Phase II evaluation of capecitabine in refractory nonsquamous cell carcinoma of the cervix: a Gynecologic Oncology Group study.

We conducted a multi-institutional study to assess the activity and toxicity of capecitabine in patients with persistent or recurrent nonsquamous cancer of the cervix. Eligible patients were required to possess adequate renal, hepatic and bone marrow function and a Gynecologic Oncology Group performance status of 0-2. Histologic confirmation of the original primary cancer was mandated. Patients must have received one prior systemic chemotherapeutic regimen for cervical cancer that did not include the chemotherapy that may have been administered in conjunction with prior radiation therapy. The initial dose schedule was 2500 mg/m2 orally daily in two divided doses for 14 consecutive days, followed by a 7-day rest, such that each cycle was 21 days. Responses were assessed using response evaluation criteria in solid tumors. Twenty-one patients were entered into the trial. One patient was declared ineligible for wrong cell type; thus, 20 were evaluable for toxicity. A median of 2.5 cycles was administered (range 1-11). There was one septic death. Grade 4 neutropenia, renal, neurologic, and pulmonary toxicity was seen in 5%, 5%, 5%, and 10% patients, respectively. There were no responses. Nine patients (45%) each had stable disease and nine showed progression. The remaining two cases (10%) did not have subsequent disease assessment and response could not be assessed. Oral capecitabine at the dose and schedule tested has insignificant activity in nonsquamous cervical cancer patients previously treated with chemotherapy.

The utility of presurgical CA125 to predict optimal tumor cytoreduction of epithelial ovarian cancer.

The objective of this study was to evaluate the ability of a preoperative serum CA125 to predict whether optimal debulking (OD) could be achieved for patients with stage III and IV epithelial ovarian cancer (EOC). The records of consecutive patients who underwent primary surgery for EOC at Indiana University Hospital between January 1997 and January 2003 were reviewed. Eligibility criteria included FIGO stage III/IV disease, surgery by gynecologic oncology faculty, preoperative CA125, and an operative note clearly defining volume of residual disease. The Medcalc software statistical package was used to generate a receiver-operating characteristic (ROC) curve. Two hundred and eighty-nine cases of stage III/IV EOC were identified, of which 164 met the eligibility criteria. Serum CA125 /=75% of the time. Conversely, OD was achieved in /=4500. The area under the ROC curve for CA125 was .670. The OD rate for those with and without ascites was 49% and 79%, respectively (P < 0.001). In a multivariate analysis using CA125, age, and ascites, the area under the curve was 0.686. We conclude that preoperative serum CA125 did not reliably predict OD in patients with stage III-IV EOC.

Role of lymphadenectomy in management of adenocarcinoma of the endometrium.

PURPOSE: To review the role of lymphadenectomy (LND) for patients with endometrial adenocarcinoma. METHODS: A review was undertaken of the English Language literature dealing with the role of LND for patients with endometrial adenocarcinoma (EC). RESULTS: The prognostic value of node status for EC patients has been recognized. LND performed by experienced surgeons has acceptable morbidity. Multiple series have suggested that significantly less external beam radiation is given to patients with known negative nodes. The decreased use of postop whole pelvic radiation has potential cost savings. However a survival advantage for LND has not yet been proven in a randomized clinical trials. United Kingdom investigators have begun a trial to determine if there is a demonstrable survival advantage for EC patients who undergo LND. CONCLUSION: Although the morbidity, potential cost savings, and prognostic impact of node status are well accepted, it remains controversial as to whether LND provides a survival advantage. Trials are underway.

The risk of nodal metastasis in early adenocarcinoma of the uterine cervix.

A functional and widely accepted definition of microinvasive cervical adenocarcinoma remains elusive. The purpose of this study was to determine at which depth of invasion the likelihood of lymph node metastasis or disease recurrence was so small that conservative surgery could be considered appropriate. Charts of patients with adenocarcinoma of the cervix (ACC) who underwent radical hysterectomy and pelvic lymphadenectomy (n = 98) at Indiana University Medical Center from 1987 to 1998 were retrospectively reviewed. Patients with stage IA1-IB1 lesions were included in the study. Patients treated with preoperative radiotherapy were excluded. Pathologic parameters evaluated included histologic type, depth of stromal invasion (DOI), and the presence of lymphatic vascular space invasion, or lymph node metastases. The patient median age was 39 years (20-65). The median time of follow-up was 30 months (4-124). Lymph node metastases were found in ten patients and 11 developed recurrences. The precise DOI could be measured in 84 patients. Of the 48 patients with cancers with a DOI 5 mm had nodal metastases (P = 0.00069). None of these 48 patients with a tumor DOI 5 mm developed recurrent disease (P = 0.0048). The risk of nodal metastases and recurrence is so low in patients with ACC and DOI

Coexistence of metastatic neuroendocrine carcinoma of the uterine cervix with human immunodeficiency virus infection.

Women now constitute 28% of new cases of human immunodeficiency virus (HIV) infection. Cervical cancer in HIV-infected women has a high recurrence and death rate, as well as decreased intervals to recurrence and death. Neuroendocrine carcinomas of the cervix are characterized by a high frequency of early nodal and distant metastases. We present the first report of a neuroendocrine carcinoma of the cervix in an HIV-positive patient. A 28 year old with a 9-year history of HIV succumbed to metastatic neuroendocrine carcinoma of the cervix 5 months after diagnosis. Given the aggressive nature of the cell type, an extended metastatic workup should be considered prior to surgery. The immune suppression present in HIV-positive patients with neuroendocrine cervical carcinoma may make such a workup particularly crucial, such that surgery is offered only to those who can be expected to benefit.

Differences in thermostability of thymidine kinase isoenzymes in normal ovary and ovarian carcinoma.

UNLABELLED: Thymidine kinase 1 (TK 1 EC. 2.7.1.21) the most specific and cell-cycle regulated salvage enzyme for pyrimidine nucleoside supply of DNA synthesis is a promising target to rationally designed chemo- and other therapies. The present study was undertaken to compare the heat stability of TK isoenzymes of both normal ovarian and epithelial ovarian cancer cells. Tissue extracts of epithelial ovarian carcinomas (N = 7) and normal ovaries (N = 9) were analyzed for thymidine kinase activity using the polyethyleneimine-cellulose disc radioassay. The TK activity in extracts of ovarian carcinomas was 12-fold higher than in extracts of normal ovaries. The TK activity of ovarian carcinomas decreased significantly even after 30 minutes incubation at 37 degrees C while, the enzyme activity of normal ovarian extracts was more stable and decreased to the same extent after 120 minutes. The half-life time of the enzyme activity was 82 min in the normal but only 36 minutes in the cancer tissue extract at 37 degrees C. CONCLUSION: The TK activity of malignant ovarian cells was much higher but more unstable (t1/2 = 36 minutes) than the enzyme isolated from healthy ovaries (t1/2 = 82 minutes). This profound difference in thermostability might provide the molecular background for hyperthermia combined with chemotherapy as a promising treatment for ovarian malignancies.

The Society of Gynecologic Oncologists Outcomes Task Force. Study of endometrical cancer: initial experiences.

OBJECTIVE: The aim of this study was to develop an outcomes measure, which incorporates patient reported information, for The Society of Gynecologic Oncologists (SGO) to establish benchmarks in the treatment of endometrial cancer and demonstrate quality to third parties. METHODS: The Outcomes Task Force (OTF) developed an outcomes tool that included preoperative, intraoperative, and 120-day-postoperative assessments. Measures included demographics, patient-reported health status (SF36), comorbid conditions, living status, satisfaction surveys, operative events and disease characteristics. Patients (n = 297) were surveyed at 11 pilot sites from 10/1/97 to 9/1/99. RESULTS: The mean age of patients was 64.4 years and their mean Quetelet index was 33.2 kg/m(2). Forty-eight percent were Medicare beneficiaries and 25% were HMO patients. Mean comorbidity score was 19.1 (maximum possible 100). This represents approximately three comorbidities per average patient. Seventy-four percent were FIGO stage I, 9% stage II, 11% stage III, and 5% stage IV. Forty percent were FIGO grade 1, 35% grade 2, and 24% grade 3. Ninety-two percent of patients were able to live independently preoperatively and 91% were independent postoperatively. Seventy-seven percent of patients underwent total abdominal hysterectomy, 8% radical abdominal hysterectomy, 9% laparoscopic hysterectomy, and 1% vaginal hysterectomy. Mean length of stay was 3. 3 days and mean operative time was 119 min. Ninety-nine percent were staged and 80% underwent lymph node sampling. Two patients required unplanned returns to surgery and 8 required blood transfusion (27 units total). Postoperatively, 20% received radiation therapy and 13% received cytotoxic chemotherapy. Mean satisfaction score (scale 0 to 100) preoperatively was 86 and postoperative was 83. SF36 component summaries were preoperatively and 120 days postoperatively: physical component 43.6 vs 43.1; mental component 49.1 vs 50.6. CONCLUSION: The SGO has developed a tool for assessing outcomes for the treatment of endometrial cancer that can be made available to the membership to assess and objectively demonstrate quality of care to third parties.

Inverted follicular keratosis of the vulvar skin: a lesion that can be confused with squamous cell carcinoma.

Although seborrheic keratoses of the vulva are described in textbooks, to our knowledge, inverted follicular keratosis has not been reported. A 27-year-old woman underwent an excisional biopsy for a small lesion of the left labium majus. Squamous cell carcinoma was considered in the clinical differential diagnosis. The initial pathologic diagnosis suggested squamous cell carcinoma in situ, and the consultation diagnosis was superficially invasive squamous cell carcinoma. On pathologic examination, a symmetrical, endophytic, epithelial tumor was observed consisting of a proliferation of basaloid cells with many areas of reactive squamous cells showing numerous squamous eddies, focal reactive nuclear atypia, and occasional mitotic figures. After the pathologic diagnosis of inverted follicular keratosis was made, a history of close perineal shaving and total body tanning was obtained. Because inverted follicular keratosis is postulated to be related to follicular injury, it is likely that the trauma of close shaving is a significant etiologic factor. There is less evidence that ultraviolet ray exposure is of etiologic importance.

Signal transduction and biochemical targeting of ovarian carcinoma.

UNLABELLED: The purpose was to identify novel targets for the chemotherapy of ovarian carcinoma. METHODS: Assays were worked out to measure the activities of P1 kinase, PIP kinase and PLC in ovarian carcinoma samples and in OVCAR-5 cells and to compare the activities to those in normal ovaries. A method was also designed for measuring the concentration of the end product of signal transduction, IP3. RESULTS AND DISCUSSION: Signal transduction activity was markedly increased in ovarian cancer cells as shown by the increased steady-state activities of the three enzymes and the elevated concentrations of IP3. Inhibitors blocked activities of PI kinase (quercetin), PIP kinase (genistein), and lowered GTP concentration required for PLC (tiazofurin). Combinations of tiazofurin with quercetin, tiazofurin with genistein, and quercetin with genistein yielded a synergistic kill of ovarian cancer cells. Tiazofurin, quercetin and genistein are in various stages of clinical trials. CONCLUSION: The increased signal transduction activity provides novel, sensitive targets to chemotherapy in ovarian cancer cells.

Phase I trial of paclitaxel and etoposide for recurrent ovarian carcinoma: a Gynecologic Oncology Group Study.

A phase I study was performed to determine the maximum tolerated doses of intravenous etoposide and paclitaxel for women with previously treated persistent or recurrent ovarian cancer. Starting doses were paclitaxel 135 mg/m2 during 24 hours and etoposide 50 mg/m2/day for 3 consecutive days. The study was designed to escalate first the dose of etoposide, and then the dose of paclitaxel, in successive cohorts of patients. In an attempt to determine whether toxicity was affected by sequence of the drugs, the order of administration of the two drugs was reversed on alternate cycles. The starting doses of paclitaxel (135 mg/m2/24 hours) and etoposide (50 mg/m2/day x 3) caused severe neutropenia even with the addition of granulocyte colony-stimulating factor, and the trial was amended to administer the paclitaxel during 3 hours. However, this also proved too myelosuppressive without growth factor support. Twenty-one women were treated. A complete response was observed in one of nine patients with measurable disease, and a major decrease in CA-125 was noted in two patients who did not have measurable disease. Because of the severe myelosuppression observed in most patients, dose reduction was often required after the first cycle. The power to detect sequence-dependent variation in toxicity was minimal; however, no large differences were observed. A combination of the usual doses of these drugs will be difficult to administer in patients who have received previous chemotherapy for ovarian cancer.

Lack of efficacy of 24-h infusional topotecan in platinum-refractory ovarian cancer: A Gynecologic Oncology Group trial.

BACKGROUND: The aim of this study was to evaluate the efficacy of a more convenient topotecan administration schedule in the second-line treatment of advanced platinum-refractory ovarian cancer. METHODS AND MATERIALS: The Gynecologic Oncology Group conducted a Phase II trial of 24-h infusional topotecan (8.5 mg/m(2)), repeated every 3 weeks in 26 patients with platinum-refractory ovarian cancer (failure to respond to initial platinum-based treatment or development of recurrent disease within 6 months of completion of chemotherapy). RESULTS: Grade 4 neutropenia (85% of patients) and thrombocytopenia (12%) were the major toxicities encountered. Of the 25 patients evaluable for response, only a single patient experienced an objective response (4%). CONCLUSIONS: When employed at this dose and schedule (24-h infusion every 3 weeks), topotecan has minimal second-line activity in platinum-refractory ovarian cancer.

Transforming growth factor-beta differentially inhibits epithelial ovarian carcinoma cells from primary and metastatic isolates without up-regulation of p21WAF1.

BACKGROUND: Transforming growth factor-beta (TGF-beta) is known to inhibit primary epithelial ovarian carcinoma cells. The mechanism by which this inhibitory response is achieved is poorly understood. Furthermore, whether this response is consistent in cells from metastatic sites compared with the primary site cells is unknown. The authors wanted to determine whether TGF-beta differentially inhibited ovarian carcinoma cells from primary tumor sites compared with metastatic sites and to establish whether this response was associated with up-regulation of p21WAF1 or overexpression of p53. METHODS: Tumor cells were purified from primary and metastatic sites in five patients with advanced epithelial ovarian carcinoma. TGF-beta effect at concentrations of 10, 1, and 0.1 ng/mL was determined by tritiated thymidine incorporation assay. Expression of p21WAF1 was determined by Northern and slot blot analysis. p53 was detected by immunocytochemistry. RESULTS: Metastatic tumor isolates were more responsive to the inhibitory effect of TGF-beta compared with their corresponding primary tumor isolates at 0.1 ng/mL. Increasing TGF-beta concentration conferred no additional inhibitory effect on the metastatic isolates; however, a dose-related phenomenon was observed in primary tumor isolates. p21WAF1 mRNA was up-regulated in only 2 of 10 primary and metastatic isolates. There was no correlation between TGF-beta responsiveness, p21WAF1 up-regulation, and p53 overexpression. CONCLUSIONS: Differential inhibition was observed between primary and metastatic tumor isolates. p21WAF1 up-regulation and p53 overexpression were not major modulators in TGF-beta regulation of primary and metastatic tumor growth in early passaged ovarian carcinoma cells.

A phase II trial of isotretinoin and alpha interferon in patients with recurrent squamous cell carcinoma of the cervix: a Gynecologic Oncology Group study.

From January 1993 through January 1996, 37 patients with unresectable squamous carcinoma of the cervix were entered on study and scheduled to receive oral isotretinoin 1 mg/kg per day with subcutaneous alpha interferon 6,000,000 units/day. A course was defined as 4 continuous weeks of therapy. The mean number of four-course cycles delivered was 1.8. One patient was ineligible because of wrong cell type and two were never treated. Thus, 34 patients were evaluable for toxicity. Eight patients were inevaluable for response. Five did not receive a complete 4-week course and three did not have additional tumor measurements; thus 26 were evaluable for response. Prior radiotherapy had been given to 25 patients and prior chemotherapy to 23 patients. There was no grade 4 neutropenia. The incidence of Gynecologic Oncology Group (GOG) grade 3 granulocytopenia and thrombocytopenia was 8.8% and 5.8%, respectively. Six patients (17.6%) developed grade 3 or worse nausea and vomiting. Four (11.7%) patients developed grade 3 neurologic symptoms. There were no complete responses and one partial response. The overall response rate was 3.8% (95% confidence interval, 0.1-19.6%). In this pretreated population, isotretinoin and alpha interferon in the dose and schedule employed exhibit minimal activity.

A phase II trial of CPT-11 in recurrent squamous carcinoma of the cervix: a gynecologic oncology group study.

OBJECTIVE: To determine the response rate and associated toxicity of weekly CPT-11 in squamous carcinoma of the cervix. METHODS: From October 1994 to May 1996, the Gynecologic Oncology Group (GOG) conducted a Phase II trial in patients with recurrent squamous cervix carcinoma. The schedule employed weekly x4 intravenous CPT-11 at 125 mg/m2 followed with a 2-week rest, to be repeated until disease progression or unacceptable toxicity. Eligibility criteria were a GOG performance status of 0-2, adequate bone marrow reserve, adequate liver function, and serum creatinine <2 mg%. None of the patients had received prior chemotherapy other than radiation sensitizers. Standard GOG toxicity and response criteria were used. RESULTS: Fifty-four patients were entered into the trial. Three patients were ineligible because of wrong cell type (N = 2) or inadequate pathology material (N = 1). Two were inevaluable because of inadequate trial of drug. An additional 4 patients were inevaluable for response. Thus, 49 were evaluable for toxicity and 45 were evaluable for response. The median age of patients was 45 years (range, 29-71 years). The median number of weekly doses delivered was 7 (range, 1-46). The incidence of grade 4 neutropenia and anemia was 6.1 and 4.1%, respectively. Nineteen patients (38.8%) developed gastrointestinal (GI) toxicity including 8 with grade 3 and 11 with grade 4 severity. The overall response rate was 13.3% (6/45). There was 1 patient death from GI toxicity. There was one complete response of 8.8 months duration and 5 partial responses. CONCLUSION: OFFis schedule of CPT-11 exhibits modest activity with moderate toxicity in patients with recurrent squamous carcinoma of the cervix.

Gynecologic cancers metastatic to the breast.

BACKGROUND: We report a series of gynecologic cancers metastatic to the breast, illustrating the diagnostic and prognostic implications of this rare event. STUDY DESIGN: By reviewing the gynecologic oncology data base, we identified 10 women with gynecologic cancer metastatic to the breast who were treated at Indiana University School of Medicine between August 1978 and February 1995. Medical records were reviewed for pertinent data concerning the presentation, evaluation, and treatment of the primary gynecologic malignancy and the metastatic breast tumor. RESULTS: The mean patient age was 56.8 years (range, 30-80 years). The most common gynecologic malignancy was ovarian cancer (five patients), followed by cervical cancer (two patients) and cancers of the vagina, endometrium, or peritoneum (one patient each). A palpable solitary breast mass was found in 8 of 10 patients (80%), and the upper outer quadrant of the breast was the most common site of tumor involvement. One woman presented with examination findings resembling inflammatory breast cancer, and one patient presented with multiple firm subcutaneous nodules. Despite further treatment, which in all cases consisted of systemic chemotherapy, 83% of the patients died with a breast metastasis within 1 year of presentation. CONCLUSIONS: Secondary breast malignancy should be suspected in any patient with a breast tumor and a known history of gynecologic cancer. A breast metastasis implies widespread tumor dissemination and a poor prognosis. Radical breast surgery should be avoided.

Increased uridine kinase (ATP: uridine 5'-phosphotransferase; EC 2.7.1.48) activity in human and rat tumors.

The activity of uridine kinase (ATP: uridine 5'-phosphotransferase; EC 2.7.1.48), the rate-limiting enzyme of the UMP salvage pathway, was measured in human ovaries and ovarian carcinomas, in a spectrum of six rat hepatomas of different growth rates and in eleven normal rat tissues of high and low cell renewal rates. In a standard isotopic method developed for the 100,000 x g fraction, uridine kinase activity was linear for 20 min and proportional with protein concentration over a range of 0.1 to 0.8 mg per 0.1 ml reaction mixture. The apparent Kms for uridine, ATP and Mg++ in normal rat liver were 5.0, 3.4 and 1.5 mM and in the rapidly growing hepatoma 3924A, 0.8, 2.1 and 1.1 mM, respectively. In normal control ACl/N and Buffalo strain rat livers, kinase activity ranged from 159 to 180 nmol/h/mg protein. In hepatomas of slow and intermediate growth rates, kinase activity increased to 1.5- to 2.6-fold, and in hepatomas of rapid growth rates, to 5.1- to 5.8-fold over that of the relevant control, normal livers. When hepatoma 3924A tissue culture cells were plated and expressed their proliferative program, kinase activity increased to 2.1-fold in early log phase. To further clarify the linkage between uridine kinase and cell replicating capacity, the enzyme activity was measured in rat organs of high and low cell renewal. The kinase activity in liver of adult male Wistar rats was 176 +/- 6 nmol/h/mg protein. Activities in thymus, spleen and bone marrow were 4.7-, 2.1-, and 1.8-fold, respectively, of rat liver values; in adipose tissue, the activities were low. The decay rates of uridine kinase were examined in rats injected with a high dose of cycloheximide, which inhibits protein biosynthesis by 90%. The t(1/2) of the kinase in rat bone marrow was 0.64 h, in rat liver longer than 6 h. In human ovary and ovarian carcinoma, the apparent Kms for uridine were 11.5 and 0.5 mM, respectively. In human ovary (n = 3), kinase activity was 38 nmol/hr/mg protein; in ovarian carcinoma (n = 6), the activity increased to 5- to 13-fold over that in ovary. The positive linkage of uridine kinase activity with proliferation and transformation is apparent in human ovarian carcinomas and in rat hepatomas of different growth rates. Therefore, the increased uridine kinase activity should be an interesting target for anticancer chemotherapy.

A phase II trial of amonafide in patients with nonsquamous cell carcinoma of the cervix. A Gynecologic Oncology Group study.

Twenty-seven patients with nonsquamous cell carcinoma of the cervix were entered into a Phase II study of amonatide; 24 patients were evaluable for toxicity, while 23 were evaluable for response. Patients received amonafide, 300 mg/m2, intravenously for 5 consecutive days every 3 weeks. The median age of patients was 45 years. All but two patients were completely ambulatory. Twelve patients had received prior chemotherapy, while 22 had been treated with radiation therapy. One of 27 (4.3%) patients had a partial response (PR) to this regimen and 13 (56.5%) had stable disease. Sixteen patients experienced a median white blood cell (WBC) nadir of 350/mm3, seven developed life-threatening thrombocytopenia, and one had severe anemia requiring transfusion. Nonhematologic toxicity was mild. Amonafide had insignificant activity in these patients with nonsquamous cell carcinoma of the cervix.

Increased thymidine kinase and thymidylate synthase activities in human epithelial ovarian carcinoma.

BACKGROUND: Thymidylate synthase (dTMP synthase, EC 2.1.1.45) is responsible for the de novo biosynthesis of thymidylate (dTMP) whereas thymidine kinase (TdR kinase, EC 2.7.1.21) is the salvage enzyme which leads to the production of dTMP even in presence of d TMP synthase inhibition. The current study was undertaken to compare the steady-state activities of d TMP synthase and TdR kinase in extracts of human epithelial ovarian carcinoma and normal ovaries. MATERIAL AND METHODS: Tissue extracts of epithelial ovarian carcinomas and normal ovaries were analyzed for activities of d TMP synthase (by a method that measures released 3H2O) and TdR kinase (by polyethyleneimine impregnated (PEI) cellulose plate radioassay), methods established in this laboratory. RESULTS: The dTMP synthase activity (mean +/- S.E.) in extracts of ovarian carcinomas (N = 11) was 0.198 +/- 0.069 and in extracts of normal ovaries (N = 12) it was 0.025 +/- 0.0004 nmol/hr/mg protein. By contrast, TdR kinase activity in extracts of ovarian carcinoma (N = 13) was 27.7 +/- 8.5 compared to 1.0 +/- 0.3 nmol/hr/mg protein in extracts of normal ovaries (N = 15). CONCLUSION: The observed 140-fold higher TdR kinase activity suggests that DNA synthesis may continue despite inhibition of dTMP synthase with current schedules of 5-fluorouracil (5-FU) and leucovorin. The addition of azidothymidine, a competitive inhibitor of TdR kinase, to 5-FU and leucovorin might be a rational biochemical strategy to employ in patients with refractory ovarian carcinoma.