Well differentiated endometrioid adenocarcinoma of the uterus: a cancer unit or centre case?

OBJECTIVE: The purpose of this study was to investigate what proportion of cases showing a well differentiated endometrioid endometrial adenocarcinoma in the hysterectomy specimen removed at two UK cancer centres had adverse pathological features or advanced stage disease at the time of presentation. STUDY DESIGN: Ninety-eight patients who were operated on at either the South East London Cancer Centre, London or the Kent Oncology Centre, Maidstone had a histological diagnosis of well differentiated (grade 1) endometrioid adenocarcinoma in their hysterectomy specimen. These were identified using the multidisciplinary meeting database as well as the respective pathology department databases. The histology reports for these patients were examined and analysed for the purpose of this study. RESULTS: Of the initial 98 cases, 65 patients (66.3%) were referred with a preoperative curettage showing a well differentiated endometrioid adenocarcinoma, 25 cases (25.5%) were referred with atypical endometrial hyperplasia, seven patients (7.1%) were referred with a moderately differentiated endometrioid adenocarcinoma, and one case (1.0%) was referred with a possible malignant mixed Mullerian tumour. Subsequent histological examination of the hysterectomy specimens revealed that all of these cases had a well differentiated endometrioid adenocarcinoma. In 20 of the 98 cases (20.4%) there was no myometrial invasion, 56 cases (57.1%) showed invasion of the inner half of the myometrium and 22 cases (22.4%) showed outer half involvement. There was no cervical involvement in 78 cases (79.6%), endocervical gland involvement in eight patients (8.2%) and cervical stromal involvement in 12 patients (12.2%). The total percentage of cases with cervical involvement was 20.4%. Thirty-eight cases (out of the 98) underwent a bilateral pelvic lymphadenectomy. Of these 38 cases, four cases had locoregional nodal metastases (10.5% of the patients who underwent lymphadenectomy). There were ovarian metastases in one case and metastasis to one fallopian tube in another. From our study, 33.6% of cases with a well differentiated endometrioid adenocarcinoma of the uterus were Stage Ic or more at the time of presentation; 12.2% were at least FIGO Stage Ic, eight patients (8.2%) were FIGO Stage IIa, seven patients (7.1%) were Stage IIb and six patients (6.1%) were Stage III. In these patients a full surgical staging operation with a pelvic lymphadenectomy was indicated according to FIGO recommendation. CONCLUSION: A significant proportion (33.6%) of well differentiated tumours in a hysterectomy were found to have Stage Ic disease or more at the time of presentation, and thus full surgical staging including a lymphadenectomy should have been carried out in these cases. Cases with a preoperative biopsy showing atypical hyperplasia or well differentiated adenocarcinoma should have a preoperative MRI scan or preferably an intraoperative frozen section examination to identify those cases with adverse pathological features which need to be fully staged with pelvic and paraaortic lymphadenectomy.

Accuracy of frozen section diagnosis at surgery in pre- malignant and malignant lesions of the endometrium.

OBJECTIVE: The purpose of this study was to correlate the histological diagnosis made during intraoperative frozen section examination of hysterectomies with atypical hyperplasia or carcinoma, with the definitive paraffin section histology. STUDY DESIGN: Frozen section pathology results of patients with a preoperative biopsy showing atypical hyperplasia or endometrial carcinoma (87 patients) were compared retrospectively with paraffin section pathology findings. Those patients with curettage specimens showing atypical hyperplasia or curettings suspicious of endometrioid carcinoma had intraoperative frozen section to determine whether an invasive lesion was present and whether they required pelvic lymphadenectomy. The purpose of frozen section assessment in those patients who had a preoperative curettage specimen showing endometrial carcinoma was to identify poor prognostic pathological factors related to histological subtype, grade, depth of myometrial invasion and cervical involvement. RESULTS: The correlation between frozen sections and paraffin histology in patients with endometrial carcinoma was 98.6% (69/70) for histological sub-type and 84.3% (59/70) for grade of differentiation. Depth of myometrial invasion was accurately diagnosed in 94.3% (66/70) while cervical involvement was accurately assessed in 86.7% (52/60). Of the 37 patients with atypical hyperplasia or suspicious curettings on preoperative curettage who had intraoperative frozen section, 23 patients had invasive malignancy, which was confirmed in subsequent paraffin sections. Of the remaining 14 patients with a non-malignant frozen section diagnosis, 11 were confirmed with paraffin sections while three had a small well differentiated invasive lesion, two were FIGO Stage 1a and one had microscopic invasion into the myometrium. CONCLUSION: Intraoperative frozen section is a useful procedure to identify poor prognostic pathological factors as well as to diagnose endometrial cancer in patients undergoing hysterectomy for a preoperative biopsy diagnosis of atypical hyperplasia.

M2-PK as a novel marker in ovarian cancer. A prospective cohort study.

BACKGROUND: Pyruvate kinase isoenzyme M2-PK is instrumental to tumour metabolism and hence over-expressed in tumour cells leading to detectable plasma concentrations. OBJECTIVES: To assess the degree of association between M2-PK plasma concentrations and ovarian cancer and to determine the cut-off values for its sensitivity and specificity for differentiating between benign and malignant ovarian disease. SETTINGS: The Gynaecological Cancer Centre at both King's College and St. Thomas' Hospitals, London, UK. METHODS: Patients with suspected ovarian cancer referred to the above centre were recruited prospectively during the years 2004-2005. Blood samples were collected before surgery for plasma M2-PK assays. Results were assessed with respect to cancer diagnosis, patient and tumour characteristics. Statistical analysis including the receiver operator characteristic (ROC) curve was performed using Analyse-It and SPSS V 13. RESULTS: 100 patients with age range 14-88 years and a median of 57 years were recruited in the study. Of whom 52 were diagnosed with invasive ovarian cancer. Of these 35 (67%) were Stage III and above with two secondary tumours. M2-PK was not related to patient age (p = 0.43). There was a significant correlation between CA125 and M2-PK (p < 0.001). The mean M2-PK concentration in cancer patients was 52 U/ml versus 27 U/ml in patients with benign conditions (p < 0.001). At a cut-off value of 22 U/ml the sensitivity of M2-PK for detecting cancer was 70% with a specificity of 65%. CONCLUSION: M2-PK was significantly raised in ovarian cancer patients, however its role in clinical practice needs further evaluation.

Tumour M2-PK as a predictor of surgical outcome in ovarian cancer, a prospective cohort study.

BACKGROUND: Optimal cytoreduction is a major prognostic factor in ovarian cancer; several clinical, radiological and biochemical predictors have been studied. Tumour M2-PK (TU M2-PK) is over-expressed in tumour cells and can be detected in plasma samples but its role in ovarian cancer has not yet been evaluated. OBJECTIVES: To assess the potential clinical applications of TU M2-PK in ovarian cancer particularly in relation to surgical cytoreduction. SETTINGS: The Gynaecological Cancer Centre at both King's College and St Thomas' Hospitals; London; UK. METHODS: Patients with suspected ovarian cancer were recruited prospectively during the years 2004-2005. Blood samples were collected before surgery for plasma TU M2-PK assays. Data were analysed in relation to cancer diagnosis and outcome. Statistical analysis was performed using Analyse-It' and SPSS' V13. RESULTS: 100 patients were recruited; 52 diagnosed with invasive ovarian cancer, 13 with borderline tumours and 35 patients had benign conditions. The mean M2-PK concentration in cancer patients was 52 U/ml vs 31 U/ml in patients with borderline tumours and 22 U/ml in those with benign conditions (p < 0.001); it was significantly raised in association with late stage disease and higher grade (p < 0.05). Taking 35 U/ml as a reference point, TU M2-PK predicted sub-optimal cytoreduction in advanced stage disease with a sensitivity of 69%, specificity of 60% and overall efficacy of 61% (95% CI: 44-75%). CONCLUSION: TU M2-PK was significantly raised in ovarian cancer patients, particularly those with higher stage disease. The potential clinical application as a predictor of surgical outcome in ovarian cancer needs further evaluation.

Malignant potential of gigantic condylomatous lesions of the vulva.

A diagnostic and therapeutic approach in the identification of malignant lesions and the types of HPV in 11 patients with gigantic condylomatous vulvar protuberances is presented. Different histological types of squamous cell vulvar carcinoma have been found in 8 (72.7%) cases: condylomatous (4), verrucous (3) and basaloid type of the carcinoma (1). HPV type 16, confirmed in 5 cases, was most often present (4 condylomatous and 1 basaloid carcinoma types). Other types of HPV such as HPV-6 was detected in 3 cases of verrucous, type 11 in 2 cases of verrucous and condylomatous carcinoma and type 18 in 1 case of condylomatous carcinoma. Radical vulvectomy followed by bilateral inguinofemoral lymphadenectomy was performed in 4 patients with condylomatous carcinoma, hemivulvectomy in basaloid carcinoma whereas wide local excision was performed in the verrucous type of carcinoma. No patient died except 1 with condylomatous carcinoma in whom 6 positive lymph nodes were detected after the primary operation. The patient died 4 years later following 3 excisions of local recurrences.

Heat-shock protein 27 (HSP27) and its role in female reproductive organs.

Heat shock, other environmental and pathophysiological stress stimulate synthesis of heat shock proteins (HSP) family. These proteins enable the cell to survive and recover from stressful conditions but as yet incompletely understood mechanisms. Beside its role in thermotolerance, it plays a role in cell proliferation and drug resistance which makes this protein of special clinical interest. Published data suggest that HSP27 is related to estrogen in breast and to estrogen and progesterone in the endometrium. It has been shown that some but not all estrogen positive breast cancers express HSP27, and overexpression has been associated with the degree of tumor differentiation, and response to hormonal therapy (Tamoxifen). In endometrial carcinomas, the presence of HSP27 is correlated with the degree of tumor differentiation as well as with the presence of oestrogen and progesterone receptors. Studies suggest that detection of HSP27 in endometrial carcinoma, should not be considered as a method for identifying hormone-responsive tumors or indicator or presence of estradiol receptors. In the cervix HSP27 is a marker of cell differentiation, and is highly expressed during the process of squamous metaplasia. Expression in the ovary is still controversial and requires further confirmation of recent observations.

Development of an evidence-based algorithm for the management of cervical cancer.

OBJECTIVE: To develop a description of the management of cervical cancer to support locally developed, regional guidelines and to identify the level of primary research evidence to support it. DESIGN: Development of a flow-charted algorithm, using regional guidelines and clinician consensus. A Medline literature search for primary research was done to validate the algorithm and selection of papers, to verify if they were valid according to pre-defined criteria and to compare algorithm management with an alternative. MAIN OUTCOME MEASURE: The highest level of evidence for algorithm management was based on the design of the supporting research. RESULTS: Twenty percent of the algorithm is supported by level I evidence (randomised controlled trials), 70% by level II evidence (cohort studies) and 10% by level IV evidence (expert opinion or case series). Level II evidence supports the management of Stage Ia, squamous cell carcinoma by cone biopsy or a simple hysterectomy. This level of evidence also applies to research on the management of Stages Ib-IIa, by radical hysterectomy and pelvic lymphadenectomy followed by radiotherapy, if the lymph nodes are positive. Radiotherapy to treat Stages IIb-IV cervical cancer is supported by level I evidence. The management of Stage I adenocarcinoma is supported by level II evidence. CONCLUSIONS: Evaluations of the effect of informing clinicians of the strengths of the proposed management are now required, as constructing evidence-based algorithms is worthwhile, only if they are likely to affect clinical practice.

Development of an evidence-based algorithm for the management of ovarian cancer.

OBJECTIVE: To describe the management of ovarian cancer to be undertaken by a gynaecologist and to describe the highest level of primary research evidence supporting it. DESIGN: Use of regional guidelines and semi-structured interviews with gynaecological oncologists to devise a flow-chart algorithm for management. Use of an algorithm to identify the key research questions and to define search strategies for primary research, which was assessed using pre-defined criteria for validity. MAIN OUTCOME MEASURES: Highest level of evidence for each research question based on the design of the valid studies. RESULTS: Prospective cohort studies (level II-2A) support the algorithm's diagnostic procedures. The evidence for accurate staging is derived from case series data (level II-2B). Preserving the uterus in young women wishing to maintain fertility is supported by prospective cohort studies (level II-2A) and by case series data (level IV) for women with germ cell tumours. Prospective cohort studies (level II-2A) support surgical management with hysterectomy, bilateral oophorectomy and debulking. The evidence for chemotherapy comes from randomised controlled trials (level I), except for germ cell tumours where the evidence was from case series data (level IV). CONCLUSIONS: The management of ovarian cancer and the level of evidence supporting it can be described using a flow-chart algorithm. Evaluations of whether this presentation helps consultants follow guidelines are required.

Tumor lymphocytes in patients with advanced ovarian cancer: changes during in vitro culture and implications for immunotherapy.

Tumor specimens and ascites of patients with advanced ovarian cancer were utilized to obtain both primary ovarian carcinoma cell cultures and lymphocytes: tumor-infiltrating lymphocytes (TILs) from solid tumor tissue and tumor-associated lymphocytes (TALs) from peritoneal fluid. Tumor lymphocytes were grown in coculture with autologous tumor cells and recombinant human IL-2 (rhIL-2) for up to 4 weeks and at weekly intervals these were examined with respect to phenotype and cytotoxicity. The phenotype was studied using flow cytometry for a variety of human immunocompetent cell surface markers (CD3, CD4 CD8, CD16, CD56, TCR alphabeta, TCRgammadelta). Cytotoxicity was investigated using 4-hr 51Cr-release assays with the primary ovarian carcinoma cell cultures and the K562 cell line as target cells. The tumor lymphocytes did not demonstrate any obvious trend in phenotype changes during culture, although for different cultures a large range was noted for the various lymphocyte populations studied. Cytotoxicity against both autologous and allogeneic targets declined with culture length for the majority (6/7) of the lymphocyte cell lines tested (greatest at 1 week and least at 3 weeks). These initial results indicate that an in vitro non-MHC-restricted cytotoxic function of peritoneal lymphocytes can be effectively activated with IL-2 and autologous tumor cells. However, if activated lymphocytes are to be employed as a form of immunotherapy, they should be given within the first week of culture for maximum cytotoxic effect.

IL-2 enhances standard IFNgamma/LPS activation of macrophage cytotoxicity to human ovarian carcinoma in vitro: a potential for adoptive cellular immunotherapy.

OBJECTIVE: The objective was to evaluate the enhancement of human peritoneal macrophage cytotoxic in vitro activity by the addition of interleukin-2 (IL-2) to the standard interferon gama (IFNgamma) and lipopolysaccharide (LPS) activation procedure used for cellular adoptive immunotherapy in a human ovarian cancer system. This cytotoxic effect of these activated macrophages was tested on cells from ovarian cancers of various stages, histology type, and grade, both prior to chemotherapy and at recurrence, in ovarian carcinoma cells lines and normal cells. Increased activation of the macrophage may make it a better candidate for intraperitoneal cellular adoptive immunotherapy as a component of ovarian cancer therapy. This was not a study of the mechanism of macrophage killing. METHODS: Ascites specimens were collected from 24 ovarian cancer patients at the time of surgery or by paracentesis. The mononuclear cell fraction was isolated by discontinuous density gradient centrifugation and used as a cellular source of peritoneal macrophages (PMs) and primary cultured ovarian cancer cells. PMs were separated by 1-h adhesion followed by intensive washing to remove floating cells. The floating cells were cultured for 24 h which left the cancer cells attached after unattached cells were removed by washing. These cells formed a monolayer of cancer cells, which could be subcultured in 22 patients. The cells from the third to fifth passages were used as target cells without coculture with other cells. PMs were identified by latex ingestion, and their purity after isolation by adhesion culture was tested by flow cytometry and immunofluorescence. PMs were activated by culturing in the presence of IFNgamma, with or without IL-2, for 18 h followed by the addition of LPS 6 h prior to use as effector cells in cytotoxicity assays. Ovarian cancer cells of both established cell lines and primary cultures were labeled with (51)Cr and utilized as target cells to quantitatively measure PM-mediated cytotoxicity. Ovarian cancer cells were also cocultured with PMs for morphologic observations to provide supporting evidence to the cytotoxicity assays. RESULTS: IL-2 enhances the cytotoxicity of the standard IFNgamma/LPS macrophage activation in this system. Peritoneal macrophages so activated are cytotoxic to autologous and allogenic primary cultured ovarian tumors and to ovarian carcinoma cell lines. The macrophages are cytotoxic to cells both prior to treatment and at recurrence, but the data from the few recurrent patients did reach statistical significance. This cytotoxicity is not MHC associated. Normal cells are minimally affected. CONCLUSIONS: IL-2 augmented the standard IFNgamma/LPS method of activating peritoneal macrophage cell killing of human ovarian cancer cells in this in vitro system. The cell killing occurred with autologous and allogenic tumor cells from patients with primary and possibly recurrent tumors. Activated PMs minimally affected the normal cells tested. This enhanced activation may improve the disappointing results of previous adoptive cellular immunotherapy human trials and should be considered for ovarian cancer clinical trials.

Cholera toxin-induced alteration of the phenotype and behaviour of an ovarian carcinoma cell line, SR8.

Cholera toxin (CT) has been reported to cause a variety of effects on several different cell types. Recently, CT has been shown to increase the susceptibility of ovarian carcinoma cells to cytotoxicity mediated by a variety of effector cells (natural killer, lymphokine-activated killer cells and tumour-associated lymphocytes derived from ascites of ovarian cancer patients) of both autologous and allogenic background. In the present study, CT demonstrated several effects on a newly established ovarian carcinoma line (SR8)1 when added to the culture medium at a concentration of 12.5 ng/mL for 2 days. Cholera toxin altered SR8 morphology to a uniform polygonal cellular shape, with less cell dispersion than the non-CT treated cells. Cholera toxin prolonged the population doubling time by approximately 10 h. The CT-treated SR8 cells exhibited reduced epidermal growth factor receptor expression (39 versus 50%), and increased carbohydrate antigen 125 expression (45 versus 2%) in both immunocytochemical and quantitative flow cytometric analyses. These changes in morphology and tumour marker expression were reversible when CT was removed from the culture. The CT-treated SR8 cells showed reduced capacity to generate tumours in female nude mice in comparison with non-CT treated cells, which produce both subcutaneous and intraperitoneal xenografts with local invasion in an animal model. Cytogenetic analysis of the cell line SR8 before and during treatment with CT showed no new clonal rearrangements. The possible mechanisms involved and the influence of CT on the biological behaviour of ovarian tumour cells are discussed.