Vulvar squamous carcinoma: prognostic role of DNA content.

DNA nuclear content was evaluated on 46 paraffin-embedded blocks of vulvar cancer by means of flow cytometry. Fifteen of 44 evaluable samples (34%) were found to have an aneuploid DNA pattern. Aneuplody showed a statistically significant relationship with tumor grading (P = 0.0004) and defined a subset of patients who have pathological characteristics of high risk, such as advanced stage of disease, deepest stromal invasion, or positive inguinal nodes. However, when a multivariate regression model was used, ploidy status did not have any prognostic role, while FIGO staging system was confirmed to be the strongest independent prognostic factor (P = 0.009). The integration of a panel of cell kinetic parameters with traditional features is worth investigating on a larger population.

Paclitaxel as salvage therapy in advanced pretreated ovarian cancer: a phase II study.

The response rate to salvage chemotherapy in advanced ovarian cancer has been disappointing in patients who do not respond or who relapse after platinum-containing regimens. In these cases, the identification of new drugs is a substantial challenge. The efficacy of one of these, paclitaxel, has already been assessed in many phase II trials. From July 1993 to October 1995, 33 patients with advanced ovarian cancer, recurrent or refractory after platinum-based regimens, entered our study. Paclitaxel was given by 3-hour intravenous infusion every 3 weeks. All the patients were evaluable for toxicity and 27 for response. Nine patients (33.3%) responded: 6 complete (22.2%) and 3 partial responses (11.1%). Six responses (35.3%) were observed in the 17 platinum-resistant patients and 3 (30%) in the 10 platinum-responders. World Health Organization (WHO) grade 3-4 neutropenia was common (13/33 patients, 39.4%) and peripheral neurotoxicity was observed in 29 patients (87.8%), but was WHO grade 3 in four cases (12.1%). Alopecia was ubiquitous, whereas other toxic effects were not significant. The overall response rate to paclitaxel in this study is similar to that reported in others and the high complete response (CR) rate should be emphasized. These data confirm the significant activity and safety of this drug in patients with advanced ovarian cancer, even in platinum-resistant cases.

A combination of ifosfamide and mitoxantrone as salvage therapy in patients with advanced ovarian cancer.

Ifosfamide (IFX) and mitoxantrone (MXN) have been found to be effective against advanced epithelial ovarian cancer. The combination of these two agents has not yet been tested in this setting but seems to be rational, given the different action mechanisms of these drugs and their not completely overlapping side effects. Between June 1987 and November 1991, 37 patients with advanced ovarian carcinoma recurrent or refractory to primary cisplatin-based chemotherapy entered the study. Therapy consisted of MXN, given i.v. at 10 mg/m2 on day 1 and IFX given i.v. at 2,000 mg/m2 per day on days 1-3 with mesna. The cycles were repeated every 3 weeks. Four patients achieved a complete remission and three achieved a partial remission, for response rates of 18.9% [95% confidence interval (CI) 6.3-31.5%] in the whole sample and 38.8% (95% CI 16.3-61.3%) in the subset of 18 patients responding to first-line cisplatin. No response was obtained in the remaining patients, whose disease was refractory to primary platinum-based chemotherapy. Clinically significant toxicity (WHO grades 3-4) included leukopenia in 46% of the patients and anemia in 32.5%. The non-hematologic toxicity was mild, except for reversible alopecia (57%) and nausea and vomiting (48.5%). This regimen seems attractive for patients who have either failed or not received platinum retreatment, especially when limiting neurotoxicity occurs. Further studies are warranted to establish the relative impact of both of these agents.

Evaluation of second generation CA 125 assays.

OBJECTIVE: This study was performed in order to evaluate and compare the serum CA 125 values obtained using an immunoradiometric (IRMA-II) and an immunoenzymatic (ETI-II) second generation assay, and to establish whether or not the two methods may be used interchangeably. STUDY DESIGN: Serum CA 125 levels were measured in parallel using IRMA-II and ETI-II CA 125 assays (Sorin Biomedica), in 82 women with benign or malignant gynecological diseases. Statistical analysis was performed by linear regression analysis and Wilcoxon's test. RESULTS: Serum CA 125 levels measured using the immunoenzymatic method were lower than those obtained by the immunoradiometric assay. The largest discrepancies between the two methods were found at concentrations of 35-100 U/ml, within which fall cutoff values for the immunoradiometric assay. The cutoff values of 35 or 65 U/ml, frequently used in the original immunoradiometric assay and retained for the immunoradiometric second generation assay, corresponded to 18 and 47 U/ml in the immunoenzymatic second generation assay. CONCLUSION: The discrepancies in CA 125 results obtained by the two detection methods imply that the cutoff values used in the immunoenzymatic procedure should have a lower reference value in order to eliminate high rates of false negative results. Furthermore, their interchangeable use should be avoided in the monitoring of ovarian cancer and other gynecological diseases.

Noninvasive monitoring of ovarian cancer: improved results using CT with intraperitoneal contrast combined with immunocytology.

The purpose of this study was to evaluate whether CT with intraperitoneal contrast (ipc/CT) in combination with immunocytochemical (ICC) tests could improve the diagnostic accuracy over conventional methods in the follow-up of ovarian carcinoma. Forty-five clinically disease-free ovarian cancer patients eligible for a second-look laparotomy were given an intraperitoneal infusion of positive contrast material followed by pelvic and abdominal CT. After the radiographic examination, the contrast fluid was collected by paracentesis and processed for morphological as well as for immunocytochemical analysis employing a panel of monoclonal antibodies identifying distinct ovarian tumor-associated antigens. While ipc/CT correctly detected the presence of peritoneal recurrences in 22 of 45 (49%) patients, the immunocytochemical tests demonstrated the presence of otherwise undiagnosed microscopic disease in an additional 8 patients (18%). Our results demonstrate that the combination of radiological and immunological methods may represent a more accurate, noninvasive means of monitoring ovarian cancer, thus reducing the need for a second-look laparotomy.

Postmenopausal endometrial hyperplasia: role of danazol therapy.

OBJECTIVES: To confirm the effectiveness of danazol in the management of simple or complex endometrial hyperplasia without atypical features, as has been demonstrated previously. METHODS: Seventy-six patients affected by postmenopausal histologically-confirmed endometrial hyperplasia with uterine bleeding were submitted to danazol therapy at a dose of 400 mg/day for 3 consecutive months. RESULTS: After cessation of treatment, 82.8% of the patients (63/76 enrolled) showed a conversion of the hyperplasia into atrophic (65.8%), secretory (11.9%) or proliferative (4.2%) endometrium at the histological examination. Uterine bleeding disappeared, during the therapy, in 90% of the responders (59/63). CONCLUSIONS: Although 17.1% of the women had a persistence of the hyperplasia and 8.4% of the symptom-free women relapsed after 4 months of follow-up, this experience confirms the effectiveness of danazol therapy in hyperplastic endometrial lesions. Nevertheless, a study comparing danazol and progestin therapy is required.

Radiotherapy for vulvar carcinoma with positive inguinal nodes. Adjunctive treatment.

Between 1981 and 1988, 58 patients with vulvar carcinoma underwent radical vulvectomy and unilateral inguinal lymphadenectomy. Sixteen patients with inguinal node metastases received complementary radiotherapy as an alternative to pelvic node dissection. They were treated with Co-60 therapy for bilateral inguinal and pelvic lymph nodes. The overall five-year actuarial survival rate in patients without node involvement was 84%; in patients with positive inguinal nodes treated with the combined radiosurgical approach, it was 64%. Patients with 1 node involved had a 74% rate of estimated survival, and those with 2 or more metastatic nodes, considered to be at high risk, had an estimated survival rate of 49%. Only mild to moderate side effects related to the radiation therapy were observed, and in no case was it necessary to interrupt the treatment. In terms of survival, the results obtained in the group of patients with postoperative radiotherapy were better than those normally expected after pelvic lymphadenectomy, and as suggested in recent literature, point to the promising role of irradiation as adjuvant management for vulvar cancer with node involvement.

Immunocytodiagnosis of atypical hyperplasia and endometrial carcinoma in post-menopausal women.

In the present study we have evaluated whether monoclonal antibodies (MAbs) B72.3 and AR-3 which display, on histological preparations, a differential reactivity with normal and transformed endometrium, could be a useful adjunct to endometrial cytology in the identification of pre-neoplastic and neoplastic conditions. Immunocytochemical (ICC) tests, using the 2 reagents, were performed on normal cycling endometrium and on hyperplastic and malignant lesions collected by the endocyte technique both from 86 surgically resected specimens and from 62 postmenopausal symptomatic and asymptomatic outpatients. The results obtained showed that the combination of the 2 MAbs can complement conventional morphology in the identification of pre-malignant atypical lesions and endometrial carcinoma of unclear cytological features, thus allowing a selection of those patients who are candidates for fractional curettage.

The effectiveness of danazol therapy in postmenopausal women affected by endometrial hyperplasia.

Forty eight patients in postmenopause affected by histologically confirmed endometrial hyperplasia (34 with simplex and 14 with complex forms) were administered Danazol therapy, 400 mg/day for 3 consecutive months. At the end of treatment, regression of the endometrial hyperplasia was histologically ascertained in 46 patients (95.9%) with disappearance of the metrorrhagia. Endometrial atrophy was obtained in 75% of the cases, while secretive (14.7%) or proliferative (6.2%) aspects resulted in the others. Only 2 patients (4.1%) showed persistence of the hyperplastic endometrium. On the basis of this experience, treatment with Danazol appears to be effective and safe with only scarce and transient side effects. This therapy is therefore proposed as a valid alternative to progestogen therapy in cases of postmenopausal endometrial hyperplasia.

The use of a panel of monoclonal antibodies can lower false-negative diagnoses of peritoneal washings in ovarian tumors.

A correct surgical staging of ovarian carcinoma and the identification of persistent microscopic disease at second-look surgery largely rely on the cytologic examination of peritoneal washings (PW). Nevertheless, the morphologic analysis of these fluids frequently provides false-negative findings. As shown in other areas of cytodiagnosis, monoclonal antibodies (MoAb) to tumor-associated antigens may be a useful adjunct to overcome the limitations of conventional cytopathologic examination of PW. To evaluate this question, immunocytochemical tests were done using a panel of four MoAb to ovarian carcinoma-associated antigens (B72.3, MOv18, MOv19, and OC-125) to analyze 117 PW sampled during initial surgical staging and 121 PW harvested at second-look operations. The results of this study showed that immunocytochemical tests using the combination of the four reagents could improve cytodiagnosis more than 15% in both groups of PW. Thus a significant fraction of patients could be correctly staged and treated or become potentially curable by second-line salvage therapy.

Expression of CAR-3 and TAG-72 macromolecules in normal and transformed endometrium: potential diagnostic application in postmenopausal patients.

Mass cytoscreening for the early diagnosis of endometrial carcinoma has thus far been hampered by the low diagnostic accuracy of current cytopathology. In this study we have analyzed the reactivity of the two monoclonal antibodies, AR-3 and B72.3, recognizing two distinct glycosylated high molecular weight carcinoma associated antigens on histological specimens from normal, hyperplastic, and transformed endometrium with the aim of establishing their diagnostic potential. Because women with a high risk of endometrial cancer are frequently postmenopausal, where normal endometrium is characterized by atrophy and cystic glandular hyperplasia, the following findings were of interest. Both antibodies reacted with variable and apical staining patterns with a minority of specimens of normal cycling endometrium from premenopausal women. However, they were constantly negative when tested on normal atrophic postmenopausal endometrium, and only monoclonal antibody AR-3 occasionally stained glandular cystic hyperplasia. By contrast, lesions with atypical hyperplasia, which represent a preneoplastic condition, were stained by both antibodies in 89 or 67% of the cases depending on the monoclonal antibody used (100% if used in combination). Furthermore, 98% of the endometrial carcinomas tested were found to react with the combination of two monoclonal antibodies. If these findings are confirmed in a multicentric study, the use of the two reagents could be a valuable adjunct in the cytodiagnosis of endometrial cancer, especially in providing a guideline to selecting patients for endometrial curettage and additional diagnostic procedures.

Four case reports presenting new acquisitions on the association between breast and endometrial carcinoma.

In recent years, the association between breast and endometrial cancer has been the subject of many studies. The present report describes four cases of this association in which tamoxifen had been administered to all of the patients. Data have been published regarding the possibility that tamoxifen may be responsible for the subsequent development of carcinoma of the corpus uteri in these patients. The authors intend to carry out a case-control study on patients treated with tamoxifen for breast carcinoma to reveal the possible presence of endometrial carcinoma.

Intraperitoneal recombinant alpha-2-interferon alternating with cisplatin as salvage therapy for minimal residual-disease ovarian cancer: a phase II study.

A phase II study was initiated in March 1987 at the Regina Elena National Cancer Institute of Rome to evaluate the efficacy of alternating intraperitoneal (IP) recombinant alpha-2-interferon (r-alpha 2-IFN) and cisplatin (DDP) as salvage therapy for less than or equal to 5 mm residual-disease (RD) ovarian carcinoma. Fourteen assessable patients entered the study. All had received prior chemotherapy (11 with DDP-based regimens); five patients had macroscopic RD (less than or equal to 5 mm), and nine had microscopic RD (histologically positive random biopsies and/or positive cytology and immunocytochemical tests). The response to IP immunochemotherapy was evaluated by laparotomy. Pathologic complete remissions (PCRs) were achieved in seven patients (50%) who have remained free of disease with a median follow-up of 22+ months (range, 11+ to 30+ months). Six patients achieved a stable disease and one presented disease progression. With the exception of chemical peritonitis-induced adhesions, no limiting toxicity was observed. The results obtained in this small, highly selected series demonstrate that a high PCR rate may be obtained with IP immunochemotherapy with DDP and r-alpha 2-IFN as salvage therapy in residual ovarian carcinoma less than or equal to 5 mm after first-line chemotherapy also including intravenous (IV) DDP. Larger comparative studies must be conducted to establish the potential role of IP DDP and r-alpha 2-IFN as compared with either of the single treatments.

426 cases of stage I endometrial carcinoma: a clinicopathological analysis.

Between February 1, 1965, and December 31, 1985, 426 patients affected with Stage I adenocarcinoma of the endometrium were submitted to surgery in the Department of Gynecologic Oncology of the Regina Elena Cancer Institute. The value of the present survey is represented by the homogeneous diagnostic data on the basis of which the treatment was planned. Criteria of histological grading and myometrial invasion were always followed, making it possible to carry out a protocol combining surgery with radiotherapy, chemotherapy, and/or hormone therapy. In fact, an accurate evaluation of the grading, the infiltration of the myometrium, and the localization and size of the lesion are necessary to establish the risk of lymph node invasion. This last parameter is the most important as far as the therapeutic protocol, recurrences, and/or metastases and survival are concerned. The high 5-year survival rate, despite the high average age of the patients (74.7% between the ages of 51 and 70), associated pathologies, and the relatively low incidence of complications from treatment, demonstrate the validity of the protocol adopted.

Carcinoma of the vulva (1981-1985): analysis of a radio-surgical approach.

Carcinoma of the vulva has recently been the subject of renewed interest of gynecologists and oncologists. That which is commonly defined as the "choice" treatment is a radical vulvectomy with bilateral inguinal lymphadenectomy and, in the case of lymph node metastases, pelvic lymphadenectomy. The usefulness of the pelvic dissection has, however, been disputed and various Authors have proposed an alternative treatment consisting of radical vulvectomy and inguinal lymphadenectomy with external radiotherapy on the inguinal and pelvic lymph nodes, in the case of N+. The present report describes 56 patients with vulvar carcinoma treated at the Regina Elena National Cancer Institute of Rome, 42 of whom were submitted to radical surgery. In 14 of these patients, metastases in the inguinal lymph nodes were found: 10 were submitted to radiotherapy (with TCT or low voltage linear accelerator for a total of 50 Gy over a 5-week period), while the remaining 4 were not treated with any further therapy. Although the survey includes only a limited number of patients, the results obtained certainly favor radio-surgical treatment, also considering data reported in international literature regarding pelvic lymphadenectomy. The actuarial 5-year survival rates for the patients treated with surgery plus radiotherapy is 50% and the recurrence rate is 20%. Although a greater experience is certainly warranted in this field, we believe it may be stated (also on the basis of a recent study conducted by the Gynecologic Oncology Group) that radiotherapy represents a valid alternative to pelvic dissection if an adequate patients selection is made.

Immunosuppressive acidic protein (IAP) and CA 125 assays in detection of human ovarian cancer: preliminary results.

Serum levels of the immunosuppressive acidic protein (IAP) and CA-125 were measured in 45 patients with ovarian tumors (30 malignant and 15 benign) before surgery. Concentrations of both markers were slightly increased in benign forms but still within the upper limit for controls. The sensitivity of IAP in detecting ovarian cancer was higher than CA-125 (83.4% versus 76.7%). Five false negatives were observed in IAP assay and seven for CA-125. Parallel determination of both markers, however, improved the diagnostic accuracy up to 90.0% of the total malignant cases. Combined measurements of circulating IAP and CA-125 are therefore recommended in the detection of ovarian cancers.

Effect of tamoxifen on steroid hormone receptors and creatine kinase activity in human endometrial carcinoma.

Estrogen receptor (ER), progesterone receptor (PR) and creatine kinase (CK) were measured in cancerous tissue from 29 post-menopausal patients with endometrial carcinoma under basal conditions and after a short course of tamoxifen treatment. ER and PR were detected in nearly all tumors. CK was detected in all of the tumors examined. After tamoxifen, PR and CK increased simultaneously in 26% of cases, while they were either enhanced, decreased or unmodified in the remainder. No correlation could be found between increase of PR and tumor differentiation. CK, however, was enhanced only in the more differentiated cancers. These results indicate that only a percentage of endometrial cancers are responsive to tamoxifen. It is hypothesized that patients bearing these tumors are those likely to benefit from endocrine therapy.