The Journey of Cancer Cells to the Brain: Challenges and Opportunities.

Cancer metastases into the brain constitute one of the most severe, but not uncommon, manifestations of cancer progression. Several factors control how cancer cells interact with the brain to establish metastasis. These factors include mediators of signaling pathways participating in migration, infiltration of the blood-brain barrier, interaction with host cells (e.g., neurons, astrocytes), and the immune system. Development of novel therapies offers a glimpse of hope for increasing the diminutive life expectancy currently forecasted for patients suffering from brain metastasis. However, applying these treatment strategies has not been sufficiently effective. Therefore, there is a need for a better understanding of the metastasis process to uncover novel therapeutic targets. In this review, we follow the journey of various cancer cells from their primary location through the diverse processes that they undergo to colonize the brain. These processes include EMT, intravasation, extravasation, and infiltration of the blood-brain barrier, ending up with colonization and angiogenesis. In each phase, we focus on the pathways engaging molecules that potentially could be drug target candidates.

Somatic mutation profiling of vulvar cancer: Exploring therapeutic targets.

BACKGROUND: Vulvar squamous cell carcinoma (VSCC) constitutes over 90% of vulvar cancer. Its pathogenesis can follow two different pathways; high risk human papillomavirus (hrHPV)-dependent and HPV-independent. Due to the rarity of VSCC, molecular mechanisms underlying VSCC development remain largely unknown. The study aimed to identify pathogenic mutations implicated in the two pathways of VSCC development. METHODS: Using next generation sequencing, 81 VSCC tumors, 52 hrHPV(+) and 29 hrHPV(-), were screened for hotspot mutations in 50 genes covered by the Ion AmpliSeq Cancer Hotspot Panel v2 Kit (Thermo Fisher Scientific). RESULTS: Mutations of TP53 (46% and 41%, of hrHPV(+) and hrHPV(-) cases respectively) and CDKN2A (p16) (25% and 21%, of hrHPV(+) and hrHPV(-) cases respectively) were the most common genetic alterations identified in VSCC tumors. Further mutations were identified in PIK3CA, FBXW7, HRAS, FGFR3, STK11, AKT1, SMAD4, FLT3, JAK3, GNAQ, and PTEN, albeit at low frequencies. Some of the identified mutations may activate the PI3K/AKT/mTOR pathway. The activation of mTOR was confirmed in the vast majority of VSCC samples by immunohistochemical staining. CONCLUSIONS: Detecting pathogenic mutations in 13/50 genes examined at comparable frequencies in hrHPV(+) and hrHPV(-) tumors suggest that genetic mechanisms of the two routes of VSCC pathogenesis may be similar, despite being initiated from different premalignant lesions. Importantly, our data provide a rationale for new anti-VSCC therapies targeting the PI3K/AKT/mTOR pathway.

Technetium-99m-based Radiopharmaceuticals in Sentinel Lymph Node Biopsy: Gynecologic Oncology Perspective.

Technetium (99mTc)-radiolabeled colloids are popular tracers used to map lymphatic vessels and regional lymph nodes (LNs). The regional LN status is a significant determinant of cancer stage and patient prognosis, and strongly influences treatment. Regional LN dissection has become a part of surgical treatment. However, not all patients with LN involvement benefit from extensive lymphadenectomy in terms of prolonged survival. Moreover, overtreatment of patients with localized disease carries the unnecessary risk of complications. It is believed that sentinel LN biopsy (SLNB) allows to assess the involvement of the most representative LN of the lymphatic basin and to decide on radical LN dissection.99mTc is an easily available radionuclide emitting gamma rays. The value of 99mTc for diagnostic procedures is associated with its relatively short half-life that makes it safe both for patients and medical personnel. A colloid presenting specific physical and biological properties, including optimal particle size, is a carrier for the radionuclide. When administered at the tumor site, a radiocolloid is absorbed by the lymphatics, and the first LN that it gets trapped in is referred to as the sentinel LN (SLN). The radiopharmaceutical must reach the SLN relatively quickly, but its storage within the SLN, and the radionuclide's half-life must be long enough to enable intraoperative imaging and evaluation. SLNB is currently the gold standard in breast cancer and malignant melanoma diagnosis, and is under extensive investigation in gynecological cancers. Here, we provide a historical perspective of the SLN concept and the clinical relevance of SLNB in gynecologic oncology. Moreover, we review the technical aspects of the application of 99mTc-based radiopharmaceuticals in lymphoscintigraphy and intraoperative lymphatic mapping.

Clinical significance of pretreatment serum levels of VEGF and its receptors, IL- 8, and their prognostic value in type I and II endometrial cancer patients.

OBJECTIVES: The study aimed to assess the usefulness of the determination of cytokines: IL-8, VEGF and its soluble receptors: VEGF-R1, VEGF-R2 in patients with endometrial cancer (EC). MATERIAL/METHODS: The study group consisted of 118 patients with EC subjected to surgical treatment. Before the treatment we determined the serum levels of cytokines IL-8, and VEGF as well as VEGFR1 and VEGFR2 receptors. For comparison, the concentration of CA 125 was also measured. VEGFR1 and CA 125 were determined in the COBAS e601 system using Roche Diagnostics kits, while IL-8, VEGF and VEGFR2 were measured by ELISA assay using R&D Systems kits. RESULTS: The concentrations of IL-8, VEGF, VEGFR1 and CA 125 allowed to distinguish patients for the control group. The highest diagnostic sensitivity has been shown for the concentrations of VEGF (AUC = 0.904) and IL-8 (AUC = 0.818). Among all studied parameters only CA125 concentrations increased with the clinical stage; being significantly higher in patients in FIGO III-IV, than FIGO I-IB. In patients at the FIGO stage I-IB, complementary determinations of CA 125 and VEGF resulted in the largest increase of diagnostic sensitivity. Patients with metastases to the para-aortic lymph nodes had significantly higher levels of VEGF compared to subjects without such lesions. The concentrations of IL-8 were an independent prognostic factor in the assessment of overall survival in patients with type I endometrial cancer, while the concentrations of VEGFR2 in those with type II. CONCLUSIONS: In patients with endometrial cancer, the clinical usefulness of IL-8 and VEGFR2 measurements as the potential prognostic factors has been demonstrated. In type I, the concentrations of IL-8 determined before treatment can be helpful in predicting overall survival. In patients qualified to type II EC, the concentrations of VEGFR2 have the value of an independent prognostic factor for overall survival, this requires research on larger groups of patients. The increased levels of VEGF may be useful in the preoperative assessment of the status of para-aortic lymph nodes.

Normalizers for microRNA quantification in plasma of patients with vulvar intraepithelial neoplasia lesions and vulvar carcinoma.

The role of circulating microRNAs as a promising tool for diagnosing cancer and monitoring anticancer therapies has been widely studied in the past decades. To date, no suitable reference microRNAs for normalizing quantitative real-time polymerase chain reaction assays has been identified in vulvar intraepithelial neoplasia lesions and vulvar squamous cell carcinoma. The purpose of this study was to select appropriate references for gene expression studies in plasma of patients with these lesions. Expression levels of six microRNAs-hsa-miR-425-5p, hsa-miR-191-5p, hsa-miR-93-5p, hsa-miR-423-5p, hsa-miR-103a-3p, and hsa-miR-16-5p-were analyzed by quantitative reverse transcription polymerase chain reaction in plasma samples obtained from 17 patients with vulvar intraepithelial neoplasia lesion and 27 patients with vulvar squamous cell carcinoma. The expression stability of these candidate normalizers was assayed using geNorm algorithm. hsa-miR-93-5p was revealed as the most stably expressed reference in plasma samples of both vulvar intraepithelial neoplasia lesion and vulvar squamous cell carcinoma patients. The results pointed at hsa-miR-93-5p and hsa-miR-425-5p as microRNAs that retained the greatest robustness in plasma of vulvar intraepithelial neoplasia lesion and vulvar squamous cell carcinoma patients, respectively. Our work is the first report on reference microRNA selection for quantitative real-time polymerase chain reaction applications in vulvar intraepithelial neoplasia lesion and vulvar squamous cell carcinoma. The candidate microRNA stability values for the two types of lesions are provided and might serve for normalization of the future novel microRNA biomarkers in these rare entities.

Neoadjuvant treatment for unresectable rectal cancer: an interim analysis of a multicentre randomized study.

PURPOSE: To present an interim analysis of the trial comparing two neoadjuvant therapies for unresectable rectal cancer. METHODS: Patients with fixed cT3 or cT4 or locally recurrent rectal cancer without distant metastases were randomized to either 5 × 5 Gy and 3 courses of FOLFOX4 (schedule I) or 50.4 Gy delivered in 28 fractions given simultaneously with 5-Fu, leucovorin and oxaliplatin (schedule II). Surgery in both groups was performed 12 weeks after the beginning of radiation and 6 weeks after neoadjuvant treatment. RESULTS: 49 patients were treated according to schedule I and 48 according to schedule II. Grade III+ acute toxicity was observed in 26% of patients in group I and in 25% in group II. There were two toxic deaths, both in group II. The microscopically radical resection (primary endpoint) rate was 73% in group I and 71% in group II. Overall and severe postoperative complications were recorded in 27% and 9% of patients vs. 16% and 7%, respectively. Pathological complete response was observed in 21% of the patients in group I and in 9% in group II. CONCLUSIONS: The interim analysis revealed no major differences in acute toxicity and local efficacy between the two evaluated strategies.

Preoperative radiotherapy and local excision of rectal cancer with immediate radical re-operation for poor responders: a prospective multicentre study.

PURPOSE: To assess local control after preoperative radiation and local excision and to determine an optimal radiotherapy regimen. METHODS: Eighty-nine patients with G1-2 rectal adenocarcinoma <3-4 cm; unfavourable cT1N0 (23.6%), cT2N0 (62.9%) or borderline cT2/cT3N0 (13.5%) received 5 × 5 Gy plus 4 Gy boost (71.9%) or 55.8 Gy in 31 fractions with 5-FU and leucovorin (28.1%). Local excision (traditional technique 56.2%, transanal endoscopic microsurgery 41.6%, Kraske procedure 2.2%) was performed 6-8 weeks later. If patients were downstaged to ypT0-1 without unfavourable factors (good responders), this was deemed definitive treatment. Immediate conversion to radical surgery was recommended for remaining patients. RESULTS: Good response to radiation was seen in 67.2% of patients in the short-course group and in 80.0% in the chemoradiation group, p = 0.30. Local recurrence at 2 years (median follow-up) in good responders was 11.8% in the short-course group and 6.2% in the chemoradiation group, p = 0.53. In the total group, a lower rate of local recurrence at 2 years was observed in elderly patients (>69 years, median value) when compared to the younger patients; 8.3% vs. 27.7%, Cox analysis hazard ratio 0.232, p = 0.016. A total of 18 patients initially managed with local excision required conversion to abdominal surgery but either refused it or were unfit. In this group, local recurrence at 2 years was 37.1%. CONCLUSIONS: This study suggests an acceptable local recurrence rate after preoperative radiotherapy and local excision of small, radiosensitive tumours in elderly patients.

Estimation of groin recurrence risk in patients with squamous cell vulvar carcinoma by the assessment of marker gene expression in the lymph nodes.

BACKGROUND: Regional lymph node (LN) status is a well-known prognostic factor for vulvar carcinoma (VC) patients. Although the reliable LN assessment in VC is crucial, it presents significant diagnostic problems. We aimed to identify specific mRNA markers of VC dissemination in the LN and to address the feasibility of predicting the risk of nodal recurrence by the patterns of gene expression. METHODS: Sentinel and inguinal LN samples from 20 patients who had undergone surgery for stage T(1-3), N(0-2), M(0) primary vulvar squamous cell carcinoma were analyzed. Gene expression profiles were assessed in four metastatic [LN(+)] and four histologically negative [LN(-)] lymph node samples obtained from four VC patients, by the Affymetrix U133 Plus 2.0 gene expression microarrays. Of the set of genes of the highest expression in the metastatic LNs compared to LN(-), seven candidate marker genes were selected: PERP, S100A8, FABP5, SFN, CA12, JUP and CSTA, and the expression levels of these genes were further analyzed by the real-time reverse transcription polymerase chain reaction (qRT-PCR) in 71 LN samples. RESULTS: All of the seven genes in question were significantly increased in LN(+) compared to LN(-) samples. In the initial validation of the seven putative markers of metastatic LN, the Cox proportional hazard model pointed to SFN, CA12 and JUP expression to significantly relate to the time to groin recurrence in VC patients. CONCLUSIONS: Our findings first provided evidence that SFN, CA12 and JUP have a potential of marker genes for the prediction of the groin recurrence LN in VC patients.

Lack of microsatellite instability in squamous cell vulvar carcinoma.

Mutator phenotypes with microsatellite instability (MSI) are observed in a subset of solid tumors. The objective of our study was to investigate the occurrence of MSI in vulvar squamous cell carcinoma (VSCC) and a possible relation between MSI and the presence of human papilloma virus (HPV). DNA samples from 44 tissue specimens of the primary VSCC as well as from six metastatic lymph node samples were analysed and compared with matched reference DNA from blood samples. The MSI status was examined by polymerase chain reaction (PCR) using the Bethesda panel of five microsatellite markers. PCR products were analysed by fluorescent capillary electrophoresis. No microsatellite instability was detected in tumor samples or in metastatic lymph nodes from any of the VSCC patients examined. Microsatellite instability seems not to play a major role in the carcinogenesis of VSCC and is probably not associated with the HPV-related genetic background of this neoplasm.

Mitochondrial genotype in vulvar carcinoma - cuckoo in the nest.

Vulvar squamous cell carcinoma (VSCC) is a rare female genital neoplasm. Although numerous molecular changes have been reported in VSCC, biomarkers of clinical relevance are still lacking. On the other hand, there is emerging evidence on the use of mtDNA as a diagnostic tool in oncology. In order to investigate mtDNA status in VSCC patients, haplogroup distribution analysis and D-loop sequencing were performed. The results were compared with available data for the general Polish population, cancer free-centenarians as well as patients with endometrial and head and neck cancer. The obtained data were also compared with the current status of mitochondrial databases. Significant differences in haplogroup distribution between VSCC cohort, general Polish population and cancer-free centenarians cohort were found. Moreover, a correlation between the VSCC patients haplogroup and HPV status was observed. Finally, a specific pattern of mtDNA polymorphisms was found in VSCC. Our results suggest that the mitochondrial genetic background may influence the risk of VSCC occurrence as well as susceptibility to HPV infection.

Squamous cell carcinoma antigen 1 and 2 expression in cultured normal peripheral blood mononuclear cells and in vulvar squamous cell carcinoma.

Squamous cell carcinoma antigen (SCCA) is expressed in normal squamous cell epithelia and in squamous cell carcinomas (SCC). Two nearly identical genes encode the inhibitory serpins SCCA1 (SERPINB3) and SCCA2 (SERPINB4). Serum levels of SCCA are elevated in patients with benign skin diseases and in patients with SCC. SCCA, used for the monitoring of SCC patients, presents no satisfactory diagnostic specificity. As we have shown previously, the reverse transcription polymerase chain reaction (RT-PCR)-based SCCA messenger RNA (mRNA) testing aimed at detecting disseminated cancer cells may be hampered by the false-positive results due to SCCA expression in activated peripheral blood mononuclear cells (PBMC). The aim of this study was to assess the expression of SCCA at mRNA and protein levels in cultured normal PBMC, compared to that in vulvar SCC (VSCC) samples. High SCCA concentrations were found in vulvar tumours and in metastatic lymph nodes, while negative inguinal lymph nodes from the same patients often presented significantly less SCCA. In normal activated PBMC, the level of SCCA protein was the lowest. At the mRNA level SCCA was detectable in normal PBMC even in cultures with no mitogen stimulation, but only by the nested RT-PCR, contrary to VSCC samples found to be SCCA positive already in one-step PCR. Both SCCA1 and SCCA2 transcripts were present in cultured PBMC; SCCA1 was expressed at a higher level than SCCA2. In conclusion, both SCCA forms are detectable in normal PBMC cultured in vitro. SCCA expression level in normal PBMC is much lower than in the squamous epithelium-derived cells. In VSCC, in addition to tumour itself, metastatic lymph nodes seem also to be a potential source of serum SCCA.

The frequency of human papillomavirus infection in polish patients with vulvar squamous cell carcinoma.

INTRODUCTION: Vulvar cancer is a rare condition representing about 4% of all female genital tract tumors. In contrast to the established relationship of virtually all cervical cancer cases with the human papillomavirus (HPV) infection, the reported HPV positivity in vulvar carcinoma ranges widely. METHODS: Using the Linear Array HPV Genotyping Test, we investigated the HPV incidence in a group of 46 Polish patients with vulvar squamous cell carcinoma (age range, 37-93 years; median age, 70.2 years) in clinical stages T1-2, N0-2, and M0. RESULTS: The presence of HPV DNA was confirmed in 7 of 46 (15%) primary tumor samples. HPV 16 was found in 5 tumors (71%). HPVs 6 and 58 were detected in the remaining 2 cases of virus-associated tumors. CONCLUSIONS: We conclude that a fraction of cancers of vulva associated with HPV is insignificant, given the HPV prevalence of 8.6% in the Polish population aged 55 to 59 years (the oldest cohort of Polish women studied to date).

The accuracy of the sentinel lymph node concept in early stage squamous cell vulvar carcinoma.

OBJECTIVE: The purpose of the study was to determine the feasibility and accuracy of the sentinel lymph node (SLN) identification in vulvar carcinoma patients. METHODS: Sixty-two patients with clinical early stage vulvar cancer underwent SLN detection procedure, followed by a complete inguinofemoral lymphadenectomy. The SLN was identified intraoperatively using lymphoscintigraphy with technetium-99m as well as patent blue V staining. The resected lymph nodes (LN) were submitted for histological examination by hematoxylin-eosin staining (H-E) and cytokeratin immunohistochemistry (IHC) and examined by the reverse transcriptase-polymerase chain reaction (RT-PCR) assay. RESULTS: A total of 109 inguinal LN were dissected in 56 patients. SLNs were identified in 76% groins with patent blue V and in 99% with the use of Tc-99m. The accuracy differed significantly (p<0.0001). An H-E examination combined with IHC revealed 7 false-negative SLNs. The sensitivity of this method was 73% (95% CI, 64% to 81%) and the negative predictive value for a negative SLN finding was 92% (95% CI, 87% to 97%). The RT-PCR assay showed 8 false-negative SLNs. The sensitivity of the RT-PCR-based assay was 83% (95% CI, 75% to 90%) and the negative predictive value for a negative SLN was 88% (95% CI, 82% to 94%). The two diagnostic methods were found not to differ significantly. CONCLUSIONS: In SLN mapping, the Tc-99m colloid lymphoscintigraphy is superior to the blue dye staining. Our data do not support the concept of the SLN identification as a highly accurate procedure in predicting the inguinofemoral LN status in patients with early stage vulvar cancer.

Combined therapy: surgery and intraoperative HDR brachytherapy for locally advanced and recurrent rectal cancer. Practical experience of Brachytherapy Department in Warsaw.

PURPOSE: Patients with locally advanced and recurrent rectal cancer have a dismal prognosis. The aim of proposed combined therapy - surgery and intraoperative brachytherapy, is to improve results of already applied methods and to define optimal group of patients for this treatment. We introduce practical experience of Brachytherapy Department in Cancer Centre - Institute in Warsaw. MATERIAL AND METHODS: Patients with primary T4NxM0 rectal cancer and isolated local pelvic recurrence were qualified for therapy. Between January 2005 and September 2008, 13 patients were included: 4 with primary cancer and 9 with recurrence, median age of 56. After surgical resection intraoperative radiotherapy was delivered with boost of high dose rate brachytherapy of 20Gy dose to the tumor bed. RESULTS: Primary point of the study is to evaluate impact of applied therapy on local control (LC), overall survival (OS) and disease free survival (DFS). Median follow-up is 16 months. Four of the patients died and 3 survivors are disease-free. There was no case of perioperative mortality. CONCLUSIONS: A multimodality approach, using surgical resection with intra operative brachytherapy improves local control as well as patients survival in comparison with historical treatment group. Combined therapy is related to high morbidity, but low mortality. The preliminary observations seem to correspond with other authors data.

Detection of carbonic anhydrase 9-expressing tumor cells in the lymph nodes of vulvar carcinoma patients by RT-PCR.

Regional lymph node status is an important prognostic factor for vulvar cancer. The goal of our study was to elaborate a reliable test for detecting micrometastases, undetectable by traditional methods, in the lymph nodes of vulvar squamous carcinoma patients. For this purpose, carbonic anhydrase-9 (CA9) was investigated as a cancer-related marker by RT-PCR. Firstly, primary carcinoma specimens were examined for CA9 expression by immunohistochemistry with M75 monoclonal antibody. All 19 tissues exhibited a variable degree of staining, which was mostly confined to the plasma membranes of tumor cells. Correspondingly, all primary tumor specimens and the control A-431 vulvar cancer cell line gave a positive signal in the nested RT-PCR assay designed to detect CA9-expressing cells with a high sensitivity. Analysis of 77 lymph node specimens from 20 patients revealed a full correlation between RT-PCR results and standard hematoxylin-eosin staining in 75% of samples, whereas 25% of specimens were negative by the standard method and positive for CA9 mRNA, accounting for 28% of all histologically negative lymph nodes. There were no false-negatives with RT-PCR. A positive inguinal lymph node with a negative sentinel node was observed in the same groin only once in 38 specimens. Our findings clearly indicate potential value of CA9 as a molecular marker for the assessment of regional lymph node status in vulvar cancer patients and support a possible utility of our RT-PCR assay in the detection of micrometastases.

[Disseminated peritoneal leiomyomatosis--case report and literature review]. / Rozsiana miesniakowatosc sródotrzewnowa--leiomyomatosis peritonealis disseminata (LPD) opis przypadku i przeglad pismiennictwa.

Leiomyomatosis peritonealis disseminata(LPD) is a rare smooth muscle pathology, characterized by the presence of multiple tumors in peritoneal cavity mimicking a malignant process with metastases. The diagnosis may be difficult in some cases as the results of ultrasonography and CT imaging may suggest malignancy. The final diagnosis was made on biopsy and pathologic examination performed during surgery. Exposure to estrogens probably plays the main etiologic role. In this report we describe the diagnostic difficulties and the clinical course of LPD in 45 year old women. The surgical treatment consisted on hysterectomy and removal of multiple nodules located in intestinal serosa. The additional hormonal treatment with GnRh agonist was applied. This report documents the possibility of effective surgical and hormonal treatment.

[Risk of lymph node metastases in patients with ovarian cancer]. / Ryzyko przerzutów do wezlów chlonnych u chorych na raka jajnika.

AIM: The aim of this study was the assessment of incidence of the lymph node spread in patients with ovarian cancer. Additionally, some of clinical and histopathology factors, as well as patients age were analyzed in relation with lymph nodes metastases. MATERIAL AND METHOD: Based on 112 operations performed in patients with ovarian cancer FIGO stage I-IV, analysis of pelvic and paraaortic lymph node metastasis was carried out. In this group only in 70 patients paraaortic lymph nodes were removed. The rest of patients underwent pelvic lymphadenectomy only because of poor general condition or very intensive cytoreductive surgery. Statistical analysis was provided using unvaried regression test and Pearson test. RESULTS: In early stages of ovarian cancer (I and II) the percent of patients with involved lymph nodes was 17.4 and in advanced stages 37.9. Strong correlation between involvement of pelvic and paraaortic lymph nodes was seen. The most frequent localization of lymph node metastases was the site around intercrossing of left renal vein and aorta. It should be stressed that in 8 cases isolated paraaortic metastases were seen. Risk factors of lymph node metastases were clinical stage, tumor grade and age of patients. Clear cell carcinoma and mixed carcinoma had also prognostic significance. CONCLUSION: This analysis proved that incidence of lymph node metastases was high even in early stage, and therefore lymphadenectomy should be an integral part of standard surgical procedures in patients with ovarian cancer.

[Surgical treatment of an isolated liver metastasis from endometrial cancer]. / Leczony chirurgicznie przerzut raka endometrium do watroby.

One of the principal features of the malignant process is the ability of the tumor to form metastases. In case of endometrial cancer pelvic and paraaortic lymph nodes and ovaries are the most frequent sites of metastases. In some cases metastases to the distant sites like the lungs and liver occur. The diagnosis of stage IVB disease bears a poor prognosis. Only a form of palliative treatment is usually offered to those unfortunate woman. The authors present a case of successful surgical treatment an isolated liver metastasis from endometrial cancer.