Differential expression of mTOR components in endometriosis and ovarian cancer: Effects of rapalogues and dual kinase inhibitors on mTORC1 and mTORC2 stoichiometry.

Endometriosis is a well­known risk factor for ovarian cancer. The genetic changes that characterise endometriosis are poorly understood; however, the mechanistic target of rapamycin (mTOR) pathway is involved. In this study, we investigated the expression of key mTOR components in endometriosis and the effects of rapalogues using an endometrioid ovarian carcinoma cell line (MDAH 2774) as an in vitro model. Gene expression of mTOR, DEPTOR, Rictor and Raptor was assessed by qPCR in 24 endometriosis patients and in silico in ovarian cancer patients. Furthermore, the effects of Rapamycin, Everolimus, Deforolimus, Temsirolimus, Resveratrol, and BEZ235 (Dactolisib, a dual kinase inhibitor) on mTOR signalling components was assessed. mTOR showed a significant increase in the expression in endometriosis and ovarian endometrioid adenocarcinoma patients compared to non­affected controls. DEPTOR, an inhibitor of mTOR, was downregulated in the advanced stages of ovarian cancer (III and IV) compared to earlier stages (I and II). Treatment of MDAH­2774 cells with the mTOR inhibitors resulted in the significant upregulation of DEPTOR mRNA, whereas treatment with rapamycin and BEZ­235 (100 nM) resulted in downregulation of the mTOR protein expression after 48 h of treatment. None of the treatments resulted in translocation of mTOR from cytoplasm to nucleus. Upregulation of DEPTOR is a positive prognostic marker in ovarian cancer and is increased in response to mTOR pathway inhibition suggesting that it functions as a tumour suppressor gene in endometrioid ovarian carcinoma. Collectively, our data suggest the mTOR pathway as a potential connection between endometriosis and ovarian cancer and may be a potential target in the treatment of both conditions.

Differential effects of rapalogues, dual kinase inhibitors on human ovarian carcinoma cells in vitro.

Ovarian cancer is the second most common gynaecological malignancy and was diagnosed in over 7,000 women in 2011 in the UK. There are currently no reliable biomarkers available for use in a regular screening assay for ovarian cancer and due to characteristic late presentation (78% in stages III and IV) ovarian cancer has a low survival rate (35% after 10 years). The mTOR pathway is a central regulator of growth, proliferation, apoptosis and angiogenesis; providing balance between available resources such as amino acids and growth factors, and stresses such as hypoxia, to control cellular behaviour accordingly. Emerging data links mTOR with the aetiopathogenesis of ovarian cancer. We hypothesised that mTOR inhibitors could play a therapeutic role in ovarian cancer treatment. In this study we began by validating the expression of four main mTOR pathway components, mTOR, DEPTOR, rictor and raptor, at gene and protein level in in vitro models of endometrioid (MDAH­2774) and clear cell (SKOV3) ovarian cancer using qPCR and ImageStream technology. Using a wound healing assay we show that inhibition of the mTOR pathway using rapamycin, rapalogues, resveratrol and NVP BEZ-235 induces a cytostatic and not cytotoxic response up to 18 h in these cell lines. We extended these findings up to 72 h with a proliferation assay and show that the effects of inhibition of the mTOR pathway are primarily mediated by the dephosphorylation of p70S6 kinase. We show that mTOR inhibition does not involve alteration of mTOR pathway components or induce caspase 9 cleavage. Preclinical studies including ovarian tissue of ovarian cancer patients, unaffected controls and patients with unrelated gynaecological conditions show that DEPTOR is reliably upregulated in ovarian cancer.

The pro-social neurohormone oxytocin reverses the actions of the stress hormone cortisol in human ovarian carcinoma cells in vitro.

The journey patients with ovarian cancer travel from non-specific symptoms causing delayed diagnosis through surgery and chemotherapy, culminating in a 5-year survival rate of 43%, must have a profound and detrimental psychological impact on patients. Emerging studies link higher levels of oxytocin (OT) and increased social support, an independent prognostic factor in cancer, with a moderating effect on stress. In contrast, there is a known association of tumour cell proliferation with elevated cortisol (stress hormone) levels. We hypothesise therefore that there is cross-talk between cortisol and oxytocin at a molecular level. Three ovarian cancer cell lines, used as in vitro models, were treated with cortisol at concentrations mimicking physiological stress in vivo in the presence or absence of OT. OT reduced cell proliferation and migration, induced apoptosis and autophagy for all three cell lines, partially reversing the effects of cortisol. Quantitative RT-PCR of tissue taken from ovarian cancer patients revealed that the glucocorticoid receptor (splice variant GR-P) and OT receptor (OTR) were significantly upregulated compared to controls. Tissue microarray revealed that the expression of GRα was lower in the ovarian cancer samples compared to normal tissue. OT is also shown to drive alternative splicing of the GR gene and cortisol-induced OTR expression. OT was able to transactivate GR in the presence of cortisol, thus providing further evidence of cross-talk in vitro. These data provide explanations for why social support might help distressed ovarian cancer patients and help define novel hypotheses regarding potential therapeutic interventions in socially isolated patients.

Surgery for ureteral repair after gynaecological procedures: a single tertiary centre experience.

PURPOSE: This study evaluates the frequency of ureteral repair and its management in patients with a history of gynaecologic surgery. MATERIALS AND METHODS: After retrospective review of the medical records of all major gynaecologic operations performed over a six-year period (2004-2010), 17 cases of ureteral repair were identified. The indication and the type of gynaecological surgery, the anatomic site, the indication, the type of ureteral repair and the associated morbidity were analyzed. RESULTS: Ureteral repair was necessary in 17 (0.26 %) out of 6,422 patients who had undergone a gynaecological operation. The indication for surgery was fibroma in 6 cases (0.11 %) out of 5,481 and malignancy in 11 cases (1.17 %) out of 941. Ureteral damage was recognized intraoperatively in eight patients and postoperatively in nine with a mean delay of 13.1 days (range 1-29). Indications for ureteral repair were ligation (11.8 %), laceration (11.8 %), partial or total accidental transection (29.5 %), metastasectomy due to tumor infiltration (17.4 %) and fistula formation (29.5 %). Ureteral repair was accomplished by ureteroneocystostomy (70.6 %), ureteroureterostomy (5.9 %), insertion of a double-j stent (17.6 %) and Boari-Ockerblad flap (5.9 %). Febrile morbidity was the most common postoperative symptom (29.0 %), followed by wound infection (18 %) and ileus (1 %). One patient (5.9 %) developed hydronephrosis due to ureteric stenosis as a late complication. CONCLUSIONS: Although the need for ureteral repair is relatively infrequent during gynaecological operations, prompt recognition and treatment within accepted guidelines result in successful outcome.

New insights of osmoregulatory system changes in ovarian hyperstimulation syndrome.

This study evaluated the osmoregulatory system changes in 39 patients with severe ovarian hyperstimulation syndrome. Plasma osmolality (Posm) less or more than 280 mOsm/kg body weight were associated with inappropriate antidiuretic hormone secretion syndrome and hypovolemia, respectively.

Comparison of diaphragmatic surgery at primary or interval debulking in advanced ovarian carcinoma: an analysis of 163 patients.

UNLABELLED: AIMS OF THE STUDY AND METHODS: Survival, complications and recurrences after diaphragmatic surgery at primary or interval debulking surgery were compared. One hundred and sixty three consecutive patients with stage III/IV ovarian cancer underwent diaphragmatic surgery between September 1993 and December 2007. Primary debulking was performed in group 1 (89) patients and interval debulking was performed in group 2 (74) patients. Cytoreductive outcome, overall survival (OS), disease-free survival (DFS) and post-operative complications were analysed. RESULTS: Despite differences in baseline mean age (p=0.015), in FIGO stage III/IV (p=0.036) and in mean largest diameter of metastatic disease at the beginning of debulking surgery (p=0.037), the optimal debulking rates (residual tumour less than 1cm) were similar (p=0.065). Excision of diaphragmatic metastases was most frequently performed in group 1 (77.53%) and coagulation was most frequently performed in group 2 (58.10%). Similar overall survival and disease-free survival rates were found. After the propensity matching procedure, the largest diameter of metastatic disease at the time of debulking and no residual tumour (complete debulking) were demonstrated as independent prognostic factors for OS. Plaque-like lesions on the diaphragm metastases were significantly (p=0.015) more associated with diaphragm recurrence than papillary lesions. Minor and major complications related to diaphragmatic surgery as well as mean operating time, post-operative care in intensive care unit and length of hospitalisation were significantly higher in group 1 rather than in group 2 (p=0.043). CONCLUSIONS: Diaphragmatic dissemination resulted in similar survival and cytoreductive rates after primary and interval debulking. However, the morbidity was less after interval debulking as fewer surgical procedures were performed.

The role of diaphragmatic surgery during interval debulking after neoadjuvant chemotherapy: an analysis of 74 patients with advanced epithelial ovarian cancer.

OBJECTIVES: The purpose of this retrospective study was to evaluate diaphragmatic surgery in achieving optimal cytoreductive results and its associated complications during interval debulking surgery in patients with advanced ovarian cancer. METHODS: After retrospective review of medical records, diaphragmatic surgery was performed in 74 of 128 consecutive patients with advanced epithelial ovarian cancer who underwent interval debulking, between September 1993 and December 2007. Four different approaches were performed: coagulation (group 1), stripping (group 2), combination of stripping with coagulation (group 3), and diaphragm full-thickness resection including muscle with pleura (group 4). Cytoreductive outcome, morbidity, overall survival, and disease-free survival were analyzed. RESULTS: Two patients (2.7%) had International Federation of Gynecology and Obstetrics stage IIIB disease; 46 (62.16%), stage IIIC; and 26 (35.13%), stage IV. After 3 to 4 cycles of neoadjuvant platinum-based chemotherapy, the diaphragmatic disease was coagulated in 43 patients (58.10%) and was only stripped in 10 (13.51%); in 19 patients (25.67%), a combination of these techniques was applied; and in 2 (2.70%), the disease was resected, with the adjacent infiltrated part of the diaphragmatic muscle and the pleura above it. Debulking to no residual was achieved in 95%, 100%, 100%, and 50% for groups 1, 2, 3, and 4, respectively. The median disease-free survival was 15, 14, and 14 months, and the median overall survival was 34, 30, and 51 months for groups 1, 2, and 3, respectively, and were not reached for group 4. Minor and major complications were comparable among the groups. Pleural effusions were the most frequent associated complication, and chest tube placement (1.3%) or thoracocentesis (4%) were necessary for the relief of respiratory distress. The perioperative mortality rate was 0%. CONCLUSIONS: Diaphragmatic surgery during interval debulking enhances optimal cytoreduction rates and improves survival with acceptable and manageable morbidity. In patients with thick (>4 mm) or large (>1 cm) lesions, stripping the diaphragm or full-thickness resection of the diaphragmatic muscle is preferred.

Laparoscopic management of the adnexal mass.

In the past few years the contribution of operative laparoscopy in all fields of gynecological surgery has been revolutionary. Nowadays laparoscopic management of adnexal masses is the most frequently performed laparoscopic intervention. Laparoscopy in comparison to laparotomy has the advantages of lower morbidity, shorter length of hospital stay, decreased postoperative pain, lesser de novo adhesion formation, better cosmetic results, faster recovery, and reduced overall cost of care. However, careful preoperative evaluation is important for the appropriate and successful use of laparoscopy for removal of adnexal masses and the advantages of the laparoscopic approach should, in no way, compromise the clinical outcome in women with malignancy. Patient's age, history, findings of physical examination, and the results of serum markers in combination with the imaging assessment, such as Doppler sonography, CT, or MRI, should be considered to reach the diagnosis preoperatively. However, only pathology of the adnexal mass can provide the definitive diagnosis. The specific characteristics of the adnexal masses in childhood, adolescent, reproductive, and postmenopausal age represent the essential parameters that will determine the therapeutic strategy to be followed. Furthermore, the clinician has to determine whether an adnexal mass requires surgery or expectant management as well as to estimate the possibility of malignancy.