Prognostic significance of DNA ploidy in endometrial cancer.

OBJECTIVE: The aim of this study was to analyze the prognostic significance of DNA ploidy in patients with endometrial cancer. METHODS: Between October 1988 and January 1997, DNA ploidy was determined prospectively in 208 women who were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy. Median follow-up was 48 months. RESULTS: Diploid tumors were identified in 154 (74%) patients and aneuploid tumors in 54 (26%). Patients with aneuploid tumors had a significantly higher prevalence of metastases to the cervix, adnexa, and omentum, malignant pelvic cytology, and advanced surgical stage. Patients with aneuploid tumors had a 4.5 times higher prevalence of pelvic lymph node metastases and a 5.8 times higher prevalence of para-aortic lymph node metastases. A significantly higher proportion of patients with aneuploid tumors was diagnosed with recurrent or progressive endometrial cancer (22.2 versus 6.5%, P = 0.002). Patients with aneuploid tumors had a significantly lower rate of survival from cancer death (P = 0.038) with 83% versus 94% surviving 5 years. CONCLUSION: Patients with aneuploid tumors are at high risk for lymph node metastases and should be surgically staged, including pelvic and para-aortic lymphadenectomy. Aneuploidy confers a risk for endometrial cancer death and these patients should be candidates for clinical trials evaluating treatment following surgery.

Expression patterns of murine lysosome-associated membrane protein 2 (Lamp-2) transcripts during morphogenesis.

We report the isolation and characterization of the murine homologues to human and chicken lysosome-associated membrane protein (Lamp)-2 transcripts and their prevalent expression patterns during development. Lamp-2 transcripts code for proteins predominant in and specific for the lysosomal membrane. The function of these proteins is still under investigation. Other than in the lysosomal membrane, Lamp-2 proteins have been detected at the plasma membrane of cells in a differentiation dependent and activation dependent manner. They were also observed at the plasma membrane of cells, which secrete lysosomal hydrolases. Involvement of Lamp-2 in cell adhesion during such events has been proposed. A study of the developmental expression patterns of m-Lamp-2 transcripts was undertaken to help elucidate possible functions of their respective proteins. The m-Lamp-2b transcript was prevalent in neural crest derived ganglia. The m-Lamp-2a and -2c transcripts were similarly expressed in structures containing neural crest derived tissue with the strongest signals detected in thymus. However, m-Lamp-2a and -2c transcript expression differed in mesoderm or endoderm derived mesenchymal and epithelial tissues. M-Lamp-2c expression was pronounced in mesenchyme early in development, in limb connective tissue, and in lung parenchyma, whereas m-Lamp-2a was prevalent in the liver, the pancreas, and in differentiating kidney epithelium, and became increasingly prominent in the epithelial lining of the digestive and the respiratory tract during development. These results correlated with the detection of m-Lamp-2 protein in these tissues. In conclusion, all m-Lamp-2 transcripts were detected in tissues undergoing apoptosis during development requiring phagolysosome involvement. In addition, m-Lamp-2a and m-Lamp-2c transcripts were observed in epithelium and mesenchyme during the time of epithelial-mesenchymal interaction, mesenchymal-epithelial transformation, and branching. Their expression pattern became more tissue and cell type specific as differentiation progressed. These patterns indicate a possible involvement of m-Lamp-2 proteins in cell/cell or cell/extracellular matrix interaction, and appear to reflect tissue and cell type specific roles of lysosomes during morphogenesis.

Surgery without radiotherapy for primary treatment of endometrial cancer.

OBJECTIVE: To analyze the role of surgery alone, including pelvic and para-aortic lymphadenectomy, in patients with endometrial cancer who did not receive radiotherapy. METHODS: Between August 1987 and January 1997, 225 women with disease clinically confined to the uterus were staged surgically by a standard protocol that included pelvic and para-aortic lymphadenectomy in women with high risk factors. No radiation was administered before or after surgery. RESULTS: The combination of preoperative endometrial biopsy grade and gross depth of myometrial invasion identified 123 (55%) high-risk patients who had lymphadenectomy and 102 (45%) low-risk patients who did not. Eighteen (15%) high-risk patients had lymph node metastases and received postoperative systemic therapy. Three low-risk, eight high-risk-node-negative, and no high-risk-node-positive patients were diagnosed with recurrent cancer, corresponding to 5-year recurrence-free proportions of 0.95, 0.89, and 1.00, respectively. Although sample sizes and limited follow-up limit conclusions, the experience to date suggests a high rate of survival in all three groups. CONCLUSION: Our preliminary experience indicates that even high-risk patients have an excellent prognosis when treated with surgery, including pelvic and para-aortic lymphadenectomy, without radiotherapy.

Prognostic significance of gross myometrial invasion with endometrial cancer.

OBJECTIVE: To determine if intraoperative estimation of gross myometrial invasion is sufficiently precise to guide surgical aggressiveness in staging patients with endometrial cancer. METHODS: Between September 1987 and September 1995, 236 women with endometrial cancer had visual estimation of gross myometrial invasion during surgical staging which included pelvic and para-aortic lymphadenectomy. RESULTS: In 213 patients (90.3%), the depth of gross myometrial invasion correctly predicted the microscopic depth of invasion on permanent histopathologic sections. Statistically significant associations were found between gross depth of myometrial invasion and tumor grade (P < .001), histopathology (P = .014), cervical metastases (P < .001), adnexal metastases (P < .001), omental metastases (P < .001), malignant pelvic cytology (P < .001), pelvic lymph node metastases (P < .001), para-aortic lymph node metastases (P = .001), and surgical stage (P < .001). Patients with more than 50% gross myometrial invasion were more likely to have poorly differentiated malignancies; nonendometrial histologies; malignant pelvic cytology; higher surgical stage; and cervical, adnexal, omental, pelvic lymph node, and para-aortic lymph node metastases. Patients with more than 50% gross myometrial invasion had a 6.4-fold higher prevalence of pelvic lymph node metastases, a 6.9-fold higher prevalence of para-aortic lymph node metastases, and a 6.7-fold higher prevalence of advanced surgical stage than patients with less than 50% myometrial invasion. CONCLUSION: Patients with endometrial cancer and more than 50% myometrial invasion on gross visual intraoperative estimation are at marked risk for extrauterine metastases, including pelvic and para-aortic lymph node metastases. Such patients should be considered for more aggressive surgical staging, including pelvic and para-aortic lymphadenectomy.

Comparison of D&C and office endometrial biopsy in predicting final histopathologic grade in endometrial cancer.

OBJECTIVE: To compare the accuracy of D&C and office Z-sampler endometrial biopsy in predicting hysterectomy tumor grade in women with endometrial cancer. METHODS: Between September 1987 and July 1994, 183 women with endometrial cancer had D&C or office Z-sampler endometrial biopsy before hysterectomy. RESULTS: One hundred thirty-one patients (72%) had Z-sampler biopsies and 52 (28%) had D&C. The Z-sampler correctly identified the hysterectomy tumor grade in 76 of 131 patients (58%), compared with 40 of 52 (77%) with D&C, a significant difference (P = .024). The major difference observed was an increased fraction of lesions undergraded (ie, a lower grade tumor found in the biopsy than in the hysterectomy specimen) by the Z-sampler (34 of 131, 26%) versus D&C (five of 52, 10%). CONCLUSION: Dilation and curettage was more accurate in identifying hysterectomy tumor grade and less likely to miss a higher-grade tumor than was Z-sampler biopsy. However, the inaccuracy of D&C alone necessitates further preoperative and intraoperative assessment for other risk factors to determine the aggressiveness with which an individual patient should be staged surgically.

Comparison of the Z-sampler and Novak endometrial biopsy instruments for in-office diagnosis of endometrial cancer.

The purpose of this study was to compare the diagnostic accuracy and specimen adequacy of in-office endometrial biopsies taken with the Novak curette and with a disposable flexible polypropylene biopsy device, the Z-sampler, in patients with endometrial cancer. Eighty women with endometrial cancer had in-office endometrial biopsies performed with the Z-sampler and the Novak curette prior to hysterectomy. The Z-sampler diagnosed 66 (82.5%) with endometrial cancer compared to 68 (85%) with the Novak curette (P = 0.724). The Z-sampler biopsies included 10 specimens (12.5%) pathologically inadequate for diagnosis, compared to 5 (6.3%) Novak curette biopsies inadequate for diagnosis (P = 0.074). When both endometrial biopsies were adequate for pathologic evaluation, the Z-sampler diagnosed 66 of 70 women (94.3%) with endometrial cancer, compared to 64 of 70 (91.4%) diagnosed with the Novak curette (P = 0.617). We did not demonstrate a significant difference in diagnostic accuracy or specimen adequacy between in-office biopsies taken with the Novak curette and those taken with the Z-sampler in patients with endometrial cancer.

Reversible valproate fulminant hepatic failure.

Valproate fulminant hepatotoxicity, usually fatal, is believed to be idiosyncratic and metabolic without an immunologic basis. There are no previous reports of a hypersensitivity reaction among numerous cases of fatal valproate fulminant hepatitis. Little is known about the electron microscopical features of valproate hepatitis. We report a case of reversible fulminant hepatitis attributable to valproate with clinical and histological characteristics of a hypersensitivity reaction. Electron microscopical findings included microvesicular steatosis with normal-appearing mitochondria.

Methylation of deoxycytidine in replicating cells treated with ultraviolet radiation and chemical carcinogens.

5-Methyl-2'-deoxycytidine (m5dC) levels were measured in DNA from three types of cultured cells following treatment with u.v. radiation and two chemical carcinogens, N-methyl-N-nitrosourea (MNU) and N-acetoxy-2-acetylaminofluorene (NA-AAF). Control values for m5dC in Raji cells (a human lymphoblastoid cell line), S49 cells (a mouse thymic lymphoma cell line) and human diploid fibroblasts are 3.6%, 3.6% and 3.2%, respectively. None of the damaging agents produced a detectable change in methylation levels of newly replicated DNA, even at levels of damage that inhibited replication by 95%. In contrast, treatment with 5-aza-2'-deoxycytidine, a known methyltransferase inhibitor, transiently reduced genomic methylation by 89% and 74% in Raji and S49 cells, respectively. Although other investigators have found a marked reduction in m5dC in DNA replicated after carcinogen treatment, our experiments indicate that extensive demethylation is not a necessary consequence of DNA damage.

Induction of replicative DNA synthesis in quiescent human fibroblasts by DNA damaging agents.

A marked induction of DNA replication was observed in confluent human diploid fibroblast cultures treated with low relatively nontoxic doses of UV radiation, N-methyl-N-nitrosourea (MNU), and N-acetoxy-2-acetylaminofluorene (AAAF). Isopycnic CsCl density gradient analysis of newly synthesized DNA labeled with BrdUrd indicated that most of the synthesis was semiconservative. The rate of semiconservative DNA synthesis was maximal 24 hr after damage. This induction of DNA replication was greatest at approximately equal to 3 J/m2 UV, 0.5 mM MNU, or 1.0 microM AAAF; was inhibited by hydroxyurea and aphidicolin; and also occurred in repair-deficient xeroderma pigmentosum fibroblasts. Autoradiographic examination of both confluent cultures and serum-arrested cultures showed a large increase in the fraction of densely labeled (S phase) cells after UV treatment. These densely labeled cells retain the capacity for cell division and subsequent proliferation. We conclude that low doses of at least three different DNA damaging agents are capable of recruiting quiescent cells into a state of DNA replication similar to that observed in the normal cell cycle.

Coupling of proadipocyte growth arrest and differentiation. I. Induction by heparinized medium containing human plasma.

The differentiation of proadipocytes in vitro typically required prolonged culture of cells as a high density in high concentrations of serum and added hormones. With such culture conditions it is difficult to design experiments to determine the mechanisms that control the differentiation process. We now describe the rapid and parasynchronous growth arrest and differentiation of low density murine proadipocytes in heparinized medium containing only human plasma. When low density cells are cultured under these conditions, growth arrest at a distinct state in the G1 phase of the cell cycle occurs within 2 d and the differentiation of 80-100% of the cell population occurs within 4 d thereafter. The factors in human plasma which promote growth arrest and differentiation are heat labile and can be separated by barium adsorption. In the following paper we have used these methods to show that there are five separate phases which regulate the coupling of proadipocyte growth arrest and differentiation. The data reported in this paper establish that: (a) high cell density and extensive cell-to-cell contact are not required for adipocyte differentiation, (b) prolonged culture is not required for adipocyte differentiation, and (c) high concentrations of serum and/or added hormones are not required for adipocyte differentiation.

Coupling of proadipocyte growth arrest and differentiation. II. A cell cycle model for the physiological control of cell proliferation.

Experimental evidence is presented that supports a cell cycle model showing that there are five distinct biological processes involved in proadipocyte differentiation. These include: (a) growth arrest at a distinct state in the G1 phase of the cell cycle; (b) nonterminal differentiation; (c) terminal differentiation; (d) loss of the differentiated phenotype; and (e) reinitiation of cell proliferation. Each of these events is shown to be regulated by specific human plasma components or other physiological factors. At two states designated GD and GD', coupling of growth arrest and differentiation is shown to occur. We propose that these mechanisms for the coupling of growth arrest and differentiation are physiologically significant and mimic the regulatory processes that control stem cell proliferation in vivo.

Differentiation of fibroblast-like cells into macrophages.

Differentiated cells with the morphological, enzymatic, antigenic, and functional characteristics of macrophages formed when a variety of nontransformed and transformed fibroblast-like mouse embryo cell lines were grown in a medium supplemented only with human plasma. Differentiated cells contained numerous lysosomes and phagosomes, nonspecific esterase and acid phosphatase activities, and cell surface la antigens and were capable of phagocytosis of iron particles. Differentiated cells were also growth arrested in the G1 phase of the cell cycle, but both growth arrest and differentiation were reversible processes. These observations suggest that cells with the morphology of fibroblasts have the capacity to undergo nonterminal differentiation into macrophages.

In the absence of nutrients, pancreatic-biliary secretions in the jejunum do not exert feedback control of human pancreatic or gastric function.

Feedback inhibition of basal pancreatic enzyme secretion by luminal pancreatic enzymes appears to be an important regulator of pancreatic secretion in some laboratory animals. To determine whether pancreatic enzymes in the jejunum influence pancreatic or gastric functions in healthy man, we intubated six subjects with a gastric sump tube and a four-lumen duodenal tube which provided (1) a duodenal perfusion site, (2) a duodenal aspiration site, (3) an inflatable balloon immediately distal to the aspiration site, and (4) a jejunal perfusion site immediately beyond the balloon. In this way, the gastroduodenal segment could be functionally separated from the remainder of the intestine. The jejunum was exposed to normal saline, active pancreatic-biliary secretions, or pancreatic-biliary secretions in which the enzymes had been inactivated by heat. Ten minutes after initiation of each jejunal perfusion, normal saline was instilled into the stomach. No differences in trypsin secretion, gastric acid secretion, or gastric emptying occurred with the different jejunal perfusates. We therefore conclude that normal man, in the absence of intraluminal nutrients, does not exhibit a jejunal pancreatic enzyme-dependent feedback control mechanism for pancreatic enzyme or gastric secretion. However, our study does not exclude the possibility of a duodenal feedback regulatory mechanism.