDR1) is inherent to the development of the malignant phenotype in several human tumors.

nm23 expression in advanced and borderline ovarian carcinoma.

Twenty-four advanced (surgical stage III and IV) ovarian carcinomas and 15 borderline ovarian tumours were studied for the overexpression of nm23 and HER-2/neu (c-erb-B2) by means of immunohistochemistry on sections from routinely processed, paraffin-embedded, archival tumour blocks, using the NCL-nm23 and the NCL-CB11 monoclonal antibodies and the streptavidin-biotin-peroxidase technique. Significantly more advanced ovarian carcinomas (p = 0.034) expressed high levels of nm23 when compared to borderline tumours. HER-2/neu (c-erb-B2) expression, as could be expected, was also significantly more frequent in advanced ovarian carcinomas (p = 0.006). We were not able to find the previously reported association between nm23 and HER-2/neu overexpression in our tumours. Our results on nm23 overexpression in ovarian cancer are coincident with those previously reported using nm23-mRNA measurements on fresh ovarian tissues. Thus, ovarian carcinoma seems to belong to the group of tumours, like colon carcinoma and neuroblastoma, in which nm23 overexpression is associated with a more malignant phenotype. Immunohistochemistry performed on archival samples from ovarian carcinomas seems adequate for the demonstration of nm23 overexpression in ovarian cancer. This opens the possibility for larger studies on series of patients with a closed follow-up, which could help to establish the role of this gene in this kind of tumour.

Angiosarcoma of the breast and pregnancy: a new therapeutic approach.

A case of angiosarcoma of the breast managed primarily by a chemotherapeutic approach is referred. A 29-year-old patient presented complaining of a painful mass in her right breast. An incisional biopsy carried out under general anesthesia showed a moderately-differentiated angiosarcoma surrounded by fibrofatty tissue. Ruled out distant metastases, a decision was made to initiate neoadjuvant chemotherapy consisting of ifosfamide, vincristine and dactinimycin. After 2 courses of chemotherapy the tumor volume was reduced by 50% and the histologic examination of the mastectomy specimen revealed a well-differentiated angiosarcoma with widespread areas of necrosis probably produced by previous chemotherapic treatment. The patient is clinically free of disease after 24 months of follow-up. Although this is a single case report, and by no means can be considered a guideline for future treatments, we nevertheless feel that the result obtained with the chemotherapeutic approach with this patient is encouraging.

Endometriosis and spontaneous abortion rate: a cohort study in infertile women.

OBJECTIVE: To ascertain if there is an association between endometriosis and spontaneous abortion. DESIGN: Prospective cohort study. SETTING: Medical School Hospital. POPULATION: 174 infertile women laparoscopically diagnosed with endometriosis and 174 infertile women in which endometriosis was ruled out by laparoscopy, in the same period of time. MAIN OUTCOME MEASURE: Spontaneous abortion. Non-progressive gestational sac and/or histological study. RESULTS: Per woman abortion rate was 7.47% (13/174) in the endometriosis group, similar to 5.74% (10/174) in the infertile women without endometriosis (RR=1.32: CI=0.53-3.36). Nor were there any differences in the per pregnancy abortion rate: 20.96% (13/62) in endometriosis vs. 16.94% (10/59) in non-endometriosis (RR=1.3; CI=0.47-3.57). The abortion rate was similar in the different AFS stages: 22.86% (8/35) in stage I, 16.67% (3/18) in II, 25% (1/4) in III and 20% (1/5) in IV. In stage I no differences were observed in patients who were managed expectantly or with medical treatment. CONCLUSION: Endometriosis is not associated with an increased abortion rate. The severity of disease expressed by AFS staging is not associated with an increase in the abortion rate. In stage I the treatment of endometriosis did not decrease abortion rates.

Spontaneous pregnancy in couples waiting for artificial insemination donor because of severe male infertility.

OBJECTIVE: To assess the spontaneous fertility in couples with severe seminal conditions while waiting for artificial insemination donor. STUDY DESIGN: Prospective follow-up during a period of 24 months. SETTING: University Medical School. PARTICIPANTS: There were 285 couples in which the male had a very severe seminal pathology: 166 azoospermia, 86 oligozoospermia and 33 severe asthenozoospermia. OUTCOME MEASURES: Pregnancy rates after being included on waiting list. RESULTS: The spontaneous pregnancy rate was 3.2% (9/285), per month spontaneous pregnancy rate being 0.13%. Spontaneous pregnancy rate was 0% in azoospermia (0/166). versus 7.6% (9/119) in non-azoospermia cases. Spontaneous pregnancy rate was 8.5% (4/47) in the group with less than 0.1 million motile sperm/cc, 6.5% (3/46) in the group between 0.1 and 1 million/cc and 7.7% (2/26) in the group with 1-2 million/cc. CONCLUSION: In a 2-year follow-up, pregnancy rate among non-azoospermic couples before undergoing artificial insemination was 7.6%. Extramatrimonial pregnancy (based on anamnesis and sperm analysis) seemed to be uncommon. Even in cases with less than 0.1 million of motile sperm/cc there was not a negligible spontaneous pregnancy rate.

The economic implication in pregnancy outcome.

The economic implication in pregnancy outcome is evaluated in a Spanish homogeneous population. The potential risk is assessed for: prematurity, intrauterine growth retardation, perinatal mortality and major malformation. The husband's employment appears worthless as an economic parameter. The best estimators of economic level in our population are the total income per capita and the monthly food allowance per capita. Study results clearly support the relationship between poverty and prematurity, intrauterine growth retardation and major malformation. No correlation is found between perinatal mortality and lower economic conditions, which differs from previous reports. The author suggests that perinatal problems be differentiated from each other in studies of risk factors.

PIP: A study was conducted into the relationship between economic factors and perinatal outcome. The study groups were taken from lower socioeconomic women who delievered at the University of Bilbao Medical School in Spain in 1974. 492 women whose perinatal outcomes were considered abnormal due to low birth weight, perinatal mortality, or a major malformation were compared with a randomly selected group of 383 women whose perinatal results were normal. Results are tabulated. It was found that the husband's employment was not a meaningful economic parameter. Instead, the best estimators of economic level were found to be total income per capita and the monthly per capita food expenditure. Poverty as measured by both these parameters correlated with prematurity, intrauterine growth retardation, and major malformation. The correlations of these various unfavorable pregnancy outcomes with the 2 economic measures were found to be signficant at the p.05, .01, and .001 levels. Unlike the results from other studies into the economic effects on pregnancy outcome, this study showed no correlation between mortality and lower economic conditions.

Verapamil to inhibit the cardiovascular side effects of ritodrine.

Side effects of beta-sympathomimetic drugs are of primary interest in the treatment of preterm labor. Incidence of side effects are dose-dependent, as is the efficacy of the beta-agonist in uterine relaxation. the effect of verapamil (Ca2+) inhibitor with antiarrhythmic action) on ritodrine does not modify the value of ritodrine in prolonging pregnancy, but clearly diminishes the incidence of maternal tachycardia and hypotension. The authors suggest that in the treatment of preterm labor with ritodrine infusion above 200 micrograms/min, the addition of verapamil (dosage, 80-120 micrograms/min) is useful because it substantially reduces the cardiovascular side effects associated with ritodrine hydrochloride.

Repeat pregnancy associated with cardiac pacemaker.

Two pregnancies in a patient with a fixed-rate pacemaker are reported. The first pregnancy was uneventful. The second had no maternal complications either. A moderate tachysystolia was detected during the second period. The newborn was delivered with forceps applied under spinal anesthesia. Newborn infant evolution presented no hazards, but umbilical cord analysis revealed a severe acidosis, in spite of a normal scalp analysis 45 min earlier. Epidural anesthesia is recommended for such patients.

Pruritic urticarial papules and plaques of pregnancy.

The authors present a rare case of pruritic urticarial papules and plaques of pregnancy in a 25-year-old caucasian primigravida admitted to our department because of pruritus in the third trimester of gestation. Recommendations for management are discussed.

Placenta percreta with bladder involvement: case report and review of literature.

The authors present a very infrequent case of invasive placenta in a 33-year-old caucasian primigravida, admitted in our Department because of labor. In the course of a cesarean section performed for failure of progress, the presence of a highly adherent placenta located in the anterior part of the lower uterine segment which affected the posterior vesical wall was discovered. Recommendations for management are discussed.