Pre-treatment white blood cell subtypes as prognostic indicators in ovarian cancer.

OBJECTIVE: Inflammatory cells can both suppress and stimulate tumour growth and their influence on clinical outcome in cancer patients has been studied in various cancer types. Here we have investigated their influence on outcome in primary epithelial ovarian cancer. STUDY DESIGN: Serum white blood cell numbers according to subtype were recorded prior to treatment in 136 patients with primary epithelial ovarian cancer. Their correlation with overall survival and disease-free survival was analysed using both univariate and multivariate analysis adjusting for the known prognostic factors (age, stage and debulking status). RESULTS: Multivariate analysis demonstrated that a lower lymphocyte fraction of total white blood cells was significantly associated with mortality (p<0.01). On univariate analysis (p=0.0027, HR=1.15), and multivariate analysis of those patients who were optimally debulked (p=0.036, HR=1.17), a higher monocyte count was significantly associated with recurrence. On multivariate analysis amongst those who were suboptimally debulked, a higher eosinophil count was predictive of both recurrence (p=0.0037, HR=1.77) and mortality (p=0.033, HR=1.73). CONCLUSION: High monocyte counts amongst those who were optimally debulked independently predict adverse outcome in primary epithelial ovarian cancer.

Differential diagnosis of adnexal masses: risk of malignancy index, ultrasonography, magnetic resonance imaging, and radioimmunoscintigraphy.

A risk of malignancy index (RMI), based on menopausal status, ultrasound (US) findings, and serum CA125, has previously been described and validated in the primary evaluation of women with adnexal masses and is widely used in selective referral of women from local cancer units to specialized cancer centers. Additional imaging modalities could be useful for further characterization of adnexal masses in this group of women. A prospective cohort study was conducted of 196 women with an adnexal mass referred to a teaching hospital for diagnosis and management. Follow-up data was obtained for 180 women; 119 women had benign and 61 women malignant adnexal masses. The sensitivity and specificity of specialist US, magnetic resonance imaging (MRI), radioimmunoscintigraphy (RS), and the RMI were determined. We identified a subgroup of women with RMI values of 25-1000 where the value of further specialist imaging was evaluated. Sensitivity and specificity for specialist US were 100% and 57%, for MRI 92% and 86%, and for RS 76% and 87%, respectively. Analysis of 123 patients managed sequentially, using RMI cutoff values of > or =25 and <1000 and then US and MRI provided a sensitivity of 94% and a specificity of 90%. Using this RMI cutoff followed by specialist US and MRI, as opposed to the traditional RMI cutoff value of 250, can increase the proportion of patients with cancer appropriately referred in to a cancer center, with no change in the proportion of patients with benign disease being managed in a local unit.

Molecular profiling of cervical cancer progression.

Most cancer patients die of metastatic or recurrent disease, hence the importance to identify target genes upregulated in these lesions. Although a variety of gene signatures associated with metastasis or poor prognosis have been identified in various cancer types, it remains a critical problem to identify key genes as candidate therapeutic targets in metastatic or recurrent cancer. The aim of our study was to identify genes consistently upregulated in both lymph node micrometastases and recurrent tumours compared to matched primary tumours in human cervical cancer. Taqman Low-Density Arrays were used to analyse matched tumour samples, obtained after laser-capture microdissection of tumour cell islands for the expression of 96 genes known to be involved in tumour progression. Immunohistochemistry was performed for a panel of up- and downregulated genes. In lymph node micrometastases, most genes were downregulated or showed expressions equal to the levels found in primary tumours. In more than 50% of lymph node micrometastases studied, eight genes (AKT, BCL2, CSFR1, EGFR1, FGF1, MMP3, MMP9 and TGF-beta) were upregulated at least two-fold. Some of these genes (AKT and MMP3) are key regulators of epithelial-mesenchymal transition in cancer. In recurrent tumours, almost all genes were upregulated when compared to the expression profiles of the matched primary tumours, possibly reflecting their aggressive biological behaviour. The two genes showing a consistent downregulated expression in almost all lymph node metastases and recurrent tumours were BAX and APC. As treatment strategies are very limited for metastatic and recurrent cervical cancer, the upregulated genes identified in this study are potential targets for new molecular treatment strategies in metastatic or recurrent cervical cancer.

Somatic mitochondrial DNA mutations in primary and metastatic ovarian cancer.

OBJECTIVE: To date, most mtDNA mutations in cancer have been identified in the control region (D-loop) containing the major promoters. However, almost all studies used one sample per tumor and there is no clear evidence whether metastatic deposits harbor different mtDNA variants. To establish whether different mtDNA variants can be found in the same cancer but at different sites, we analyzed a series of unilateral and bilateral primary epithelial ovarian cancers as well as paired metastatic tumor deposits. METHODS: We sequenced the D-loop region in 52 different tumor samples of 35 ovarian cancer cases, as well as matched normal tissues. Seventeen of those 35 cases had bilateral ovarian cancer, with a sample from each tumor analyzed. RESULTS: Eighty-six polymorphisms (4 new in ovarian cancer) were detected, and 9 different somatic mtDNA mutations were found in 26% (9 of 35) of ovarian cancer cases; all were homoplasmic in nature. Six of the mutations were novel in ovarian cancer. In 24% (4 of 17) of cases with bilateral ovarian tumors, different mtDNA variants were found between paired tumors, suggesting the presence of different clonal populations of cancer cells. Metastatic tumor deposits showed identical mtDNA variants to those found in at least one of the ovarian tumors in cases with bilateral ovarian cancer. CONCLUSION: Our data demonstrate that multiple tumor samples from the same patient may harbor different mtDNA variants.

The sentinel node in gynaecological malignancies.

As lymph node metastasis is one of the earliest features of tumour cell spread in most human cancers, assessment of the regional lymph nodes is required for tumour staging, determining prognosis and planning adjuvant therapeutic strategies. However, complete lymph node dissections are frequently associated with significant complications. Conjugating the diagnostic advantages with decreased morbidity, the sentinel node concept represents one of the most recent advances in surgical oncology. In this review we briefly highlight the historical background of the development of the sentinel node concept, the anatomical evidence for applying the sentinel node concept in pelvic gynaecological cancers and the technical aspects of sentinel node detection. We discuss recent studies in vulval, cervical and endometrial cancer.

Radioimmunoscintigraphy with Tc-99m-labelled SM3 in differentiating malignant from benign adnexal masses.

OBJECTIVE: Ultrasound scanning, serum CA125 and menopausal status have previously been combined in a risk of malignancy index for the differential diagnosis of adnexal masses. Although this approach has greater accuracy than either individual tests or clinical assessment, it has a significant false positive and false negative rate. Efforts have been directed at refining differential diagnosis and this study assessed the role of radioimmunoscintigraphy using the stripped mucin 3 (SM3) antibody that has a 17-fold greater uptake in malignant than benign ovarian tumours in vitro. DESIGN: Prospective study of patients with a pelvic mass using radioimmunoscintigraphy. SETTING: Department of Nuclear Medicine of St Bartholomew's Hospital in collaboration with Cancer Network. POPULATION: A total of 93 patients with pelvic masses were recruited for this study of which 32 had ovarian cancer and 61 had benign lesions. METHODS: Radioimmunoscintigraphy was performed with Tc-99m-labelled SM3 (600 MBq), anterior and posterior pelvis imaged at 10 minutes and at 4 and 24 hours and evaluated with change detection analysis and probability mapping. MAIN OUTCOME MEASURES: Sensitivity and specificity of radioimmunoscintigraphy for ovarian cancer. RESULTS: Radioimmunoscintigraphy had a sensitivity for ovarian cancer of 84% (27 true positive and 5 false negatives) and a specificity of 87% (53 true negatives and 8 false positives) giving a negative predictive value of 91%. CONCLUSION: These results suggest that radioimmunoscintigraphy could be used to reduce the number of false positive findings in a strategy to refine differential diagnosis of the pelvic mass.

A model for co-expression pattern analysis of genes implicated in angiogenesis and tumour cell invasion in cervical cancer.

To date, numerous genes have been identified which are involved in both tumour neovascularisation (angiogenesis) and tumour cell invasion, and most of them are also expressed to some extent under normal physiological conditions. However, little is known about how these genes co-express in these settings. This study was undertaken to quantitate mRNA levels in normal and malignant cervical tissues of nine selected genes (VEGF(121), VEGF(165), VEGF(189), VEGF-C, eIF-4E, b-FGF, TSP-2, MMP-2 and MMP-9) implicated in the above processes using real-time quantitative RT-PCR. In addition, the Spearman's rank correlation was used to determine their co-expression patterns. The transcript levels for the different VEGF-A splice variants (VEGF(121), VEGF(165), VEGF(189)) were at least 10-fold higher in the cancer cases, with the highest levels in the primary tumours demonstrating lympho-vascular space involvement. The lymphangiogenic factor VEGF-C and MMP-9 were upregulated 130- and 80-fold respectively in cervical cancers. The highest levels of VEGF-C mRNA were found in the lymph-node positive group. The transcript levels for b-FGF were similar in normal cervical tissue and early-stage cervical cancer, however, higher levels were found in the cervical cancers with advanced stage disease. Comparing gene transcript levels between recurrent and non-recurrent cervical cancer patients revealed significant differences (P=0.038) in transcript levels for the angiogenesis inhibitor TSP-2, with the highest levels in non-recurrent cases. Co-expression pattern analysis in normal cervical tissue revealed highly significant co-expressions (P<0.0001) between TSP-2 and most other genes analysed (VEGF(121), VEGF(165), VEGF-C, b-FGF and MMP-2). In cervical cancer, TSP-2 appears only to be highly co-expressed with MMP-2 (P<0.0001). In contrast to normal cervical tissue, we found a highly significant co-expression (P<0.0001) between MMP-9 and VEGF(189) in cervical cancer. The combined application of real-time quantitative RT-PCR and Spearman's rank correlation identifies gene transcripts which are simultaneously co-expressed. Our results revealed a significant co-expression between the angiogenesis inhibitor TSP-2 and most other genes analysed in normal cervical tissue. In cervical cancer, we found a strong upregulation of VEGF-C and MMP-9 mRNA, with a highly significant co-expression between MMP-9 and VEGF(189).

Molecular quantification and mapping of lymph-node micrometastases in cervical cancer.

BACKGROUND: A proportion of patients with cancer and lymph nodes negative on histology will develop recurrence. Reverse-transcriptase PCR (RT-PCR) is a highly sensitive method for detection of lymph-node micrometastases, but accurate quantitative assessment has been difficult. METHODS: We studied primary tumours and 156 lymph nodes from 32 patients with cervical cancer (stage IA2, IB1, and IB2) and 32 lymph nodes from nine patients with benign disease. A fully quantitative, real-time RT-PCR assay was used to document absolute copy numbers of the epithelial marker cytokeratin 19. Primers and probe were designed not to amplify either of the two cytokeratin 19 pseudogenes. FINDINGS: All primary tumours and histologically involved lymph nodes (six) had more than 106 copies of cytokeratin 19 mRNA per microg total RNA. Expression of cytokeratin 19 (up to 1.1 x 10(5) copies per microg RNA) was detected in 66 (44%) of 150 histologically uninvolved lymph nodes, and in nodes from 16 of 32 patients with cervical cancer. 15 of these 16 patients with evidence of micrometastases had the highest cytokeratin 19 transcription level in a first lymph-node drainage station (three obturator, six internal, and six external iliac node). Transcription of cytokeratin 19 was found at a low level in just one of 32 lymph nodes obtained from nine patients with benign disease. Median copy number of cytokeratin 19 transcription was significantly higher (>10(3) copies) in association with adverse prognostic features. INTERPRETATION: The results suggest that about 50% of early-stage cervical cancers shed tumour cells to the pelvic lymph nodes. The amount of cytokeratin 19 expression was related to clinicopathological features. Further studies are required to document the clinical implications of molecular micrometastases.

Abdominal pain with anorexia in patients with breast carcinoma.

Breast cancer is the second commonest primary tumour responsible for gastrointestinal metastases after malignant melanoma. The real incidence of gastrointestinal metastases in breast cancer patients is probably underestimated owing to the non-specific presenting symptoms and death of patients caused by other more obvious metastases. The predominant histological subtype of gastrointestinal metastases of breast cancer is invasive lobular carcinoma and the median interval from diagnosis of primary breast cancer to gastrointestinal metastases is five years. We report two cases of disseminated breast cancer with gastrointestinal involvement with a rather long survival.

Vaginoplasty by inverted perineal and labia minora flaps-a retrospective study.

Absence of the vagina occurs most frequently in the Rokitansky-Küster-Mayer (RKM) syndrome. Since Küster has reviewed the literature in 1910 many techniques have been described to create a neovagina. We describe a technique in which both a part of the labia minora and of the perineal skin are used as flaps to cover the neovagina and report on the long-term outcome in a series of 16 patients with RKM syndrome treated with this technique. No intra-operative or immediate postoperative complications were recorded. The average depth of the neovagina was 8 cm, at the end of the operation and 1 year later. After 3 months the neovagina was completely lined with vaginal epithelium. In six out of 16 patients scar formation and polypoid formation was observed at the apex of the neovagina. This could be successfully handled by excision and coagulation in all six cases. Ten patients reported a satisfactory sexual life. The technique is simple and easy to perform. The anatomical result and sexual gratification was outstanding in two-thirds of the patients. We conclude that flaps derived from the genital region offer the most physiological tissue for construction of a neovagina.

Protein binding of propranolol and verapamil enantiomers in maternal and foetal serum.

The protein binding of the enantiomers of propranolol and verapamil was measured in 19 pairs of maternal and foetal serum obtained at delivery. The binding of the enantiomers of both drugs was lower in foetal than in maternal serum. In maternal serum the mean (+/- s.d.) unbound percentages were 22.4 +/- 6.2 and 20.7 +/- 6.6 for R- and S-propranolol, and 16.8 +/- 5.5 and 22.5 +/- 6.2 for R- and S-verapamil; in foetal serum the values were 38.8 +/- 8.6 and 40.4 +/- 10.6 for R- and S-propranolol, and 34.7 +/- 10.5 and 44.8 +/- 10.7 for R- and S-verapamil. For propranolol, in maternal, but not in foetal serum, the difference between the binding of the R- and S-enantiomers was significant; the R/S ratio was significantly (P < 0.01) larger in the mother (1.099 +/- 0.072) than in the foetus (0.973 +/- 0.068). For verapamil, the difference in binding between the R- and S-enantiomers was significant in both maternal and foetal serum, but the R/S ratio was similar in mother (0.735 +/- 0.098) and foetus (0.763 +/- 0.070). Serum alpha 1-acid glycoprotein (AAG) concentrations were markedly higher and albumin concentrations slightly lower in maternal than in foetal samples. The binding of the four enantiomers in maternal and foetal serum was correlated (P < 0.001) with the AAG concentration (r propranolol: R 0.749, S 0.746; r verapamil: R 0.753, S 0.782). Our findings show that measurement of concentrations of total, unresolved drug allow a reasonably accurate assessment of transplacental gradients of individual isomers.