Imaging and cancer of the cervix in low- and middle-income countries.

Cervix cancer is the fourth most common cancer globally but the second most cancer in women in resource-limited countries. It has remained a clinically-staged neoplasm as per the International Federation of Gynecology and Obstetrics staging classification. As the imaging machines are becoming more available worldwide, the resource-stratified guidelines recommended the inclusion of imaging whenever possible to guide treatment planning. In this report, the utility of imaging in low- and middle-income countries for diagnosis and treatment of cancer of the cervix will be reviewed.

Intraoperative high-dose-rate brachytherapy: An American Brachytherapy Society consensus report.

PURPOSE: This report presents recommendations from the American Brachytherapy Society for the use of intraoperative high-dose-rate (IOHDR) brachytherapy. METHODS AND MATERIALS: Members of the American Brachytherapy Society with expertise in IOHDR formulated this document based on their clinical experience and a review of the literature. This report covers the use of IOHDR in colorectal cancer, soft tissue sarcoma, gynecologic cancers, head and neck cancers, and pediatric cancers. This report does not cover intraoperative brachytherapy for breast cancer. Details about treatment planning and delivery are emphasized so this document can serve as a guide to practices implementing this technique. RESULTS: IOHDR brachytherapy is generally most beneficial for patients with either close or positive margins and/or recurrent disease in a previous resection bed or previously irradiated area. IOHDR brachytherapy requires a well-coordinated multidisciplinary team. IOHDR brachytherapy is recommended in the treatment of both recurrent and primary locally advanced disease for colorectal and gynecologic malignancies, soft tissue sarcoma, and selected head and neck and pediatric malignancies. Other techniques such as perioperative fractionated brachytherapy are also acceptable in many cases with some advantages and disadvantages compared to IOHDR. CONCLUSIONS: IOHDR brachytherapy is a specialized technique in radiation therapy with unique properties and advantages in cancer control. Special considerations for treatment planning and delivery are outlined herein.

Fifth Ovarian Cancer Consensus Conference of the Gynecologic Cancer InterGroup: recurrent disease.

This manuscript reports the consensus statements regarding recurrent ovarian cancer (ROC), reached at the fifth Ovarian Cancer Consensus Conference (OCCC), which was held in Tokyo, Japan, in November 2015. Three important questions were identified: (i) What are the subgroups for clinical trials in ROC? The historical definition of using platinum-free interval (PFI) to categorise patients as having platinum-sensitive/resistant disease was replaced by therapy-free interval (TFI). TFI can be broken down into TFIp (PFI), TFInp (non-PFI) and TFIb (biological agent-free interval). Additional criteria to consider include histology, BRCA mutation status, number/type of previous therapies, outcome of prior surgery and patient reported symptoms. (ii) What are the control arms for clinical trials in ROC? When platinum is considered the best option, the control arm should be a platinum-based therapy with or without an anti-angiogenic agent or a poly (ADP-ribose) polymerase (PARP) inhibitor. If platinum is not considered the best option, the control arm could include a non-platinum drug, either as single agent or in combination. (iii) What are the endpoints for clinical trials in ROC? Overall survival (OS) is the preferred endpoint for patient cohorts with an expected median OS < or = 12 months. Progression-free survival (PFS) is an alternative, and it is the preferred endpoint when the expected median OS is > 12 months. However, PFS alone should not be the only endpoint and must be supported by additional endpoints including pre-defined patient reported outcomes (PROs), time to second subsequent therapy (TSST), or time until definitive deterioration of quality of life (TUDD).

Two novel mutations causing familial benign hypocalciuric hypercalcaemia in three Scottish families.

BACKGROUND AND AIMS: Familial benign hypocalciuric hypercalcaemia (FBHH) is a benign autosomal dominantly inherited condition which results in elevated serum calcium and low urinary calcium. This condition is of clinical interest because it can be mistakenly diagnosed as primary hyperparathyroidism (PHP). In most cases FBHH can be shown to be due to a mutation in the calcium sensing receptor (CASR) gene and we aimed to find the causative mutation in three Scottish kindreds with FBHH. METHODS: We used a combination of denaturing gradient gel electrophoresis and direct DNA sequencing to detect mutations in the CASR gene. RESULTS: We detected a mutation in the CASR gene in each of the three kindreds. Two different mutations were detected (the same one was present in two kindreds). Neither mutation has been reported previously. All hypercalcaemic individuals from each kindred had the appropriate mutation while all normocalcaemic individuals did not. CONCLUSION: In the vast majority of kindreds with FBHH which have been reported previously, the CASR mutation responsible is private to that kindred. In three Scottish kindreds we have identified two new mutations.

Changes in gene expression induced by chemoradiation in advanced cervical carcinoma: a microarray study of RTOG C-0128.

PURPOSE: To evaluate gene expression patterns in patients with advanced cervix cancer before and during chemoradiation in a multi-institutional cooperative group setting. METHODS: RTOG C0128 was designed as a Phase II trial of radiation therapy with concomitant chemotherapy and Celecoxib at 400 mg twice daily for one year. Tumor samples were obtained for microarray gene expression analysis before treatment and at the time of the first implant (paired sample). RNA was extracted, linearly amplified, and purity was assessed by gel electrophoresis. Each sample was hybridized against a universal RNA mixture on a customized spotted array consisting of >10,000 genes. Gene expression pre-treatment was compared with clinical characteristics. Changes in gene expression following radiation were assessed within the paired samples (same patient) and then compared across all paired samples. Data were normalized using the AROMA software, and clustering analysis was performed using Ward's method in Spotfire. Differences in paired samples were calculated with Significance Analysis of Microarrays (SAM). RESULTS: From August 2001 to March 2004, 84 patients were accrued to the trial. Tissue was obtained prior to initiation of therapy from 34 patients (40%). FIGO stages of the patients providing tissue were IB (23%), II (57%), and IIIA-IVA (20%). RNA quality was sufficient in 22 pre-treatment and 14 post-treatment samples. Among pre-treatment samples, no significant differences in gene expression were observed by FIGO stage, age, or race. However, between comparison of histologic subtypes (adenocarcinoma, n=5; squamous cell carcinoma, n=17) demonstrated 45 genes differentially expressed with a false discovery rate of 0.018. Cluster analysis segregated unpaired samples into 2 groups: 18/22 comprising pre-treatment samples and 10/14 in group 2 representing post-treatment samples. In all 13 paired samples, gene expression after chemoradiation was significantly upregulated in 91 genes and downregulated in 251 genes (false discovery rate of 0.0018). Genes significantly upregulated included bax, cdk inhibitor 1, MMP2, and adhesion molecules PECAM1, VCAM1, and ICAM2. Genes significantly downregulated included topoisomerase II alpha, myc, H2AX, MSH2, RAD51, RAD53, PCNA, and cell cycle-regulating molecules chk1, CDK2, cyclinB1, cyclin D3, cdc2, and cdc25. CONCLUSIONS: Microarray analysis was successfully performed in a multi-institutional cooperative group trial. Gene expression significantly correlated with histology, but not stage, age or race. Cluster analysis identified two groups of gene expression profiles correlating with pre or post-treatment acquisition of tissue. Notably, paired samples showed significant changes in gene expression following chemoradiation, including several downregulated radiation response genes. Further analysis comparing gene expression to clinical outcomes, acute and late toxicities awaits maturation of clinical data. Hopefully, this data will lead to the development of molecularly based therapies.

Survival impact of lymph node dissection in endometrial adenocarcinoma: a surveillance, epidemiology, and end results analysis.

The therapeutic benefit of lymph node dissection (LND) in women with endometrial cancer remains controversial. The purpose of this study is to analyze the impact of LND on survival. Data were obtained from the Surveillance, Epidemiology, and End Results program of the US National Cancer Institute for the years 1988-2003. Women with adenocarcinoma of the endometrium who underwent surgery as primary management of their disease were eligible. Multivariate analyses of pertinent variables were performed for the end points of overall survival and cause-specific survival. Women included in the analysis were 42,184. The average frequency of LND was 31%, 40%, 47%, and 53%, for the years 1988-1991, 1992-1995, 1996-1999, and 2000-2003, respectively (P < 0.0001). On multivariate analysis, presence of LND was associated with overall and uterine-specific survival benefits with hazard ratios (HR) of 0.81 (P < 0.0001) and 0.78 (P < 0.0001) and removal of greater than 11 lymph nodes (LN) associated with a HR of 0.74 (P < 0.0001) and 0.69 (P < 0.0001), respectively. Further multivariate analyses demonstrated greater than 11 LN to associate with all other cause-specific and cardiac-specific survival benefits, with HR of 0.77 (P < 0.0001) and 0.82 (P = 0.0062), respectively. We conclude that the presence of LND and increased number of nodes dissected predicted for improved overall and uterine-specific survival in women with adenocarcinoma of the endometrium. Improved cause-specific survival was most pronounced for greater than 11 nodes removed and stage II or higher disease. The improvement in noncancer-related mortality with LND predicted by this data suggests the presence of inherit biases, and the need for caution in analyzing retrospective data.

Clinical trials in gynecological cancer.

The Gynecologic Cancer Intergroup is comprised representatives from international gynecological cancer trials organizations, which collaborate in multicenter studies to answer the clinical challenges in gynecological cancer. This review article highlights the key clinical questions facing clinical trialists over the next decade, the information and infrastructure resources available for trials, and the methods of trial development. We cover human papillomavirus (HPV)-associated neoplasia, including cervical cancer, together with endometrial cancer, ovarian cancer, and vulvar cancer. Infrastructure for clinical trials includes a database for trials, templates for protocol development, patient educational material, and financial support for clinical trials. Other critical issues include support from government and charities and government regulations.

Assessment of thiopurine methyltransferase enzyme activity is superior to genotype in predicting myelosuppression following azathioprine therapy in patients with inflammatory bowel disease.

BACKGROUND: Myelosuppression occurs in 2-7% of inflammatory bowel disease (IBD) patients treated with azathioprine, and can be associated with reduced activity of thiopurine methyltransferase (TPMT) in some patients. It has been proposed that pretreatment assessment of TPMT status reduces the incidence of toxicity and is cost-effective. AIMS: To determine if screening for TPMT status predicts side-effects to azathioprine in patients with IBD and to ascertain whether screening by TPMT enzyme activity or genotype is superior. METHODS: Sequential IBD patients were identified and azathioprine tolerance recorded. Blood was collected for measurement of TPMT activity and TPMT*3C, TPMT*3A and TPMT*2 genotypes. RESULTS: Of 130 patients, 25% stopped azathioprine because of toxicity. Four patients experienced severe myelosuppression (WCC < 2). Eleven of 17 patients with reduced TPMT activity were heterozygotes, including one patient with marked TPMT deficiency who experienced severe myelosuppression. There was no association between intermediate TPMT deficiency and any side-effect. CONCLUSIONS: Moderate reduction of TPMT activity in heterozygotes was not associated with toxicity, but very low TPMT activity caused severe myelosuppression in one patient. This would have been predicted by measuring TPMT activity but not by genotyping. Measurement of TPMT activity may therefore be superior to genotype in predicting severe myelosuppression.

Twenty-four novel mutations in Wilson disease patients of predominantly European ancestry.

Wilson disease (WND), an autosomal recessive disorder of copper transport, shows wide genotypic and phenotypic variability, with hepatic and/or neurological symptoms. The WND gene, ATP7B, encodes a copper transporting ATPase that is involved in the transport of copper into the plasma protein ceruloplasmin, and in the excretion of copper from the liver. ATP7B mutations result in copper storage in liver and brain. From 247 WND patients worldwide whose DNA has been sequenced in our laboratory, we have identified 24 new mutations. The origins of the patients were European white (one deletion, one nonsense, one splice site, and 18 missense), Chinese (one deletion, one missense) and Bangladeshi (one missense). Most of these had strong support as disease causing mutations, based on conservation between species, structural changes, and absence in controls. One missense mutation in a Chinese patient was considered uncertain because of its conservative nature and position in the protein. We also identified 15 nucleotide substitutions (11 of them new) causing silent or intronic changes, none of which produce an additional splice site that could lead to disease. Characterization of mutations, both disease-causing and normal variants, is essential for accurate molecular diagnosis of this condition.

Feasibility of RNA collection for micro-array gene expression analysis in the treatment of cervical carcinoma: a scientific correlate of RTOG C-0128.

PURPOSE: To determine the feasibility of RNA collection in a multi-institutional cooperative group setting to be utilized for micro-array gene expression analysis, and to describe the methodology. METHODS: RTOG C0128, a phase I-II, protocol was designed to look at the safety and efficacy of external beam radiation therapy to 45 Gy with concomitant 5-FU and cisplatin chemotherapy, brachytherapy to deliver 85 Gy to point A, and Celecoxib at 400 mg twice daily for 1 year. Patients had the option of participating in a tissue collection portion of the protocol to be utilized for micro-array gene expression analysis before treatment and at the time of the first implant. RNA quality was determined by two parameters: the absorbance ratio at 260 nm/280 nm, and by the ratio of the integrated peak of 28S RNA to 18S RNA after gel electrophoresis. RESULTS: From August 2001 to March 2004, 84 patients were accrued to the trial, and tissue was obtained prior to initiation of therapy on 34 patients (40%). FIGO stages for the patients who provided tissue were IB (23%), II (57%), and IIIA-IVA (20%). Additionally, biopsies were obtained at the time of the first implant from 22 of the accrued patients making paired samples available on 26% for RNA extraction and micro-array gene expression analysis. The mean +/- SEM amount of tissue obtained pretreatment was 97 +/- 13 mg compared with 51 +/- 8 mg for tissue obtained at the time of the first implant (P = 0.009). The mean total RNA extracted from the samples prior to treatment was 119 +/- 19 microg versus 35 +/- 6 microg at the time of the first procedure (P = 0.001). The RNA quality was assessed via the absorbance ratio at 260 nm divided by 280 nm. The mean values pretreatment and at first implant were 1.87 +/- 0.07 versus 1.66 +/- 0.11, respectively (P = 0.002); however, the integrated peak of 28S RNA to 18S RNA after gel electrophoresis was not significantly different (P = 0.26). CONCLUSIONS: RNA extraction for gene expression analysis can be successfully performed in the multi-institutional cooperative group setting. Fresh tissue samples were obtained on 40% of accrued patients prior to treatment. The amount of biopsy material and the quantity of RNA extracted were greater prior to treatment compared with the first implant. The quality of RNA was superior prior to treatment as measured by the ratio of absorbance at 260/280 nm. These results indicate that gene expression analysis is feasible in the cooperative group setting utilizing amplification techniques for the RNA. Hopefully, this will allow for improvement in prognosis, therapeutic development, and correlation with acute and late toxicities in patients with cancer.

Cost-effectiveness of thiopurine methyltransferase genotype screening in patients about to commence azathioprine therapy for treatment of inflammatory bowel disease.

BACKGROUND: Azathioprine is a useful agent in the management of inflammatory bowel disease. Its use is limited by its side-effect profile. Marrow toxicity occurs in approximately 3.2% of patients and is known to be associated with diminished thiopurine methyltransferase enzyme activity resulting from genetic polymorphisms. AIM: To evaluate the cost-effectiveness of screening for thiopurine methyltransferase gene polymorphisms prior to initiation of azathioprine therapy. METHODS: Analysis of the literature was undertaken to calculate the expected frequency of leucopenia and its relationship with thiopurine methyltransferase polymorphisms in a model of theoretical inflammatory bowel disease patients. Decision analysis was then applied to assess the cost of a pre-treatment genotyping strategy, taking account of direct costs and cost per life-year saved. RESULTS: In 1000 inflammatory bowel disease patients treated with azathioprine, 32 will develop myelosuppression and one will die because of this. Of those who develop myelosuppression during azathioprine therapy, 32% are attributable to lower thiopurine methyltransferase activity. Pre-treatment genotyping costs pound 347 per life-year saved for a 30 year old and pound 817 per life-year saved for a 60 year old. This compares favourably with other health care technologies. CONCLUSION: The use of pre-treatment screening for thiopurine methyltransferase polymorphisms in inflammatory bowel disease patients commencing azathioprine therapy represents good value for money.

Haemochromatosis gene mutations and risk of coronary heart disease: a west of Scotland coronary prevention study (WOSCOPS) substudy.

OBJECTIVES: To measure the frequency of genotypes of the HFE (haemochromatosis) gene in patients recruited to the west of Scotland coronary prevention study (WOSCOPS), and relate them to the subsequent occurrence of coronary clinical events. DESIGN: Nested case-control study, drawing samples of DNA from the biological bank of a cohort study. PATIENTS: Men aged 45-64 years in 1989, with moderate hypercholesterolaemia and no evidence of coronary heart disease at baseline. INTERVENTIONS: Follow up for a mean period of 4.9 years. Typing for C282Y and H63D mutations of the HFE gene in 482 subjects with a subsequent coronary event and 1104 without an event. RESULTS: The C282Y mutation was present in 81 of 482 cases (16.8%) and 182 of 1104 controls (16.5%). Comparing the prevalence of gene mutations in the cases and controls, there were no significant differences. The hazard ratio for C282Y heterozygotes was 1.03 (95% confidence interval (CI) 0.77 to 1.36) and for C282Y/H63D compound heterozygotes 1.04 (95% CI 0.50 to 2.14). Prespecified subgroup analyses of the pravastatin, placebo, smoking, and non-smoking groups showed no significant differences between cases and controls. Repeating the analyses after adjusting for possible confounding factors produced no change in the results. CONCLUSIONS: In a population of moderately hypercholesterolaemic middle aged Scottish men who did not have any evidence of coronary heart disease at baseline, the presence of a C282Y mutation in the HFE gene did not predict the occurrence of coronary events over a mean follow up of 4.9 years.

Virulence in rodent malaria: host genotype by parasite genotype interactions.

In an effort to understand what limits the virulence of malaria parasites, we infected inbred mice of three genotypes (C57Bl/6J, CBA/Ca and DBA/2) with one of two parasite lines of the rodent malaria Plasmodium chabaudi. One of these parasite lines had been serially passaged through C57Bl/6J mice and had evolved higher asexual growth rate, virulence and transmission in the process. The other parasite line was the unadapted ancestral line which had low virulence. In all three host genotypes, the C57Bl/6J-adapted parasite line was more virulent than the ancestral line thus indicating that trade-offs in virulence between alternative host genotypes had not placed strong constraints on the evolution of high virulence in this system. By examining the infection dynamics for fitness-related components-asexual parasite population growth, transmission and virulence-we revealed alternative possible explanations for what sets the upper limit to virulence in nature. The total number of transmission forms (gametocytes) produced during the infection, a measure of parasite Darwinian fitness, was four-fold higher in mice that survived the infection than those which died. Among mice that survived, total gametocyte production was greatest in the host genotype that suffered intermediate levels of morbidity (anaemia and weight loss). Thus, there were transmission costs of high virulence that were partly due to host death (as most theoretical models of virulence evolution assume), but perhaps partly due to some factor related to high morbidity. Both mortality and morbidity-related factors might therefore influence the upper limit on virulence of malaria parasites.

Electron arc irradiation of the postmastectomy chest wall with CT treatment planning: 20-year experience.

PURPOSE: Since 1980, electron arc irradiation of the postmastectomy chest wall has been the preferred radiotherapy technique at the University of Utah for patients with advanced breast cancer. We report the results of this technique in 156 consecutive Stage IIA-IIIB patients treated from 1980 to 1998. METHODS: CT treatment planning was used in all patients to identify chest wall thickness and internal mammary lymph node depth. Computerized dosimetry was used to deliver total doses of 50 Gy in 5-1/2 weeks to the chest wall and the internal mammary lymph nodes with electron arc therapy. Patients were assessed for local, regional, and distant control of disease and for survival. Univariate and multivariate proportional hazards were modeled using a hierarchical nonproportional semiparametric model testing the following prognostic factors: age, stage, tumor size, number of positive lymph nodes, estrogen receptor status, and dose. End points evaluated included disease-free survival, cause-specific survival, and overall survival. RESULTS: Eighty-one percent of patients were at high risk for local-regional failure because of > T2 primary tumor or > 3 positive axillary lymph nodes. The median number of positive lymph nodes was 5, and the median tumor size was 3.5 cm. Actuarial 10-year local-regional control and overall survival were 95% and 52%, respectively. In multivariate analysis, the only factor prognostic for disease-free survival, cause-specific survival, and overall survival was the number of positive lymph nodes (p < 0.001). The 10-year rates of local-regional control for patients with 0, 1-3, 4-9, and > or = 10 involved lymph nodes were 100%, 98%, 93%, and 89%, respectively. The only rates of acute and chronic radiotherapy toxicity > or = 2 by RTOG/EORTC criteria were skin related and observed in 44% and 10% for acute and late reactions, respectively. CONCLUSION: These data demonstrate excellent local-regional control rates with electron arc therapy of the postmastectomy chest wall in patients with advanced breast cancer. Our 20-year experience with electron arc radiotherapy has demonstrated the safety and efficacy of this technique. The advantage of this technique is that the internal mammary lymph node chain can be easily encompassed while the dose to heart and lung is minimized; it also obviates match lines in areas of high risk.

Elevated COX-2 expression in cervical carcinoma: reduced cause-specific survival and pelvic control.

The purpose of this study was to correlate the level of cyclooxygenase-2 (COX-2) expression in carcinoma of the cervix with the clinical endpoints: local control, cause-specific survival, and patterns of failure in patients treated with radiotherapy. Formalin-fixed, paraffin-embedded tumor biopsies were stained for COX-2. Clinical factors such as stage, grade, tumor size, pre- and posttreatment hemoglobin level, and radiotherapy dose were also evaluated. Actuarial local control rates and cause-specific survival were determined according to the Kaplan-Meier method. COX-2 distribution staining was the only prognostic factor that was associated with local control and cause-specific survival. High COX-2 distribution staining was associated with decreased local control and decreased cause-specific survival by log rank comparison of Kaplan-Meier survival curves. The 5-year cause-specific survival rates for tumors with low versus high COX-2 distribution values were 90% and 22%, respectively (p = 0.0003). Actuarial pelvic control at 5 years was superior in patients with low COX-2 distribution staining (92%) compared with high staining (42%, p = 0.005). COX-2 staining intensity was found to correlate positively with tumor size (p = 0.02). These findings indicate that increased expression of COX-2 yields reduced pelvic control and cause-specific survival in patients with invasive carcinoma of the cervix treated with radiotherapy. Previously, inhibition of COX-2 has been demonstrated to sensitize tumors to radiation without effect on normal tissue. Taken together, these data may support a novel therapeutic application of COX-2 inhibitors in the treatment of carcinoma of the cervix.