Is it possible to diagnose malignancy from fluid in cystic ovarian tumors?

OBJECTIVE: p53 gene mutations are frequently identified in ovarian cancer tissue. The aim of this study was to investigate whether wild type or mutated genomic DNA can be identified in ovarian cystic fluid specimens. STUDY DESIGN: Forty-eight Japanese patients with cystic ovarian tumors (30 benign cysts, 8 borderline malignant tumors, and 10 cancers) were investigated. Cystic fluid and tumor tissue were obtained during surgery. After DNA extraction from the cystic fluid, polymerase chain reaction (PCR) and sequence analysis for exons 4-9 of the p53 gene was performed. In two cases of mucinous cystic tumor of borderline malignancy and endometrioid adenocarcinoma, the p53 gene sequences were determined. Immunohistochemical staining for abnormal p53 gene product was also performed. RESULTS: DNA was successfully extracted from all cystic fluid specimens. Furthermore, exons 4-9 of the p53 gene could be identified by electrophoresis from all samples. In a mucinous cystic tumor of borderline malignancy, one point mutation was identified at codon 223 in exon 6 (CCT → CTT) of the p53 gene. Aberrant p53 gene product was also observed in the tumor cells by immunohistochemical staining. Moreover, in another case of endometrial adenocarcinoma, a point mutation at codon 245 in exon 7 (GGC → AGC) was detected by the direct sequencing of the amplified Exon. Notably, the mutation was not present in the peripheral blood (PB) sample and tissue specimens from the patient. CONCLUSION: In cystic ovarian tumors, cystic fluid may provide informative material for molecular studies since it reflects the p53 status of tumor tissue in the cyst wall. This system might help to identify ovarian malignancy without resection of the tumor tissues.

Detection of Merkel cell polyomavirus in cervical squamous cell carcinomas and adenocarcinomas from Japanese patients.

BACKGROUND: Merkel cell polyomavirus (MCPyV) was identified originally in Merkel cell carcinoma (MCC), a rare form of human skin neuroendocrine carcinoma. Evidence of MCPyV existence in other forms of malignancy such as cutaneous squamous cell carcinomas (SCCs) is growing. Cervical cancers became the focus of our interest in searching for potentially MCPyV-related tumors because: (i) the major histological type of cervical cancer is the SCC; (ii) the uterine cervix is a common site of neuroendocrine carcinomas histologically similar to MCCs; and (iii) MCPyV might be transmitted during sexual interaction as demonstrated for human papillomavirus (HPV). In this study, we aimed to clarify the possible presence of MCPyV in cervical SCCs from Japanese patients. Cervical adenocarcinomas (ACs) were also studied. RESULTS: Formalin-fixed paraffin-embedded tissue samples from 48 cervical SCCs and 16 cervical ACs were examined for the presence of the MCPyV genome by polymerase chain reaction (PCR) and sequencing analyses. PCR analysis revealed that 9/48 cervical SCCs (19%) and 4/16 cervical ACs (25%) were positive for MCPyV DNA. MCPyV-specific PCR products were sequenced to compare them with reference sequences. The nucleotide sequences in the MCPyV large T (LT)-sequenced region were the same among MCPyV-positive cervical SCCs and AC. Conversely, in the MCPyV viral protein 1 (VP1)-sequenced region, two cervical SCCs and three cervical ACs showed several nucleotide substitutions, of which three caused amino acid substitutions. These sequencing results suggested that three MCPyV variants of the VP1 were identified in our cases. Immunohistochemistry showed that the LT antigen was expressed in tumor cells in MCPyV-positive samples. Genotyping of human HPV in the MCPyV-positive samples revealed that infected HPVs were HPV types 16, 31 and 58 for SCCs and HPV types 16 and 18 for ACs. CONCLUSIONS: This study provides the first observation that MCPyV coexists in a subset of HPV-associated cervical cancers from Japanese patients. The prevalence of MCPyV in these lesions was close to that observed in the cutaneous SCCs. Further worldwide epidemiological surveys are warranted to determine the possible association of MCPyV with pathogenesis of cervical cancers.

Comparison of four malignancy risk indices in the preoperative evaluation of patients with pelvic masses.

OBJECTIVE: The aim of this study was to evaluate the ability of four malignancy risk indices (RMI 1, RMI 2, RMI 3, and RMI 4), incorporating menopausal status, serum CA125 levels, and ultrasound findings, to discriminate a benign from a malignant pelvic mass. STUDY DESIGN: This is a retrospective study of 253 women admitted to the Department of Obstetrics and Gynecology of Kochi Medical School, between January 2002 and April 2005 for surgical exploration of pelvic masses. To diagnose ovarian cancer, the sensitivity, specificity, and positive predictive value of serum CA125, ultrasound findings and menopausal status were taken separately and combined into RMI 1, RMI 2, RMI 3, and RMI 4. RESULTS: This study confirms that, for the diagnosis of malignancy, four malignancy risk indices were more accurate than menopausal status, serum CA125 levels, and ultrasound findings separately. The accuracy of the RMI 4 was better than RMI 1 (P=0.0013), RMI 2 (P=0.0009) and RMI 3 (P=0.0013). The RMI 4 at a cutoff level of 450 yielded a sensitivity of 86.8%, a specificity of 91.0%, a positive predictive value of 63.5%, a negative predictive value of 97.5%, and an accuracy of 90.4%. CONCLUSION: We found that, in the discrimination between benign and malignant pelvic disease, the RMI 4 method was more reliable than RMI 1, RMI 2 and RMI 3. The RMI 4 method is a simple technique that can be used in gynecology clinics as well as less-specialized centers.

Preoperative evaluation of pelvic masses with combined 18F-fluorodeoxyglucose positron emission tomography and computed tomography.

OBJECTIVE: To prospectively evaluate the diagnostic value of combined 18F-fluorodeoxyglucose position emission tomography and computed tomography (FDG-PET/CT) to discriminate malignant or borderline malignant tumors from benign pelvic masses. METHODS: A prospective study of 30 women with suspected ovarian cancer who presented from July 2006 through August 2007. Selection was based on evidence from ultrasound, magnetic resonance imaging, and rising tumor marker levels. All patients underwent FDG-PET/CT prior to standard debulking surgery for a pelvic mass. RESULTS: The sensitivity and specificity of FDG-PET/CT to detect malignant or borderline malignant pelvic tumors were 71.4% and 81.3%, respectively. The sensitivity and specificity of FDG-PET/CT to detect ovarian cancer were 100% and 85.0%, respectively. The maximum standardized uptake value in borderline tumors was significantly lower compared with malignant tumors, but not significantly different compared with benign tumors. CONCLUSION: FDG-PET/CT had a high diagnostic value in differentiating between malignant and benign tumors, and a low diagnostic value in differentiating between borderline malignant and benign tumors.

Decreased human leukocyte antigen-DR expression in the lipid raft by peritoneal macrophages from women with endometriosis.

OBJECTIVE: To investigate the macrophage response in endometriosis by determining the expression and localization of human leukocyte antigen (HLA)-ABC and HLA-DR by the peritoneal fluid (PF) macrophages and PF concentrations of interferon (IFN)-gamma that regulate HLA expression. DESIGN: Case-control study. SETTING: University hospital. PATIENT(S): 64 Japanese endometriosis patients, and 65 women with other laparoscopic diagnoses. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): Expression and localization of HLA-ABC and HLA-DR in PF macrophages were determined by flow cytometry and confocal microscopy. The concentration of IFN-gamma in PF was determined by enzyme-linked immunosorbent assay. RESULT(S): In women with endometriosis, expression of HLA-ABC and HLA-DR by PF macrophages, and the IFN-gamma concentrations in PF were statistically significantly lower than in controls. Women with endometriosis showed a statistically significant positive correlation between HLA expression and IFN-gamma concentration. By confocal microscopy, HLA-ABC was distributed homogenously on the macrophage surface whereas HLA-DR expression on these cells corresponded to the lipid raft. CONCLUSION(S): In women with endometriosis, low HLA expression and particularly reduced HLA-DR in the lipid raft may be influenced by low IFN-gamma and may compromise antigen presentation, limiting the immune response to peritoneal cavity antigens such as implanted or metaplastic endometrial tissue.

Primary yolk sac tumor concomitant with carcinosarcoma originating from the endometrium: case report.

BACKGROUND: A primary yolk sac tumor (YST) with carcinosarcoma originating from the endometrium is extremely rare, to our knowledge, this is the third documented instance. Several hypotheses exist is to its histogenesis. CASE: A 65-year-old Japanese woman was diagnosed with a uterine malignancy and underwent surgical treatment and chemotherapy. The postoperative diagnosis was primary carcinosarcoma concomitant with a YST of the uterus. Immunohistochemical staining revealed that the tumor area suspected to be a YST was positive for alpha-fetoprotein. CONCLUSION: We report a case of carcinosarcoma concomitant with a YST of uterus. This case is the third documented instance of a YST with concomitant with carcinosarcoma originating from the endometrium. The histogenesis in this case is suggests aberrantly differentiated somatic cells.

Killer immunoglobulin-like receptor and human leukocyte antigen expression as immunodiagnostic parameters for pelvic endometriosis.

PROBLEM: We investigated host immunologic responses to endometriosis by comparing immune cell surface antigens in peripheral blood (PB) and peritoneal fluid (PF) from women with endometriosis with those in PB and PF from other patients. METHOD OF STUDY: Japanese women with endometriosis (n = 56) were compared with controls with other laparoscopic diagnoses (n = 68). PB and PF were collected at the time of laparoscopy for flow cytometry. RESULTS: No significant difference in phenotypic parameters of T cells (CD3, CD4, and CD8), B cells (CD19), natural killer (NK) cells (CD56), or monocytes/macrophages (CD14) was seen between women with and without endometriosis. However, increased killer immunoglobulin-like receptor (CD158a) expression by NK cells and decreased human leukocyte antigen (HLA)-ABC and -DR expression by macrophages, all suggesting decreased functional activation were found in endometriosis. These markers showed significant association with endometriosis by odds ratio, logistic regression, and decision tree analyses. CONCLUSIONS: Increased CD158a(+) NK cells in PB and PF indicated decreased NK cell cytotoxicity in endometriosis, while decreased HLA expression on PF macrophages suggested impaired antigen presentation. Thus, aberrant immune responses by NK cells and macrophages may represent risk factors for endometriosis.

Malignant müllerian mixed tumor (carcinosarcoma) of the fallopian tube: an immunohistochemical study of neoplastic cells.

The patient was a 65-year-old woman who complained of lower abdominal pain. Salpingo-oophorectomy and hysterectomy were performed due to suspicion of ovarian cancer. At surgery a polypoid mass was observed in the fimbria of the left fallopian tube. Histologically, proliferation of undifferentiated neoplastic cells with marked cytological atypia predominated in the tumor. Proliferation of rhabdomyoblastic cells or spindle cells, as well as adenocarcinoma arising from the mucosa of the fallopian tube, was observed. A diagnosis of malignant müllerian mixed tumor (MMMT) was made. CD10 was expressed in adenocarcinoma, undifferentiated, spindle and rhabdomyoblastic cells. Furthermore, rhabdomyoblastic cells were positive for desmin and myoglobin. Undifferentiated and spindle neoplastic cells were focally positive for ASMA and negative for h-caldesmon. Finally, our preliminary report suggests that MMMT of the fallopian tube may contain immature smooth muscle cells or cells with the myofibroblast-like immunohistochemical phenotype in the undifferentiated component.

Non-puerperal uterine inversion associated with endometrial carcinoma--a case report.

BACKGROUND: Non-puerperal uterine inversion is rare, and a case associated with endometrial carcinoma is even rarer. It is difficult to diagnose the condition preoperatively and most cases are diagnosed at surgery. CASE: We describe a case of uterine inversion associated with endometrial carcinoma. Initially, the patient was thought to have a cervical adenocarcinoma and treated with chemotherapy; however, a diagnosis of uterine inversion was made with magnetic resonance imaging (MRI) and ultrasonography during pre-surgical chemotherapy. We performed total abdominal hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymphadenectomy. CONCLUSION: MRI and ultrasonography can be extremely useful tools for diagnosing uterine inversion.

Human leukocyte antigen expression by peritoneal macrophages from women with pelvic endometriosis is depressed but coordinated with costimulatory molecule expression.

OBJECTIVE: To investigate the macrophage response in endometriosis, we determined expression of human leukocyte antigen (HLA)-ABC, HLA-DR, and their costimulatory molecules by peritoneal fluid (PF) macrophages. DESIGN: Case-control study of immunologic markers. SETTING: University hospital. PATIENT(S): We compared 38 Japanese women with endometriosis with 59 control subjects who were given other laparoscopic diagnoses. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): Expression of HLA-ABC, HLA-DR, CD54, CD40, CD58, CD80, and CD86 by peripheral blood (PB) monocytes and PF macrophages was quantitated as mean fluorescence intensities by flow cytometry. Expression of each marker on PF macrophages was divided by that on PB monocytes as an index of macrophage activation (macrophage activation ratio). RESULT(S): In women with endometriosis, PF macrophages showed significant positive correlations between expression of HLA-ABC and other costimulatory molecules and also between HLA-DR and their costimulatory molecules. However, expression of HLA-ABC and DR by PF macrophages, and also their activation ratios, were significantly lower than in controls. CONCLUSION(S): Coordination with costimulatory molecules but relatively low expression of HLA-ABC and HLA-DR indicates a positive but limited immune response (antigen presentation) to events in the peritoneal cavity in women with endometriosis. This may induce immune tolerance to implanted or metaplastic endometrial tissue.

MRI of endocervical glandular disorders: three cases of a deep nabothian cyst and three cases of a minimal-deviation adenocarcinoma.

The incidence of cervical adenocarcinoma is increasing. Nabothian cysts are a common gynecologic condition; if multiple and/or large cysts are present, it is difficult to differentiate them from a minimal-deviation adenocarcinoma (MDA), which is classified as a special type of cervical adenocarcinoma. We report three cases of deep nabothian cysts and three cases of MDAs. Magnetic resonance imaging (MRI) findings, signs, and symptoms of these cases are described. The absence of a watery discharge and an MR image displaying a round or oval cyst without enhancement after intravenous gadolinium are helpful in the diagnosis of a deep nabothian cyst.

Killer inhibitory receptor CD158a overexpression among natural killer cells in women with endometriosis is undiminished by laparoscopic surgery and gonadotropin releasing hormone agonist treatment.

PROBLEM: Natural killer (NK) dysfunction is considered to contribute to the pathogenesis of endometriosis. In this study, we investigated the host immune response to endometriosis in terms of killer inhibitory receptor (KIR) expression by NK cells. METHOD OF STUDY: We compared cells from Japanese women laparoscopically diagnosed with endometriosis and treated with laparoscopic surgery (n = 98), 1 month after laparoscopic surgery (n = 36), and 12 weeks after gonadotropin releasing hormone agonist (GnRHa) treatment (n = 18) to cells from 104 women with other laparoscopic diagnoses. KIR expression by NK cells was assessed in peripheral blood and peritoneal fluid samples by flow cytometry. RESULTS: In women with endometriosis, the percentage of CD158a-expressing cells among CD16-expressing NK (CD158a(+)NK) cells in both peritoneal fluid and peripheral blood was significantly higher than in control subjects. No significant differences in proportion of CD158a(+)NK cells were identified between peripheral blood NK cells sampled before and 1 month after laparoscopic surgery, or 12 weeks after initiating GnRHa treatment. CONCLUSIONS: Increased percentage of CD158a(+)NK cells in peripheral blood from women with endometriosis was undiminished by laparoscopic surgery and GnRHa treatment; the persistence of CD158a(+)NK cell excess is probably related to NK cell suppression in endometriosis. This overexpression may represent a risk factor for development of endometriosis and its recurrence after treatments.

Thymidine phosphorylase expression is preserved after radiotherapy in patients with cervical squamous cell carcinoma.

PURPOSE: The aim of this study was to investigate the changes in two of the enzymes involved in fluorouracil metabolism, thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD), in uterine cervical squamous cell cancer tissue after radiotherapy. SUBJECTS AND METHODS: Cervical tissue from 27 patients diagnosed with stage IIIB or IV uterine cervical squamous cell cancer was compared with normal cervical tissue from 33 patients with benign gynecologic diseases. Expression of TP and DPD in the cervical tissues was measured using enzyme-linked immunosorbent assays. TP and DPD expression before and after irradiation with 10 and 20 Gy was measured in 9 of the 27 patients with cervical cancer. RESULTS: Before irradiation, DPD expression in cancer tissue did not differ from that in normal tissue. TP expression and the TP/DPD ratio were significantly higher in cancer tissue than in normal tissue ( P<0.00001). TP and DPD expression and the TP/DPD ratio were not significantly changed by irradiation with 10 and 20 Gy. TP expression and the TP/DPD ratio after irradiation with 10 and 20 Gy were significantly higher than in normal tissue. CONCLUSION: The increased TP expression and the elevated TP/DPD ratio following irradiation with up to 20 Gy may offer an increased clinical advantage to chemoradiotherapy with capecitabine or doxyfluridine over radiotherapy alone.

Coordinated but depressed expression of human leukocyte antigen-DR, intercellular adhesion molecule-1, and CD14 on peritoneal macrophages in women with pelvic endometriosis.

OBJECTIVE: To investigate the macrophage response in endometriosis, we determined the expression of human leukocyte antigen (HLA)-DR, intercellular adhesion molecule (ICAM)-1, and CD14 on peritoneal macrophages. DESIGN: Case-control study of immunologic markers. SETTING: University hospital. PATIENT(S): Forty-five Japanese women with endometriosis were compared with 48 control subjects with other laparoscopic diagnoses. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid (PF) collection. MAIN OUTCOME MEASURE(S): Expression of HLA-DR, ICAM-1, and CD14 on peripheral blood (PB) monocytes and PF macrophages were quantitated as mean fluorescence intensities by flow cytometry. Expression of each marker on PF macrophages was divided by that on PB monocytes, as an index of macrophage activation (macrophage activation ratio). RESULT(S): In women with endometriosis, PF macrophages showed significant positive correlations between expression of HLA-DR and ICAM-1, HLA-DR and CD14, and ICAM-1 and CD14. However, expression of individual markers on PF macrophages and their activation ratios were significantly lower than in control. CONCLUSION(S): Coordinated but relatively low expression of HLA-DR, ICAM-1, and CD14 on PF macrophages indicates a positive but limited immune response to events in the peritoneal cavity in women with endometriosis, which may induce immune tolerance to implanted or metaplastic endometrial tissue.

Aberrant expression of intercellular adhesion molecule-1 and killer inhibitory receptors induces immune tolerance in women with pelvic endometriosis.

OBJECTIVE: To investigate host immunologic response to endometriosis in terms of intercellular adhesion molecule (ICAM)-1 expression by macrophages and killer cell inhibitory receptor (KIR) expression by natural killer (NK) cells. DESIGN: Case-control study of immunologic markers. SETTING: University hospital. PATIENT(S): Twenty-eight Japanese women with endometriosis. Control subjects were 26 women without endometriosis. Diagnoses were made at laparoscopy. INTERVENTION(S): Venipuncture and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): ICAM-1 expression by macrophages and KIR expression by NK cells, measured by flow cytometry. RESULT(S): In women with endometriosis, expression of ICAM-1 by peritoneal macrophages was significantly lower and expression of KIR by NK cells in peritoneal fluid and peripheral blood was significantly higher than in control subjects. CONCLUSION(S): Properties of macrophages and NK cells in women with endometriosis promote immunotolerance to implanted tissue in the peritoneal environment. Increased KIR(+)NK cells in peripheral blood may represent a risk factor for endometriosis.

Increased killer inhibitory receptor KIR2DL1 expression among natural killer cells in women with pelvic endometriosis.

OBJECTIVE: To investigate the host immunologic response to endometriosis in terms of killer inhibitory receptor (KIR) expression by natural killer (NK) cells. DESIGN: Case-control study of immunologic markers. SETTING: University hospital. PATIENT(S): We compared cells from Japanese women with laparoscopically diagnosed endometriosis to cells from 40 women with other laparoscopic diagnoses. INTERVENTION(S): Peripheral venous blood sampling and laparoscopic peritoneal fluid collection. MAIN OUTCOME MEASURE(S): Flow cytometry was used to assess expression of KIR by NK cells in the cell samples. RESULT(S): The percentage of cells that expressed KIR2DL1 among NK (KIR2DL1(+)NK) cells in peritoneal fluid and peripheral blood was significantly higher in women with endometriosis than in controls. The proportion of KIR2DL1(+)NK cells in peripheral blood NK cells before and 1 month after laparoscopic surgery did not differ significantly. CONCLUSION(S): The proportion of KIR2DL1(+)NK cells was increased in peritoneal fluid and peripheral blood in women with endometriosis; this difference is probably related to NK cell suppression in endometriosis. This increase in KIR2DL1 expression by NK cells may represent a risk factor in the pathogenesis of endometriosis.