The value of surgical staging in patients with apparent early stage epithelial ovarian carcinoma.

OBJECTIVE: The value of surgical staging of apparent early stage epithelial ovarian carcinoma (EOC) is unclear. The aim of this study was to evaluate the importance of surgical staging on the stage of disease and treatment plan. MATERIAL AND METHODS: All patients with apparent stage I EOC undergoing staging from 01/01/2005 to 30/06/2017 in all Danish hospitals and in the Radboud University Hospital Nijmegen, the Netherlands, were evaluated to identify the pathological findings responsible for upstaging and changes in treatment plans. RESULTS: We included 1234 patients with apparent stage I EOC. The staging steps often missed were the biopsy from the right diaphragmatic surface (missed in 96.9% of all patients) and lymph node (LN) sampling or lymphadenectomy (missed in 65.5% of all patients). Upstaging occurred in 393 patients (31.8%) due to microscopic spread to both ovaries (0.8%); ovarian surface (5.8%); positive cytology (10.0%); fallopian tubes (3.1%), ovary (1.5%) and/or uterus serosa (1.2%); pelvic peritoneum (4.3%); LNs (4.7%); omentum (3.7%); abdominal peritoneum (0.6%) and right diaphragmatic surface (2.6%). Of the 393 upstaged patients, 138 (35.1%) had an altered treatment plan due to metastases found by surgical staging. CONCLUSION: Staging was incomplete in most patients, mainly because a biopsy of the diaphragm was omitted. However, surgical staging led to adjuvant treatment in 35.1% of the upstaged patients. Peritoneal biopsies (para-colic gutters and right diaphragm) were of little value, since few patients had an adjustment of treatment plan due to these biopsies. Omitting these biopsies, in the absence of peritoneal abnormalities, is justifiable.

An overview of Clinical Quality Registries (CQRs) on gynecological oncology worldwide.

INTRODUCTION: Clinical Quality Registries (CQRs) were initiated in order to compare clinical outcomes between hospitals or regions within a country. To get an overview of these CQRs worldwide the aim of this study was to identify these CQRs for gynecological oncology and to summarize their characteristics, processes and QI's and to establish whether it is feasible to make an international comparison in the future. METHODS: To identify CQRs in gynecological oncology a literature search in Pubmed was performed. All papers describing the use of a CQR were included. Administrative, epidemiological and cancer registries were excluded as these registries do not primarily serve to measure quality of care through QI's. The taskforce or contact person of the included CQR were asked to participate and share information on registered items, processes and indicators. RESULTS: Five nations agreed to collaborate: Australia, Denmark, Italy, the Netherlands and Sweden. Denmark, Netherlands and Sweden established a nationwide registry, collecting data on multiple tumor types, and various QI's. Australia and Italy included patients with ovarian cancer only. All nations had a different process to report feedback results to participating hospitals. CONCLUSION: CQRs serve the same purpose to improve quality of care but vary on different aspects. Although similarities are observed in the topics measured by the QI's, an international comparison was not feasible as numerators or denominators differ between registries. In order to compare on an international level it would be useful to harmonize these registries and to set an international standard to measure the quality of care with similar indicators.

Validating genetic risk associations for ovarian cancer through the international Ovarian Cancer Association Consortium.

The search for genetic variants associated with ovarian cancer risk has focused on pathways including sex steroid hormones, DNA repair, and cell cycle control. The Ovarian Cancer Association Consortium (OCAC) identified 10 single-nucleotide polymorphisms (SNPs) in genes in these pathways, which had been genotyped by Consortium members and a pooled analysis of these data was conducted. Three of the 10 SNPs showed evidence of an association with ovarian cancer at P< or =0.10 in a log-additive model: rs2740574 in CYP3A4 (P=0.011), rs1805386 in LIG4 (P=0.007), and rs3218536 in XRCC2 (P=0.095). Additional genotyping in other OCAC studies was undertaken and only the variant in CYP3A4, rs2740574, continued to show an association in the replication data among homozygous carriers: OR(homozygous(hom))=2.50 (95% CI 0.54-11.57, P=0.24) with 1406 cases and 2827 controls. Overall, in the combined data the odds ratio was 2.81 among carriers of two copies of the minor allele (95% CI 1.20-6.56, P=0.017, p(het) across studies=0.42) with 1969 cases and 3491 controls. There was no association among heterozygous carriers. CYP3A4 encodes a key enzyme in oestrogen metabolism and our finding between rs2740574 and risk of ovarian cancer suggests that this pathway may be involved in ovarian carcinogenesis. Additional follow-up is warranted.

Do risk factors for epithelial ovarian cancer have an impact on prognosis? Focus on previous pelvic surgery and reproductive variables.

OBJECTIVES: The prognostic impact of risk factors for ovarian cancer development is sparsely explored, but previous sterilisation has been shown to have a negative impact on survival. METHODS: Ovarian cancer cases were from the Danish MALOVA study. Information on previous pelvic surgery as well as reproductive variables was obtained from a personal interview conducted closely after primary surgery. Cox regression models were used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) for ovarian cancer specific death in relation to previous pelvic surgery and reproductive variables including lifetime number of ovulation years. RESULTS: A total of 295 women with Stage III ovarian carcinomas were identified and followed to death or for a median of 7.3 years (range 5.4-9.5 years). Previously sterilised or hysterectomised women seemed to have a slightly decreased risk of ovarian cancer death (HR = 0.62; 95% CI: 0.36-1.08 and HR = 0.82; 95% CI: 0.55-1.21), although none of these associations reached statistical significance. The prognostic impacts of the individual reproductive variables followed the same pattern as the impact of the variables on ovarian cancer development, although significance was only reached for age at menarche (HR = 0.91 per year; 95% CI: 0.84-0.99). By accumulation of the possible minor effects of the reproductive variables in calculation of the total lifetime number of ovulation years, we found that survival decreased significantly with increasing number of ovulations (HR = 1.53 per 10 years; 95% CI: 1.09-2.14). CONCLUSION: Increasing lifetime number of ovulations was a negative prognostic factor for ovarian cancer specific survival. Previous sterilisation or hysterectomy seemed to be associated with improved survival.

Increased risk of ovarian cancer in integrin beta3 Leu33Pro homozygotes.

We previously demonstrated that integrin beta(3) Leu33Pro homozygotes have an increased risk of cancer, possibly most pronounced for ovarian cancer. We now test the latter hypothesis in case-control and prospective studies. We genotyped 463 Danish women with ovarian cancer, and 4291 women from the Danish general population. Calculation of odds ratios by conditional logistic regression was performed in the case-control study (n = 463 + 3543), and of ovarian cancer incidence, log-rank statistics and hazard ratios by Cox regression in the prospective study (n = 4291) with 9.5-year follow-up. In the case-control study matched for age and marital status, the odds ratio for ovarian cancer in homozygotes versus non-carriers was 1.6 (95% confidence interval: 1.0-2.6). In the prospective study with 28 incident ovarian cancers, non-carriers and homozygotes had incidences of 7 (4-11) and 30 (10-92) per 10 000 person-years (log-rank P = 0.02). The age-adjusted hazard ratio for ovarian cancer in homozygotes versus non-carriers was 3.9 (1.1-13). Risk of ovarian cancer did not differ between heterozygotes and non-carriers in either study. Integrin beta(3) Leu33Pro homozygotes have an increased risk of ovarian cancer.

Plasma tetranectin and colorectal cancer.

The prognostic significance of plasma tetranectin (PL-TN) in colorectal cancer was retrospectively examined in 504 patients (80 Dukes' A, 174 Dukes' B, 98 Dukes' C and 152 Dukes' D). Follow-up time was 7-12 years. No significant prognostic variable was found for Dukes' A patients by Cox multivariate analysis. In stage B, PL-TN was the second strongest prognostic variable [relative hazard (RH) = 3.3 for patients with PL-TN < or = 7.5 mg/l]. The other prognostic variables were perineural invasion (RH = 3.7), tumour distance < or = 10 cm from the anal verge (RH = 3.0), postoperative radiotherapy (RH = 2.9) and a high carcinoembryonic antigen (CEA) score (RH = 1.8). In Dukes' C, only CEA score and gender were of prognostic significance. For Dukes' D, PL-TN was the only prognostic variable (RH = 1.7). Testing all patients in one multivariate analysis, Dukes' staging was the strongest and PL-TN the second strongest prognostic variable. The shortened survival for patients with low PL-TN levels is illustrated with lifetables.

Immunoreactive inhibin concentration in blood tested under variable sampling conditions.

The stability of immunoreactive (i.r.) inhibin in blood samples drawn and handled under different conditions and at different time intervals were studied. Ten serum and plasma samples drawn in 1994 from healthy volunteers were compared to samples collected in 1986 from 10 healthy women admitted for laparoscopic sterilization and analysed 6 years later. All samples were drawn on the twelfth day of the menstrual cycle and handled under identical clinical conditions (22 degrees C). The concentrations in the 1986 samples were similar to the Se-i.r. inhibin levels from 1994. Different clotting temperatures, repetitive freezing and thawing or hemolysis had no effects on the i.r. inhibin values, whereas non-hemolysed samples left at room temperature (22 degrees C) for 3 days were significantly lower, which might be due to a statistical type 2 error. No differences in concentration between serum and plasma i.r. inhibin were demonstrated. In conclusion, i.r. inhibin is a very stable peptide hormone in both serum and plasma if drawn and handled under normal conditions.

Changes in plasma tetranectin following hip surgery with or without thrombotic complications.

The fibrinolytic system seems to play a role in the development of postoperative thromboembolic complications (DVT). The newly described tetrameric protein tetranectin (TN), which has been found to enhance the activation of plasminogen to plasmin, therefore was studied in 55 patients who had total hip replacement and solely elastic stockings as physical thromboprophylaxis. No significant difference in plasma TN was found between the 5 patients with DVT and those without DVT, neither preoperatively or postoperatively at day 0, 1, 3, 7 or 10. A significant decrease in plasma TN was found from preoperative to postoperative values, indicating that TN may be a possible marker for other postoperative events. Because of the observed postoperative decrease it is important to consider the sampling time in the future research with TN.

Alpha-fetoprotein in human fetal cerebrospinal fluid.

Alpha-fetoprotein (AFP) is a fetal glycoprotein. It has been ascribed a regulatory function of growth factor responses and immune functions. The concentrations of AFP and albumin (ALB) are highly variable in fetal serum and CSF and change with gestational age. The AFP index=[AFP(CSF)/AFP(SERUM)]/[ALB(CSF)/ALB(SERUM)] was determined in six normal fetuses at gestational age 17-23 weeks and found to be independent of gestational age and close to unity, mean 0.90+/-0.11 (S.D.). The ratio of CSF-serum concentrations of AFP and ALB both decreased significantly (p<0.05) with gestational age. The mean fraction of AFP being non-reactive with concanavalin A was 1.7% in serum and 1.9% in CSF, suggesting a common hepatic origin of AFP in both compartments. In conclusion, the concentration of AFP in CSF seems to be determined largely by the serum-CSF concentration gradient in normal fetuses. This finding, combined with the remarkable constancy of the AFP index compared to the highly variable absolute concentrations of AFP in both serum and CSF should make the AFP index the marker of choice when analyzing for intrathecal AFP synthesis during development and in pathological conditions.

Alpha-fetoprotein and the acute phase response. A study using acute pelvic inflammatory disease as a model system.

Alpha-fetoprotein (AFP) is used as a tumor marker for hepatomas and germ cell tumors. In healthy non-pregnant adults the serum concentration (S-AFP) is very low and we examined whether it was affected when the acute phase response was activated, using patients with acute pelvic inflammatory disease (PID) as a model system. In 70 PID patients the median S-AFP was 1.2 kIU/l (range: 0.5-5.9 kIU/l), within the normal range. S-AFP did not correlate with the clinical grade of disease nor with the serum concentrations of acute phase reactants and albumin. Thus, S-AFP is not significantly affected by activation of the acute phase response and presence of infection should not per se interfere with the use of S-AFP as a tumor marker. However, a negative correlation was found with the serum concentration of alpha-2-macroglobulin (P = 0.05), but whether this has any biological significance remains to be clarified.

Determination of serum tetranectin: technical and clinical evaluation of three sandwich immunoassays.

The performance of two sandwich-type immunoassays for the determination of the tumour marker tetranectin using monoclonal antibodies Hyb 130-13 and 130-14 as catching layer was compared with the performance of a polyclonal assay. Sensitivities were 0.4-0.6 microg/l, and intra- and inter-assay coefficients of variation were < 10% in all assays. One-hundred-and-ten blood donors were examined, and women had higher concentrations of tetranectin in serum than men when measured with monoclonal assays (P < 0.05). In preoperative serum samples from 43 patients with ovarian cancer, tetranectin concentrations were reduced (P < 0.001), and the mean tetranectin concentration decreased with increasing FIGO stage of the patients (P < 0.05). In sera from patients with ovarian cancer, tetranectin concentrations were lower in the polyclonal assay than in the monoclonal assays. This could, hypothetically, be explained by ligand-binding or other conformational changes in tetranectin, influencing the antigenicity of the molecule.

Monoclonal antibodies against human tetranectin, epitope characterization and use in immunohistochemistry.

Two IgG2a/kappa- and three IgG1/kappa monoclonal antibodies (MAbs) were produced against human tetranectin (TN): this is the first report of stable hybridomas producing MAbs against TN. All the MAbs reacted with non-conformational epitopes located within amino acid residues 50-181 of the primary sequence. In relative epitope mapping with enzyme immunoassay and isotachophoresis the five MAbs defined two independent epitope groups. One of them is suggested to be immunodominant in rabbits, since MAbs inhibited binding of a polyclonal rabbit antibody. Several combinations of MAbs were suitable for TN-ELISA and two MAbs could be used for immunohistochemical detection of TN in both fresh frozen and paraffin-embedded tissues. The MAbs will facilitate future studies on structure, function, clinical significance and immunolocalization of TN.

Serum tetranectin and CA125 in endometrial adenocarcinoma.

BACKGROUND: CA125 and tetranectin (TN) are prognostic markers in ovarian cancer. This study examines the values of these markers in endometrial cancer. MATERIALS AND METHODS: TN and CA125 were determined preoperatively in 99 patients with primary endometrioid adenocarcinoma and evaluated in relation to tumor grade, stage and cancer survival. RESULTS: The CA125 levels correlated significantly with tumor stage. Dichotomized according to a cut-off level of 35 U/ml, CA125 significantly correlated with cancer death. Multivariate regression analysis of cancer survival time showed that CA125 > 35 U/ml was not an independent factor when stage was introduced. TN levels were within the normal range in all patients and did not show any association with tumor grade, stage or survival. CONCLUSIONS: The study confirmed the role of CA125 as a prognostic factor in endometrial cancer and may be of aid in pointing out patients at high risk, whereas tetranectin did not show any prognostic effect.

Evaluation of sample handling in relation to levels of tissue inhibitor of metalloproteinases-1 measured in blood by immunoassay.

BACKGROUND: The possible effect of preanalytical conditions such as blood sample preparation and handling on TIMP-1 levels in blood needs thorough investigation. MATERIALS AND METHODS: Blood was collected in dry tubes and tubes containing EDTA and kept at 4 degrees C or 20 degrees C for 1, 3, 8, 24 or 72 hours before processing into serum or EDTA plasma. In addition, serum and EDTA plasma samples were frozen and thawed 1-8 times. TIMP-1 was measured by ELISA. RESULTS: Time to processing for up to 72 hours did not significantly affect TIMP-1 levels in serum. In EDTA plasma, TIMP-1 levels were stable for up to eight hours; however, if samples were kept for 24 hours or longer the TIMP-1 levels increased (p < 0.0001). Repeated freezing and thawing had a significant effect on TIMP-1 levels in serum (p = 0.04). In plasma, repeated freezing and thawing for up to six times did not influence TIMP-1. However, in plasma samples exposed to seven or eight freeze/thaw cycles TIMP-1 levels decreased, although not significantly (p = 0.23). CONCLUSIONS: Handling and processing of blood samples is crucial for TIMP-1 measurement by immunoassay. In serum, TIMP-1 levels are unaffected by time to processing. Plasma samples should be processed within eight hours to avoid a TIMP-1 increase. For the measurement of TIMP-1 in archival material, serum should not be used because TIMP-1 levels are significantly affected by repeated freezing and thawing; archival plasma can readily be used provided that samples have not been frozen and thawed more than six times.

Feasibility study of a randomised trial of ovarian cancer screening.

OBJECTIVES: To assess the feasibility of a randomised trial of ovarian cancer screening by vaginal ultrasonography. SETTING: A population based study, recruiting a random sample of the female population aged 46 to 65 years living in Copenhagen, Denmark. DESIGN: Randomised controlled trial allocating 50% to the study group having vaginal ultrasonography, and 50% to the control group having no examination. (a) Acceptability of the study was evaluated by the proportion of eligible women willing to participate in the study. (b) The false positive rate was evaluated as the proportion of women without ovarian cancer referred for an operation because of abnormal ovaries detected by ultrasonography. RESULTS: 950 (64.3%) of the 1477 eligible women participated in the study. At the first scan abnormal ovaries were detected in 54 of 435 women (12%), significantly more frequently among younger women. Nine women were referred for an operation because of abnormal findings in the ovaries, giving a false positive rate of 2%. Ovarian size and morphology found at operation corresponded with those at ultrasonography; none of them was malignant. CONCLUSIONS: A randomised controlled trial of ovarian cancer screening using vaginal ultrasonography seems acceptable in the general population. The rate of abnormal ovaries at ultrasonography with the cut offs used in this study was quite high. Such a study is, therefore, feasible, but it is proposed that it is carried out in an older age group (50-64 years) and that the cut offs used for ovarian size and morphology are re-evaluated. Second line tests, such as colour Doppler flow, should be considered in order to reduce the false positive rate.

Ovarian carcinoma serum markers and ovarian steroid activity--is there a link in ovarian cancer? A correlation of inhibin, tetranectin and CA-125 to ovarian activity and the gonadotropin levels.

In a previous study, we have demonstrated that inhibin-production may be associated with improved survival and, also, that tetranectin (TN) is a valuable prognostic marker in ovarian epithelial cancer. We investigated the possible correlation between inhibin, tetranectin, CA-125, ovarian steroid activity and the gonadotropin levels. Preoperative serum levels of the tumor markers inhibin, tetranectin (TN) and CA-125 were measured and related to ovarian steroid function and the pituitary-gonadal axis (gonadotropin levels) in 28 postmenopausal ovarian cancer patients. The following median levels and 95% confidence limits were demonstrated for the tumor markers: Inhibin 0.4 U/l (0.2-0.9), TN 8.9 mg/l (6.8-9.2), CA-125 160 kU/l (75-687). A significant inverse correlation was demonstrated between inhibin and the gonadotropins. The Spearman correlation coefficients showed a highly significant correlation of inhibin with the examined ovarian steroid hormones except DHEAS which also has a suprarenal component. This indicates a synthesis of inhibin and the steroid hormones from the same cell compartment as known from the normal ovary and an apparently intact negative feed back mechanism. Inhibin may be produced in the normal ovary as a defense mechanism against an elevated gonadotropin level and inhibin acts by lowering the gonadotropins or by altering their biological activity. Elevated values of the tumor markers TN and CA-125 due to gonadotropin stimulation could not be demonstrated but a significant inverse correlation between TN and CA-125 was confirmed.

Influence of the mode of delivery on initiation of breast-feeding.

The initiation and the prevalence of breast-feeding after discharge from hospital was investigated in 370 singleton parturients and compared to the mode of delivery. Infants delivered by vacuum extraction or by caesarean section started suckling later, they were more often given formula prescription during the first 4 days, they were less often breast-fed during the night, and their mother's milk 'came in' later, but it did not affect the prevalence of breast-feeding after discharge. A sleepy infant, which was not very willing to suckle, was the most frequent nursing-problem mentioned by the mothers 4 days after delivery. Failure to start breast-feeding occurred in only 2.2% of the women, and after 6 months 52% were still breast-feeding their children.

Hormonal factors and prognosis in epithelial ovarian cancer: a multivariate analysis.

When a significantly lower follicle stimulating hormone (FSH) level was found in patients with epithelial ovarian carcinoma, it was decided to analyze the influence of hormonal factors on prognosis. Thirteen factors were tested for prognostic significance in 35 women with epithelial ovarian carcinoma. Age, FIGO-stage, histopathological grade, residual tumor, treatment, gonadotrophins and steroid hormones were tested. By univariate log-rank testing a significantly shorter survival time was found for patients with ascending FIGO-stage, residual tumor mass, estradiol < 0.10 nmol/l, progesterone < 2.0 nmol/l and DHEAS < 1300 nmol/l. In the Cox model the independently significant prognostic factors found were residual tumor mass (P < 0.001) with a risk estimate of 2.65, progesterone (P < 0.05) with a risk estimate of 0.29 for a progesterone level > 2.0 nmol/l and total testosterone (P < 0.03) with a risk estimate of 0.29 for a total testosterone level > 1.15 nmol/l. The present findings, together with the assumption that an elevated gonadotrophin level may induce ovarian tumor growth (the gonadotrophin theory), earlier findings of estrogen and progesterone receptors in human ovarian cancer, and the in vitro demonstration of gonadotrophin-growth-stimulation of human malignant epithelial tumors, justify a thorough investigation of the interaction between steroid hormones and receptors, gonadotrophins, tumor bulk and survival in future research protocols.

Serum tetranectin and CA-125 used to monitor the course of treatment in ovarian cancer patients.

Serum tetranectin (Se-TN) and CA-125 were measured in serum samples obtained before primary surgery, before start of chemotherapy and monthly during chemotherapy in 8 patients with ovarian cancer. The median Se-TN level before chemotherapy (7.3 mg/l) increased significantly after the start of chemotherapy (13.7 mg/l), with the highest increase for one survivor (145%). Five patients who died of cancer in the study period, had pronounced decreases (30-50%) in Se-TN with a maximal concentration during chemotherapy to the lowest concentration in the last sample. One patient who died 10 months after closure of the study had continuously normal Se-TN values, but the last CA-125 value elevated. The lead time could be calculated in four patients for Se-TN and six patients for CA-125. Median lead times of 3.6 months and 3.8 months were found for Se-TN and CA-125 respectively. In conclusion, chemotherapy induces significant increases in Se-TN levels. A decrease in Se-TN during chemotherapy is highly suspect for recurrence and a poor outcome. Measurements of TN should therefore be included in other comparative studies.

Cobalamin binding proteins in the human fetus.

Cobalamin binding proteins are synthesized by the fetus from at least 16-19 gestational weeks. Cerebrospinal fluid contained transcobalamin with size and isoelectric points identical to adult transcobalamin. The unsaturated cobalamin-binding capacity in the fetal cerebrospinal fluid was comparable to adult levels, that is 0.01-0.04 nmol/l, median 0.03 nmol/l, n = 4. The unsaturated cobalamin-binding capacity in serum was low compared to adult values (0.02-0.04 nmol/l, median 0.03 nmol/l, n = 4). The unsaturated cobalamin-binding capacity in at term umbilical cord serum was alike for arterial and venous blood. The values obtained was 0.14-1.03 nmol/l, median 0.66 nmol/l, n = 22, which was two thirds of the corresponding values in maternal serum: In the amniotic fluid haptocorrin, intrinsic factor and transcobalamin were identical with the adult binders regarding the size and the isoelectric point.