RESUMEN
BACKGROUND: BRCA1 expression can be lost by a variety of mechanisms including germline or somatic mutation and promotor hypermethylation. Given the potential importance of BRCA1 loss as a predictive and prognostic biomarker in high-grade serous ovarian cancer, we sought to evaluate the utility of BRCA1 immunohistochemistry (IHC) in screening for BRCA1 loss by germline, somatic, and epigenetic mechanisms. PATIENTS AND METHODS: Patients with advanced high-grade serous ovarian cancer who had previously undergone germline BRCA1 testing were identified. Samples from each tumor were stained for BRCA1 and reviewed independently by two pathologists blinded to BRCA status. Tumors with abnormal BRCA1 IHC and wild-type germline testing underwent further evaluation for somatic BRCA1 mutations and promoter hypermethylation. McNemar's test was used to determine the association of BRCA1 IHC with germline BRCA1 mutations and BRCA1 loss through any mechanism. Kaplan-Meier methods were used to estimate overall survival (OS), and the log-rank test was used to assess differences between groups. RESULTS: Inter-rater reliability between the two pathologists on BRCA IHC interpretation was very good (kappa coefficient 0.865, P = 0.16; McNemar's test). BRCA1 IHC was abnormal in 36% (48/135) of cases. When compared with germline BRCA1 status, BRCA1 IHC had a high negative predictive value (95.4%) but a low positive predictive value (PPV, 52.1%). When accounting for promoter hypermethylation and somatic mutations as alternative methods of BRCA1 loss, the PPV rose to 87.5%. Five-year OS rate was 49.6% [95% confidence interval (CI) 26.3% to 69.3%] for patients with germline BRCA1 mutations, 50.4% (95% CI 27.5% to 69.5%) for germline wild-type BRCA1 and abnormal IHC, and 52.1% (95% CI 38.4% to 64.2%) for germline wild-type BRCA1 and normal IHC (P = 0.92). CONCLUSIONS: BRCA1 IHC interpretation was a highly reproducible and accurate modality for detecting germline, somatic, or epigenetic mechanisms of BRCA1 loss. These results support further development of BRCA1 IHC as a potential biomarker for BRCA1 loss in high-grade serous ovarian cancer.
Asunto(s)
Epigénesis Genética , Genes BRCA1 , Mutación de Línea Germinal , Neoplasias Ováricas/genética , Adulto , Anciano , Anciano de 80 o más Años , Metilación de ADN , Femenino , Humanos , Inmunohistoquímica , Persona de Mediana Edad , Regiones Promotoras GenéticasRESUMEN
BACKGROUND: The hereditary basis of endometrial cancer is apparent in young women with endometrial cancer. The objective of this study was to examine risk factors and outcomes in patients 40 years of age and younger with endometrial cancer. METHODS: We performed a retrospective cohort study of patients aged 40 years or less who were diagnosed with endometrial carcinoma between 1/93 and 5/08. Clinical and pathologic data were extracted from medical records. Paraffin-embedded slides from hysterectomy specimens were obtained and DNA mismatch repair (MMR) immunohistochemistry was performed. Cases were analyzed according to the presence of DNA MMR protein defects. Standard two-sided statistical tests were performed. RESULTS: Of the 56 identified patients, the median age was 36 years (range, 24-40). The majority of the endometrial carcinomas were of endometrioid histology (91%), stage I (71%), and FIGO grade 1 (59%). Abnormal DNA MMR was found in 9 cases (16%). Cases with abnormal DNA MMR had lower body mass index (BMI) (P=0.05), and had a family history suggestive of Lynch syndrome (P=0.001). Tumors were more likely to have advanced stage disease (P<0.001), be high grade (P<0.001), have deep myometrial invasion (P<0.001), and have lymphovascular invasion (P=0.002). Cases with abnormal DNA MMR had significantly worse overall survival (P=0.028) and progression-free survival (P=0.042). CONCLUSIONS: Endometrial cancer is rare in women aged 40 years or less. In this group of patients, loss of DNA MMR was associated with lower BMI, worse clinicopathologic factors, and worse outcome. These results may have implications when young women diagnosed with endometrial cancer are counseled regarding prognosis.
Asunto(s)
Carcinoma Endometrioide/genética , Reparación de la Incompatibilidad de ADN/fisiología , Neoplasias Endometriales/genética , Proteínas Adaptadoras Transductoras de Señales/metabolismo , Adenosina Trifosfatasas/metabolismo , Adulto , Factores de Edad , Carcinoma Endometrioide/metabolismo , Carcinoma Endometrioide/patología , Estudios de Cohortes , Enzimas Reparadoras del ADN/metabolismo , Proteínas de Unión al ADN/metabolismo , Neoplasias Endometriales/metabolismo , Neoplasias Endometriales/patología , Femenino , Humanos , Inmunohistoquímica , Endonucleasa PMS2 de Reparación del Emparejamiento Incorrecto , Homólogo 1 de la Proteína MutL , Proteína 2 Homóloga a MutS/metabolismo , Estadificación de Neoplasias , Proteínas Nucleares/metabolismo , Estudios Retrospectivos , Adulto JovenAsunto(s)
Proteína BRCA1/genética , Proteína BRCA2/genética , Genes BRCA1 , Genes BRCA2 , Neoplasias/epidemiología , Femenino , Humanos , Masculino , Mutación , Neoplasias/genéticaRESUMEN
BACKGROUND: Patients with BRCA-associated ovarian cancer (OC) have a survival advantage over those with sporadic OC. To further explore this, we examined the impact of prognostic factors on disease-free survival (DFS) and overall survival (OS) in patients with known BRCA mutation status. PATIENTS AND METHODS: We reviewed stage III-IV OC patients treated at our institution between 1 December 1996 and 30 September 2006 and also tested on protocol for BRCA mutations. Impact on DFS and OS was determined by Kaplan-Meier analysis and a Cox proportional hazards model. RESULTS: Of the 110 patients, 36 had deleterious BRCA mutations [BRCA (+)] and 74 were BRCA wild type [BRCA(-)]. Thirty-one of 36 (86%) BRCA (+) and 60 of 74 (81%) BRCA (-) patients were platinum sensitive (P = 0.60). Median OS was longer for BRCA (+) patients (not reached versus 67.8 months; P = 0.02), but DFS was similar (26.9 versus 24.0, P = 0.3). On multivariate analysis, OS correlated with primary platinum sensitivity [HR = 0.15; 95% CI (confidence interval) 0.06-0.34] and BRCA (+) mutation status (HR = 0.33; 95% CI 0.12-0.86). CONCLUSIONS: BRCA mutation status predicted OS independent of primary platinum sensitivity, suggesting that underlying tumor biology contributes to disease outcome and may be worthy of consideration in future clinical trial design.
Asunto(s)
Antineoplásicos/uso terapéutico , Proteína BRCA1/genética , Proteína BRCA2/genética , Estudios de Asociación Genética , Mutación INDEL , Platino (Metal)/uso terapéutico , Carcinoma Epitelial de Ovario , Supervivencia sin Enfermedad , Femenino , Humanos , Estimación de Kaplan-Meier , Persona de Mediana Edad , Análisis Multivariante , Estadificación de Neoplasias , Neoplasias Glandulares y Epiteliales/tratamiento farmacológico , Neoplasias Glandulares y Epiteliales/genética , Neoplasias Glandulares y Epiteliales/mortalidad , Neoplasias Ováricas/tratamiento farmacológico , Neoplasias Ováricas/genética , Neoplasias Ováricas/mortalidadRESUMEN
OBJECTIVE: The standard management for women diagnosed with endometrial carcinoma (EC) is hysterectomy with salpingo-oophorectomy. However, more conservative treatment approaches, including uterine and ovarian preservation, may be used for women who have a strong desire to maintain fertility in spite of potential oncologic risks. METHODS: We reviewed the literature regarding fertility-preserving treatment for EC. We also conducted medical chart reviews for two young patients diagnosed with EC whose treatment deviated from the standard approach in order to preserve fertility. These patients were subsequently diagnosed with ovarian cancer. Our review summarizes the literature regarding the clinical and emotional implications of fertility preservation in young women. CASES: Two young nulliparous women (29 and 23 years, respectively) with grade 1 endometrioid adenocarcinoma were initially treated with conservative fertility-sparing endocrine therapy. Upon failure of endocrine treatment both women underwent hysterectomy and staging with ovarian preservation. During surveillance, both women were subsequently diagnosed with ovarian carcinoma and underwent bilateral salpingo-oophorectomy (BSO) and comprehensive staging. CONCLUSION: The management of young women with endometrial cancer can be complex and challenging. Patients and physicians are confronted with the dilemma of following standard surgical guidelines versus the desire to maintain fertility and avoid surgical menopause. Careful oncologic, psychotherapeutic, genetic and reproductive counseling is advised before offering a non-standard treatment strategy to young endometrial cancer patients.
Asunto(s)
Neoplasias Endometriales/patología , Neoplasias Endometriales/terapia , Neoplasias Ováricas/patología , Adulto , Femenino , Fertilidad , Humanos , Factores de Riesgo , Adulto JovenRESUMEN
BACKGROUND: A major limitation in counseling unaffected women from families with inherited breast and ovarian cancer is that a "true-negative" interpretation of wild type BRCA analysis of the proband cannot be inferred in the absence of demonstration of a BRCA mutation segregating in the kindred. Documentation of familial BRCA mutations from paraffin-derived DNA of deceased patients has been limited due to reports of technical complications leading to lack of reproducibility of BRCA testing of archival material. METHODS: DNA was extracted from formalin-fixed paraffin-embedded (FFPE) morphologically normal tissue of 161 blinded, coded samples from women previously genotyped for the three Ashkenazi Jewish BRCA founder mutations from lymphocyte-derived DNA. Multiplex PCR followed by denaturing polyacrylamide gel electrophoresis was performed for the three founder mutations to determine if analysis on FFPE tissue could produce results concordant with those of the lymphocyte-derived DNA. RESULTS: After disclosure of the sample codes, the results were compared with the original lymphocyte-derived DNA genotypes. Excluding one sample unevaluable due to PCR failure, there was 100% concordance of 160 genotypes (120 mutation samples) derived from DNA from archival FFPE tissue compared to peripheral lymphocytes. CONCLUSIONS: The method described reliably detected BRCA founder mutations in archival DNA derived from FFPE tissue. These results suggests that this technique may be useful in clinical settings to inform wild type BRCA results of unaffected probands, leading to avoidance of unnecessary intensified surveillance or risk-reducing surgery. With further validation this approach can also be applied to other populations where founder mutations are observed.
Asunto(s)
Efecto Fundador , Genes BRCA1 , Genes BRCA2 , Mutación , ADN/aislamiento & purificación , Análisis Mutacional de ADN , Femenino , Formaldehído , Humanos , Adhesión en Parafina , Reacción en Cadena de la Polimerasa , Fijación del TejidoAsunto(s)
Neoplasias de la Mama/genética , Efecto Fundador , Genes BRCA1 , Genes BRCA2 , Predisposición Genética a la Enfermedad/genética , Mutación de Línea Germinal/genética , Judíos/genética , Neoplasias Ováricas/genética , Adulto , Anciano , Anciano de 80 o más Años , Neoplasias de la Mama/epidemiología , Estudios de Cohortes , Femenino , Predisposición Genética a la Enfermedad/epidemiología , Humanos , Incidencia , Persona de Mediana Edad , Neoplasias Ováricas/epidemiología , Factores de RiesgoRESUMEN
PURPOSE: Risk-reducing surgery is an important option for women with BRCA1 and BRCA2 mutations. There are reports in the literature that insurance reimbursement for these procedures varies greatly. Because health insurance coverage significantly affects medical decision-making, current information regarding reimbursement practices of third-party payers is needed. METHODS: Retrospective study of hospital billing records of 38 women with documented BRCA1 or BRCA2 mutations who underwent either a risk-reducing mastectomy or a risk-reducing oophorectomy between March 1, 1997, and July 30, 2000. RESULTS: Complete billing and reimbursement information was available for 35 women undergoing a total of 39 risk-reducing surgeries. A total of 38 of 39 (97%) risk-reducing surgeries were covered in full, less applicable coinsurance and deductibles. The rate of insurance reimbursement did not vary with type of insurance, personal history of cancer, or type of procedure. CONCLUSION: Insurance carriers reimbursed the vast majority of BRCA mutation carriers undergoing risk-reducing surgery.
Asunto(s)
Neoplasias de la Mama/prevención & control , Cobertura del Seguro/estadística & datos numéricos , Reembolso de Seguro de Salud/estadística & datos numéricos , Mastectomía/economía , Neoplasias Ováricas/prevención & control , Ovariectomía/economía , Adulto , Proteína BRCA2/genética , Neoplasias de la Mama/genética , Neoplasias de la Mama/cirugía , Toma de Decisiones , Femenino , Genes BRCA1 , Asesoramiento Genético , Predisposición Genética a la Enfermedad , Heterocigoto , Registros de Hospitales , Humanos , Programas Controlados de Atención en Salud/economía , Persona de Mediana Edad , Mutación , New York , Neoplasias Ováricas/genética , Neoplasias Ováricas/cirugía , Estudios Retrospectivos , Factores de RiesgoRESUMEN
BACKGROUND: Acceptance of liquid-based fixatives for cervical cytology has been limited by the more complex slide-preparation procedures, increased cost, and reports that increased sensitivity has been based largely on comparison with conventional cytology without histologic correlation. Here the authors describe and evaluate a technically simple and relatively inexpensive method (which they call SpinThin) for preparing Cytospin (Shandon Inc., Pittsburgh, PA) cervical cytology slides from samples in liquid fixative using a modified electric toothbrush holder to put the cells in suspension. Results are compared with conventional cytology and histologic biopsy. METHODS: A total of 791 cervical cytology specimens from 2 patient groups at high risk of uterine cervical neoplasia were entered into this study, and a spatula and cytobrush (174 specimens) or cytobroom (617 specimens) were used to collect conventional smears. The collection device with remaining cellular sample was placed in an alcohol-based fixative solution; the cells were put into suspension by a brief burst of vibration using a modified electric toothbrush holder, then cytocentrifuged on a slide and stained with the Papanicolaou technique. RESULTS: Specimen adequacy in SpinThin slides was better than that of conventional cytology smears. However, the prevalence of dysplasia, including atypical squamous cells of undetermined significance (ASCUS-D), in conventional smears and SpinThin slides was the same--27% and 25%, respectively--and excluding ASCUS-D, it was 20% in both. The prevalence of neoplasia (low or high grade squamous intraepithelial lesion, or carcinoma) histologically was 31% in the 647 cases biopsied, and agreement with histology was similar for SpinThin and conventional smears. CONCLUSIONS: Using a simple and relatively inexpensive new technique (Spin-Thin), slides prepared from fluid-based cervical cytology specimens obtained with the cytobrush or cytobroom correlated very well with the corresponding conventional smears within major diagnostic categories, and both correlated well with histology.
Asunto(s)
Técnicas de Preparación Histocitológica , Prueba de Papanicolaou , Manejo de Especímenes/métodos , Neoplasias del Cuello Uterino/patología , Frotis Vaginal , Adolescente , Adulto , Anciano , Carcinoma de Células Escamosas/patología , Análisis Costo-Beneficio , Femenino , Humanos , Microtomía , Persona de Mediana Edad , Factores de Riesgo , Sensibilidad y Especificidad , Displasia del Cuello del Útero/patologíaRESUMEN
Hemorrhage is one of the most frequent complications after dilation and evacuation. A small fraction of patients with hemorrhage will not respond to standard therapies. We discuss a case where both reaspiration and standard pharmacologic therapy failed to control hemorrhage and where hemorrhage was ultimately controlled by tamponade with two Foley catheters. We propose this method as an additional alternative for controlling hemorrhage after dilation and evacuation before resorting to angiographic embolization or surgery.