Fibrolamellar hepatocellular carcinoma in a 65-year-old woman: CT features.

A 65-year old woman with recurrent deep vein thrombosis underwent a CT scan of the upper abdomen for detection of underlying malignancy. A fibrolamellar hepatocellular carcinoma with extrahepatic subdiaphragmatic satellite lesion was found. This uncommon tumor has distinct clinical, pathological, radiological and prognostic features and therefore it is important to distinguish it from benign liver tumors, especially FNH, and from other malignant liver tumors such as conventional HCC. Though the tumor characteristically occurs in younger patients, our case proves that older patients can also be affected.

Markers of apoptosis in stage IB squamous cervical carcinoma.

AIMS: To examine the prognostic relevance of the expression of the Bcl-2, Bcl-xL, and Bax proteins in stage IB squamous cervical carcinoma (SCC). METHODS: In total, 220 patients who underwent radical hysterectomy and bilateral lymphadenectomy at the Norwegian Radium Hospital for stage IB SCC between 1987 and 1993 were studied. Immunohistochemistry using monoclonal antibodies against Bcl-2, Bcl-xL, and Bax was used to examine protein expression. Ten patients who underwent hysterectomy for uterine prolapse served as controls. RESULTS: Cytoplasmic expression of Bcl-2, Bcl-xL, and Bax was low (< 5% positive cells) in 159 of 220 (73%), 193 of 220 (87%), and 39 of 220 (18%) tumours, respectively, and high (> or = 5% positive cells) in 61 of 220 (27%), 27 of 220 (13%), and 181 of 220 (82%) tumours, respectively. In univariate analysis, all classic clinicopathological parameters but none of the investigated proteins were associated with prognosis. In multivariate analysis, only deep stromal invasion was independently related to survival. CONCLUSION: Bcl-2, Bcl-xL, and Bax were not independently associated with prognosis in stage IB SCC.

CT colonography with fecal tagging after incomplete colonoscopy.

The objective of this study was to evaluate dietary fecal tagging (FT) as a cleansing method prior to CT colonography (CTC) in patients with incomplete conventional colonoscopy (CC). After written informed consent was obtained, 24 patients had standard colonoscopic preparation (ScCl), and 25 patients had FT as cleansing method. Segmental distention, fluid levels, fecal residues, tagged appearance of fluid levels, and residual stool were evaluated. Mann-Whitney U test was used to test for significant differences between FT and ScCl groups. Compared with ScCl, FT improved distention (p=0.001), reduced the amount of fluid (p=0.043), but suffered from residual stool (p=0.046). A clear correlation was found between distention and fluid. No differences were found in stool size between FT and ScCl. FT showed a good labeling of fecal residues, and acceptable labeling of fluid levels. Compared with ScCl, FT reduces fluid, favors distention, but suffers from fecal residues. The tagged nature of these residues, however, allows differentiation from polyps.

Primary ovarian small cell carcinoma of the pulmonary type: a case report and review of the literature.

Small cell carcinoma of the ovary is a rare type of ovarian carcinoma with a poor prognosis. Two types should be distinguished: the hypercalcemic type and the pulmonary type. We report the case history of a 54-year-old woman with both a Stage IIIC small cell carcinoma, pulmonary type and a well-differentiated endometrioid adenocarcinoma of the left ovary in combination with a Brenner tumor in the right ovary. A review of the literature on small cell carcinoma of the ovary is given and the findings of our patient are brought into perspective in terms of both histopathogenesis and treatment outcome.

The potential role of neoadjuvant chemotherapy in advanced ovarian cancer.

There is a multitude of evidence from retrospective analyses and meta-analyses showing that the amount of residual tumor after debulking surgery and before chemotherapy is one of the most powerful prognostic determinants in advanced ovarian cancer. This supports the important role of maximum cytoreductive surgery as one of the cornerstones in the treatment of this disease. These same analyses, however, do not suggest that patients whose tumors cannot be debulked optimally derive a significant survival benefit from upfront surgery. For these patients and those who have a poor performance status or other morbidity, making comprehensive upfront surgery contraindicated, different therapeutic approaches have to be explored. One possible way to go is to change the timing of the different therapeutic modalities: upfront chemical cytoreduction, followed by a maximal surgical effort, in turn followed by the remainder of the first-line chemotherapy or neoadjuvant chemotherapy and interval or delayed debulking surgery. The potential role of this approach and the experience with it thus far are discussed.

Claudication type lower limb pain in an athlete without atherosclerotic risk factors: a case of cystic adventitial disease of the popliteal artery.

Cystic adventitial disease (CAD) of popliteal artery is a rare cause of lower limb claudication. Since its first description in 1947 only about 323 cases have been reported in the literature. We report the case of a 45 year old man with CAD of the popliteal artery causing progressive left lower leg claudication detected by US and Doppler US and characterized with spiral CT angiography. No communication with the knee joint could be demonstrated.

A phase II study of weekly paclitaxel in platinum and paclitaxel-resistant ovarian cancer patients.

OBJECTIVE: In platinum-resistant ovarian cancer weekly paclitaxel has shown an equal efficiency and better toxicity profile compared to three-weekly paclitaxel in platinum-resistant ovarian cancer. We wanted to study response rate, response duration and toxicity in platinum-resistant tumors with emphasis on tumors also resistant to three-weekly paclitaxel. MATERIAL AND METHODS: Fifty-seven patients with platinum-resistant disease, treated with weekly paclitaxel 80 mg/m2, 1-hour infusion, were evaluable for response and toxicity (Group A). Of these, 39 patients (Group B) had tumors resistant to paclitaxel as well. RESULTS: Overall response rate was 56% (12% CR, 44% PR, 19% SD, 25% PD) and 49% in group B: 5% CR, 44% PR, 23% SD, 28% PD. Median progression-free survival was 5.0 months and 4.0 months in group A and B, respectively. Median survival was 13.7 months in both groups. Toxicity was mild. Only two patients had grade 2 neutropenia and no neutropenic fever was recorded. No worsening in pre-existing neurotoxicity or hypersensitivity reactions was observed. CONCLUSION: Weekly administration of paclitaxel is associated with promising response rates in patients with platinum- and paclitaxel-resistant ovarian cancer. The treatment is well tolerated with non-cumulative hematologic and non-hematologic toxicity.

Optimisation of colon cleansing prior to computed tomographic colonography.

Colon preparation technique is a major determinant factor for patient compliance and polyp detection in computed tomographic colonography (CTC). The purpose of this study is to compare three different colon cleansing techniques in terms of patient discomfort, sensitivity and specificity. The following colon cleansing methods were compared in 20 patients each: 1. standard colonoscopy cleansing (ScCl) the day of the examination, based on polyethylene glycol (PEG), 2. a slightly reduced cleansing (RcCI) the day prior to the examination, based on a combination of diet, bisacodyl and a reduced intake of PEG, and 3. a cleansing with dietary fecal tagging (FT) the day prior to the examination, based on a combination of diet, bisacodyl, magnesium citrate and a dedicated barium suspension. ScCl resulted in a clean colon, but produces fluid levels hampering a complete CTC and possibly resulting in false negative diagnosis. RcCl reduced the problem of fluid levels, but was faced with the problem of fecal residues, resulting in false positive diagnosis. FT offered the possibility to obtain a dry colon, with labelled fecal residues, thus reducing false positive findings. Optimisation of the diet and replacement of PEG by magnesium citrate in FT reduced the preparation related discomfort and improved the final opinion. FT is the preferred colon cleansing technique because, compared to ScCl, fluid levels are reduced, and compared to RcCl, differentiation between faecal residues and polyps is improved. Moreover, FT reduces preparation related discomfort, compared to both RcCl and ScCl.

Prevalence of human papillomavirus in elderly women with cervical cancer.

To investigate the relation between the prevalence of human papillomavirus (HPV) and age in cervical cancer patients, material from 93 patients with Ia-IIb cervical carcinoma was analyzed for the presence of HPV by both type-specific and general primer polymerase chain reaction. Patients were divided into 2 groups: 64 years or younger, and 65 years and older. There was no statistically significant difference in either the prevalence of HPV DNA or distribution of genotypes amongst the 2 groups. Therefore, HPV detection can be equally well used in the management and follow-up of elderly cervical cancer patients.

Phase I/II trial of the multidrug-resistance modulator valspodar combined with cisplatin and doxorubicin in refractory ovarian cancer.

PURPOSE: To determine the maximum-tolerated dose (MTD) of doxorubicin when given in combination with cisplatin and the multidrug-resistance (MDR) modulator valspodar and the remission rate induced by this combination in patients with platinum- and anthracycline-resistant ovarian cancer. PATIENTS AND METHODS: Fifty-nine patients who had failed prior platinum- and anthracycline-based chemotherapy were enrolled. During the dose-finding phase, patients received a loading dose of valspodar (1.5 or 2 mg/kg) via 2-hour intravenous (IV) infusion on day 1 and continuous IV infusion (CIVI) of valspodar (2, 4, or 10 mg/kg/d) over 3 days. Doxorubicin (starting from 20 up to 50 mg/m(2)) and cisplatin (50 mg/m(2)) were administered via 15- to 20-minute IV infusions on day 3. During the efficacy phase, patients received at least two treatment cycles unless toxicity was unacceptable, and responding patients and those with stable disease received four to six cycles. RESULTS: All patients completed at least one cycle of combined treatment. The MTD of doxorubicin was determined to be 35 mg/m(2) when administered with valspodar at 2 mg/kg loading dose and 10 mg/kg/d CIVI plus 50 mg/m(2) cisplatin. At these doses, valspodar blood concentrations known to reverse MDR in vitro were reached in all patients. Valspodar was well tolerated at all dose levels. Dose-limiting toxicities of the combination were primarily hematologic and included febrile neutropenia and prolonged leucopenia. The addition of valspodar to the treatment did not worsen cisplatin-related toxicity. Among 33 patients treated at the MTD for doxorubicin, one (3%) had a complete response, and four (12%) had a partial response. An additional seven patients experienced a stabilization of their previously progressive disease. The survival rates at 6 and 12 months were 59% and 19%, respectively. CONCLUSION: Valspodar can be safely coadministered with doxorubicin and cisplatin. Although the regimen used in this trial produced renewed responses in patients with heavily pretreated, refractory ovarian cancer, the value of valspodar in reversing resistance mediated by P-glycoprotein remains to be determined.

[Borderline tumors of the ovary]. / Borderlinetumorer i ovariene.

Only within the last decade we have begun to fully appreciate the natural history and biologic behaviour of borderline tumours in the ovaries. In contradiction to invasive epithelial tumours, most borderline tumours are confined to the ovary(ies) (stage I). Because the prognosis of stage I serous borderline tumours is excellent, with five-year survival rates of almost 100%, some experts are advocating that this subset should be classified as benign. Although the standard treatment for older patients is abdominal hysterectomy and bilateral salpingo-oophorectomy, many young patients who have not completed childbearing can be safely treated with unilateral salpingo-oophorectomy coupled with comprehensive surgical staging, thereby preserving their fertility potential. Another major controversy associated with borderline tumours is the clinical management of patients with advanced-stage disease or peritoneal implants. Many experts strongly believe that surgery is the only effective treatment for borderline tumours. Others routinely employ postoperative chemotherapy for at least some subset of patients with peritoneal implants. Several investigators have focused on DNA ploidy as a predictor of recurrence and survival, but their findings are conflicting.

Carcinoma of the fallopian tube.

BACKGROUND: The objective of the current study was to increase insight into the biology of fallopian tube carcinoma through an analysis of possible clinical and pathologic determinants of prognosis and to formulate recommendations with regard to a more optimal therapeutic approach for patients with this rare disease. METHODS: A study was performed of the pathology specimens and clinical case records from 151 patients with fallopian tube carcinoma who were treated consecutively. Both univariate and multivariate analyses of possible prognostic factors were performed for the whole group and for the subgroup of 41 patients with Stage I disease. The possible significance of serum CA-125 levels as a tumor marker and a marker of response to platinum-containing chemotherapy was evaluated. RESULTS: In multivariate analysis, disease stage, the presence of residual tumor, and a hydrosalpinx-like appearance of the fallopian tube were of independent prognostic significance for the whole cohort. For patients with Stage I disease, the depth of infiltration in the tubal wall and intraoperative tumor rupture were of independent prognostic significance. The marked tendency of this disease for extraperitoneal spread, even in apparently early stages, was confirmed. In 37 evaluable, platinum-naïve patients, an overall response rate of 70% was obtained with platinum-based chemotherapy, with a median response duration of 12.5 months. In view of its low efficacy and high rate of serious complications, the use of postoperative radiotherapy in the treatment of patients with fallopian tube carcinoma is no longer recommended. Serum CA-125 level measurements in fallopian tube carcinoma patients have the same significance as tumor and surrogate markers of response as in ovarian carcinoma patients. CONCLUSIONS: Prognostic factors in patients with early stage (Stages 0 and I) fallopian tube carcinoma seem to differ from those in patients with early stage ovarian carcinoma. For patients with more advanced stage disease, due to the striking similarities in prognostic and clinical characteristics between the two diseases, the authors recommend that the treatment and follow-up strategies for patients with ovarian carcinoma be adopted in the management of patients with fallopian tube carcinoma.

Expression of apoptosis-related proteins is an independent determinant of patient prognosis in advanced ovarian cancer.

PURPOSE: The present study was undertaken to investigate the prognostic and predictive relevance of the expression of apoptosis-related proteins Bax, Bcl-X(L), and Mcl-1 in advanced ovarian cancer. PATIENTS AND METHODS: Tumor biopsies from 185 consecutive and homogeneously treated patients with stage III ovarian cancer were examined immunohistochemically for the expression of Bax, Bcl-X(L) and Mcl-1 proteins. Their prognostic relevance was examined in a uni- and multivariate survival analysis. RESULTS: Sixty-six percent of cancer cases expressed Bax, 62% Bcl-X(L), and 53% Mcl-1. The expression of Bax correlated with tumor differentiation (P: =.016) and less residual disease after surgery (P <.0001). In univariate analysis, Bax expression was associated with improved (P =.0004) prognosis and Mcl-1 expression with poorer (P =.011) prognosis. None of the factors studied was of independent prognostic significance by itself, but when Bax and Bcl-2 expression data were considered together, this combined variable was of independent prognostic significance (P =.0115), together with residual disease status (P =.0016), differentiation grade (P =.0014), and the presence of ascites (P =.0122). Patients with a long median survival (104 months) could be discriminated from those with a short one (16 months) by combining the individual patients' expression data for p53, Bax, and Bcl-2 with their residual disease status (P <.00001). None of the factors studied was able to predict response to chemotherapy. CONCLUSION: The expression of selected apoptosis-related proteins is of independent prognostic significance and may be helpful in a molecular substaging of patients with stage III ovarian cancer.

[DNA ploidy in epithelial ovarian cancer--an independent prognostic factor]. / DNA-ploiditet ved epitelial ovarialkreft--en uavhengig prognostisk faktor.

Ovarian cancer is the most lethal of the gynecological malignancies. One of the aims of the ongoing research in this field is the search for prognostic and/or predictive factors which can contribute to a more individualized patient treatment. All studies performed at The Norwegian Radium Hospital with regard to the prognostic significance of DNA ploidy in borderline, early and advanced ovarian cancer, were reviewed. The conclusions emanating from these studies were compared to the international literature. DNA ploidy analysis is of definite independent prognostic significance in borderline and early (FIGO stage I) ovarian cancer, and is of help in the selection of patients expected to benefit from adjuvant chemotherapy, or in whom a more conservative surgical procedure can be acceptable. DNA ploidy status is also of prognostic significance in advanced ovarian cancer; however, for the time being this information has no direct consequences for patient treatment. We conclude that DNA ploidy analysis should be incorporated in the routine histopathological evaluation of borderline and early (stage I) ovarian cancer.

[Controversies in surgical treatment of advanced ovarian cancer]. / Kontroverser ved kirurgisk behandling av avansert ovarialcancer.

Cytoreductive surgery has traditionally been regarded as a cornerstone in the primary treatment of advanced ovarian cancer. Both five year survival and median survival are better for patients with small residual masses. Despite many similar reports showing the prognostic significance of postoperative residual tumour, the survival benefits of cytoreductive surgery still remain scientifically unproven and controversial. There have been no prospective controlled clinical trials. The question remains as to whether the observed survival benefits for patients subjected to primary cytoreductive surgery are an effect of surgery skills or tumour biology. The proponents of tumour biology claim that cytoreductive surgery is a selective procedure and that patients with better prognosis are selected. Therefore a randomized study between primary cytoreduction and neoadjuvant chemotherapy in patients that cannot be optimally cytoreduced seems warranted, though one problem with such a study is how to select eligible patients. During chemotherapy and after relapse several types of operations are used in ovarian cancer: secondary cytoreductive surgery, interval cytoreductive surgery, second-look surgery and palliative secondary surgery. So far interval cytoreductive surgery during chemotherapy is the only type of operation which in a prospective randomized study showed significant improvement in long-term survival. This paper discusses indirect evidence in the literature in support of or in contradiction to the primary debulking hypotheses and also indications and impact of surgical procedures during chemotherapy.

P-glycoprotein expression is a marker for chemotherapy resistance and prognosis in advanced ovarian cancer.

BACKGROUND: It was our aim to study the prevalence and possible prognostic and predictive significance of the expression of P-glycoprotein, a transmembrane transport protein related to classical multidrug resistance, in patients with advanced ovarian cancer. STUDY DESIGN: Tumor tissue from 73 previously untreated patients with FIGO stage 3 ovarian cancer was examined with immunohistochemistry for the expression of P-glycoprotein before and after chemotherapy. Response to 4 cycles of combination chemotherapy with cisplatin and epirubicin was assessed with second look laparotomy. The log rank test was used for univariate survival and the Cox proportional hazards regression model for multivariate survival analysis. RESULTS: P-glycoprotein expression was detected in 47% of untreated cases, and correlated with unfavourable prognostic factors such as advanced age, presence of ascites and larger residual disease deposits after primary surgery. P-glycoprotein negative cases responded significantly better to chemotherapy (P < .001). In the multivariate survival analysis P-glycoprotein expression was an independent predictor of both overall (P = .045) and progression free (P = .006) survival. When P-glycoprotein expression and residual disease status were considered together, the patients could be divided in three clearly distinct prognostic groups (P = .0009). CONCLUSION: P-glycoprotein expression is a predictor of response and survival in a uniformly treated and followed cohort of advanced ovarian cancer patients.