Determination of test performance of two contemporary screening tests for Lynch syndrome in endometrial cancer: A clinical trial.

BACKGROUND/PURPOSE: Published data on the performance of the immunohistochemistry (IHC) test for mismatch repair (MMR) protein expression to detect Lynch syndrome (LS) index cases suggests it is highly variable; its performance in our system was unknown. Moreover, a brief family history questionnaire (bFHQ) developed by Eiriksson and colleagues in Canada demonstrated 100% sensitivity for LS case identification thus was of interest to us, but its performance outside of its original setting was unknown. Determination of the performance of these tests requires complete LS case identification in the testing population. METHODS: Two hundred women were recruited during routine care for endometrial cancer (EC) to administer the bFHQ and perform genetic testing for the LS genes. Independently, the IHC test was performed to screen for presumptive LS cases. We determined the sensitivity, specificity, and positive and negative predictive values of the bFHQ and IHC test as well as simulating outcomes of the complete protocols. RESULTS: Genetic testing all participants identified 8 cases of LS out of 200 (4% prevalence), the bFHQ identified 5 of 8 of these cases (62.5%, CI: 31.5%-87.6%), and the IHC test identified 6 or 7 of 8 cases (mean of 75% or 87.5%) depending on interpretation of test results. The specificities of the bFHQ and IHC test were 56.8% (CI: 49.8%-63.7%) and 79.8% (CI: 73.6%-85.1%), respectively. CONCLUSIONS: This study is the first, to our knowledge, to test the effectiveness of the bFHQ in an EC population since its original reporting; our results are consistent with many reports of the challenges of collecting family health history. The performance of the IHC test as a screen falls within ranges reported in the literature but do not provide the confidence to drive a decision for or against continued use of this test as a LS screen.

Extraskeletal Myxoid Chondrosarcoma of the Vulva Confirmed by EWSR1 FISH: A Case Report and Review of the Literature.

Extraskeletal myxoid chondrosarcoma of the vulva is a very rare tumor, with less than 10 cases reported in the literature. We report a case of a 45-yr-old woman with extraskeletal myxoid chondrosarcoma of the vulva confirmed by EWSR1 fluorescence in situ hybridization. Given the unusual site and prominent myxoid morphology, a broad differential diagnosis and a variety of ancillary testing was required. This article aims to review extraskeletal myxoid chondrosarcoma of the vulva, the differential diagnosis of a myxoid spindle cell neoplasm of the vulva, and the diagnostic importance of immunohistochemistry and EWSR1 fluorescence in situ hybridization.

FFPEcap-seq: a method for sequencing capped RNAs in formalin-fixed paraffin-embedded samples.

The majority of clinical cancer specimens are preserved as formalin-fixed paraffin-embedded (FFPE) samples. For clinical molecular tests to have wide-reaching impact, they must be applicable to FFPE material. Accurate quantitative measurements of RNA derived from FFPE specimens is challenging because of low yields and high amounts of degradation. Here, we present FFPEcap-seq, a method specifically designed for sequencing capped 5' ends of RNA derived from FFPE samples. FFPEcap-seq combines enzymatic enrichment of 5' capped RNAs with template switching to create sequencing libraries. We find that FFPEcap-seq can faithfully capture mRNA expression levels in FFPE specimens while also detecting enhancer RNAs that arise from distal regulatory regions. FFPEcap-seq is a fast and straightforward method for making high-quality 5' end RNA-seq libraries from FFPE-derived RNA.

Recurrent early stage endometrial cancer: Patterns of recurrence and results of salvage therapy.

OBJECTIVE: To analyze our institutional experience and oncologic outcomes for salvage treatment for the recurrence of early-stage endometrial cancer patients. METHODS: We included women of all ages diagnosed with FIGO stage I-II, any grade endometrial cancer from 2000 to 2016 at our institutions who were treated with at least a hysterectomy. Recurrences in the pelvis and/or vagina were considered locoregional recurrences (LRR). Overall survival (OS) was assessed using Kaplan-Meier survival analysis. Univariate (UV) and multivariate (MV) Cox proportional hazards modeling was also used. RESULTS: A total of 2691 women were analyzed. The majority had endometrioid histology (91%), stage IA disease (61%), and were grade 1 (57%). With a median follow-up of 6.1 years, the overall rate of recurrence was 7.2%, and the rate of LRR was 3.7%. Women with vaginal-only recurrences had a longer median OS after recurrence (14.0 years) compared to both pelvic (1.2 years) and distant (1.0 year) failures. For women with vaginal-only recurrences, salvage radiotherapy (RT) was the only factor associated with improved OS on MVA (HR 0.1, p = .04). For women with pelvic recurrences, salvage surgery (HR 0.3, p = .01), salvage RT (HR 0.3, p < .01), and salvage chemotherapy (HR 0.4, p = .03) were associated with improved OS. CONCLUSIONS: Failure rates for women with early-stage endometrial cancer are low. Women with vaginal-only recurrences have improved OS compared to pelvic or distant recurrences. Salvage RT appears to be an important factor for treatment of women with vaginal-only recurrences. Aggressive multimodality treatment may be beneficial for women with pelvic recurrences.

Do vaginal recurrence rates differ among adjuvant vaginal brachytherapy regimens in early-stage endometrial cancer?

PURPOSE: We sought to retrospectively examine clinical outcomes for three adjuvant vaginal high-dose-rate (HDR) brachytherapy regimens after hysterectomy for early-stage endometrial cancer. METHODS: Included were women of all ages from two independent hospital systems diagnosed with Stage I-II endometrial cancer of any grade between 2000 and 2016 who underwent hysterectomy followed by adjuvant vaginal cylinder HDR brachytherapy with either 7.0 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, 6.5 Gy × 3 fractions prescribed to 0.5 cm vaginal depth, or 6.0 Gy × 5 fractions prescribed to the vaginal surface. Outcomes included vaginal recurrence (VR), pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival. RESULTS: Of the 348 women, 45 (13%) received 7.0 Gy × 3 fractions, 259 (74%) received 6.5 Gy × 3 fractions, and 44 (13%) received 6.0 Gy × 5 fractions. Women receiving 5-fraction brachytherapy were more likely to be younger with a higher performance status. At a median follow-up of 4.5 years, VR rates were 2.2%, 0.8%, and 4.5%, respectively. Multivariate analysis revealed no significant differences in the risks for VR among brachytherapy regimens. Risks for VR, pelvic recurrence, distant recurrence, locoregional recurrence, recurrence-free survival, and overall survival did not differ between propensity score-matched five- and 3-fraction brachytherapy cohorts. CONCLUSIONS: VR rates after hysterectomy and adjuvant vaginal brachytherapy for early-stage endometrial cancer were low and not significantly different by HDR dose fractionation.

Hyperglycosylated hCG and Placenta Accreta Spectrum.

OBJECTIVE: We aimed to evaluate the relationship between hyperglycosylated human chorionic gonadotropin (hCG-H) and placenta accreta spectrum (PAS) in the second and third trimesters of pregnancy. STUDY DESIGN: This was a case-control study of PAS and controls. hCG-H was measured in the second and third trimesters of pregnancy in women with pathologically confirmed cases of PAS and in gestational age-matched controls without PAS. We compared serum hCG-H levels in cases and controls, calculated summary statistics for diagnostic accuracy, and used receiver operating characteristic (ROC) curves to define an optimal cut-point for diagnosis of PAS using hCG-H. RESULTS: Thirty case samples and 30 control samples were evaluated for hCG-H. Mean hCG-H was lower in the case compared with control group (7.8 ± 5.9 µg/L vs. 11.8 ± 8.8 µg/L, p = 0.03). At an optimal cut-point for hCG-H of ≤7.6 µg/L, the sensitivity, specificity, positive likelihood ratios, negative likelihood ratios, and area under the ROC curve were 66.7%, 69.7%, 2.20%, 0.48%, and 0.68%, respectively. CONCLUSION: Hyperglycosylated hCG levels in the second and third trimesters of pregnancy were lower in patients with PAS than in controls, but hCG-H showed only modest capability as a diagnostic test for PAS.

Imiquimod Induces Apoptosis in Human Endometrial Cancer Cells In vitro and Prevents Tumor Progression In vivo.

PURPOSE: The increasing incidence of endometrial cancer (EC), in younger age at diagnosis, calls for new tissue-sparing treatment options. This work aims to evaluate the potential of imiquimod (IQ) in the treatment of low-grade EC. METHODS: Effects of IQ on the viabilities of Ishikawa and HEC-1A cells were evaluated using MTT assay. The ability of IQ to induce apoptosis was evaluated by testing changes in caspase 3/7 levels and expression of cleaved caspase-3, using luminescence assay and western blot. Apoptosis was confirmed by flow cytometry and the expression of cleaved PARP. Western blot was used to evaluate the effect of IQ on expression levels of Bcl-2, Bcl-xL, and BAX. Finally, the in vivo efficacy of IQ was tested in an EC mouse model. RESULTS: There was a decrease in EC cell viability following IQ treatment as well as increased caspase 3/7 activities, cleaved caspase-3 expression, and Annexin-V/ 7AAD positive cell population. Western blot results showed the ability of IQ in cleaving PARP, decreasing Bcl-2 and Bcl-xL expressions, but not affecting BAX expression. In vivo study demonstrated IQ's ability to inhibit EC tumor growth and progression without significant toxicity. CONCLUSIONS: IQ induces apoptosis in low-grade EC cells in vitro, probably through its direct effect on Bcl-2 family protein expression. In, vivo, IQ attenuates EC tumor growth and progression, without an obvious toxicity. Our study provides the first building block for the potential role of IQ in the non-surgical management of low-grades EC and encouraging further investigations.

Adjuvant radiation therapy is associated with improved pelvic control and overall survival in FIGO IB endometrial carcinoma with high grade histology.

OBJECTIVE: High grade histologies of endometrial carcinomas portend a worse prognosis. Previous randomized, prospective studies examining the role of radiation have excluded endometrial cancer patients with FIGO IB with high risk histologies (clear cell, papillary serous, and Grade 3 endometrioid adenocarcinoma). METHODS: We retrospectively identified 51 patients who underwent a hysterectomy for a FIGO IB endometrial carcinoma with clear cell, papillary serous or Grade 3 endometrioid adenocarcinoma histology. Adjuvant radiation therapy was delivered in 44 of 51 patients (86%). We assessed pelvic control, vaginal control, and overall survival using Kaplan Meier estimate and the log rank test. We completed univariate analysis. RESULTS: The 5-year vaginal control rate in patients without and with adjuvant radiation therapy was 67% and 93.3%, respectively (p=0.0066). At 5-years, the pelvic control rate in patients without and with adjuvant radiation therapy was 0% and 81.5%, respectively (p=0.0003). At 5-years, the overall survival was 80% in patients who had adjuvant radiation compared to 21.4% in patients who did not have adjuvant radiation (p=0.0026). Radiation therapy was the only studied variable that was associated with pelvic control. Radiation therapy, advanced age and pelvic lymphadenectomy were associated with overall survival. CONCLUSIONS: Adjuvant radiation therapy in patients with FIGO IB endometrial carcinoma with high risk histologies was associated with improved vaginal control, pelvic control, and overall survival.

Survival Analysis of Cancer Patients With FIGO Stage IIIA Endometrial Cancer.

OBJECTIVE: Endometrial cancer patients with positive serosa and/or adnexae (FIGO stage IIIA) have a variable prognosis and are at a significant risk for recurrence. We investigated how tumor characteristics and adjuvant treatments influence the overall survival (OS) and recurrence patterns in these patients and patients with positive cytology alone (previously classified as stage IIIA before 2009). MATERIALS AND METHODS: This multi-institution retrospective study reviewed 55 patients with positive serosa and/or adnexae and 18 patients with positive cytology only, surgically staged from 1990 to 2010. The study cohort was evaluated using the Kaplan-Meier estimates of OS and Cox proportional hazards modeling. RESULTS: The 5-year OS for all IIIA patients was 55%. Administration of adjuvant therapy was associated with improved OS when compared with surgery alone (P=0.0018). The 5-year OS was 20% for patients treated with surgery alone (n=10), 55% with surgery and radiation therapy (n=26), 75% with surgery and chemotherapy (n=7), and 79% with surgery followed by both radiation therapy and chemotherapy (n=12; P=0.005). The tumor characteristics showed that nonendometrioid histology (P=0.0143) and lymph vascular space invasion (P=0.0483) had a poorer OS. Recurrence occurred in 29% of IIIA patients, with 9% locoregional failures and 20% distant failures. Patients with positive cytology only had a similar OS to patients with positive serosa and/or adnexae (76% vs. 55%; P=0.104) and recurrence rate (22% vs. 29%; P=0.4101). CONCLUSIONS: This retrospective study suggests benefit from the use of adjuvant radiotherapy and chemotherapy for stage IIIA patients. We recommend further investigation of adjuvant therapies for IIIA patients in prospective studies and randomized clinical trials.

Survival analysis of endometrial cancer patients with cervical stromal involvement.

OBJECTIVE: Stage II endometrial cancer is relatively uncommon. There is no consensus for appropriate adjuvant therapy in endometrial cancer patients with cervical stromal involvement (International Federation of Gynecology and Obstetrics [FIGO] stage II). This study investigates how adjuvant treatments and tumor characteristics influence overall survival (OS) and disease-free survival (DFS) in stage II patients in order to establish better treatment guidelines. METHODS: This multi-institution, Institutional Review Board approved, study is a retrospective review of 40 endometrial cancer patients with cervical stromal involvement treated from 1993 to 2009. Kaplan-Meier estimates were used to evaluate OS and DFS. RESULTS: OS was 85% at three years and 67% at five years. There were no significant differences in age, histology, depth of invasion, comorbid conditions, surgical staging or recurrence between patients who received radiation therapy (RT) and those who did not. However, patients with FIGO grade 1 cancers were less likely to receive RT (p=0.007). Patients treated with RT had a similar 5 year OS (n=33, 69%) to those treated with surgery only (n=7, 60%, p=0.746). There were no OS differences when evaluating by grade, histology, or depth of invasion between patients who did and did not receive RT. Four patients recurred: three were locoregional failures only, and one failed locally and distant. CONCLUSION: Patients receiving RT had higher grade tumors. Despite this, OS was comparable between the RT and the no RT cohorts. Local failure was the predominant pattern of failure. Endometrial cancer patients with cervical stromal involvement likely receive better locoregional control with the addition of adjuvant RT and we continue to advocate for RT in most cases.

Adjuvant radiation in early stage, unfavorable histology endometrial carcinoma is associated with improved local control and survival.

OBJECTIVE: Unfavorable histology endometrial carcinomas confer worse prognosis. We determined the association of adjuvant radiation on local recurrence and survival for unfavorable, early stage endometrial cancer. METHODS: We retrospectively identified 125 patients who had a hysterectomy for early stage (FIGO IA), unfavorable histology (clear cell, papillary serous or grade 3 endometrioid), endometrial carcinoma treated between 1992 and 2011. Patients were restaged according to current FIGO 2009 guidelines. Primary endpoint was local control and secondary endpoints were distant recurrence and overall survival. RESULTS: The median age of the cohort was 67 years old with a mean follow up 152 months. Adjuvant radiation was delivered in 60 patients (48%). There were a total of 24 recurrences; 5 had local-regional recurrences, 4 local and distant recurrence, 12 distant only recurrences, and 3 had unspecified recurrences. The 5-year local-regional control was 97.8% in patients who received radiation and 80.1% in patients who did not receive radiation (p=0.018). The 5-year overall survival rate was 68.1% if patients did not receive radiation and 84.9% if they did receive radiation (p=0.0062). On univariate analysis, only radiation (HR 0.12, 95% CI: 0.03 to 0.49, p-value=0.018) was associated with a significant increase in local relapse free survival. CONCLUSIONS: Adjuvant radiation therapy was significantly associated with an improvement in local-regional control and overall survival in patients with unfavorable histology, early stage endometrial cancer.

Mucoadhesive hybrid gel improves intraperitoneal platinum delivery.

A leading cause of death and suffering in patients with abdominal or pelvic malignancies is progression of peritoneal surface disease. Changes in the use of chemotherapy have shown significant survival benefits for intraperitoneal or combined intraperitoneal and intravenous treatment following optimal surgical cytoreduction. However, broader clinical use of intraperitoneal therapy has not reached its full potential due to limited efficacy, accessibility and nonspecific toxicity. To overcome these problems, we developed a mucoadhesive hybrid gel (HG) for a local, intraperitoneal drug delivery. In vivo studies confirmed reliable adherence and residence of the gel to the peritoneal sidewall for at least 72 h exhibiting no signs of tissue toxicity. Functionally active CDDP was released from HG within 2h and was equal to free CDDP in vitro. Moreover, intraperitoneal application of HG-CDDP significantly enhanced CDDP accumulation in the genomic DNA of peritoneal tissues compared to the same CDDP dose administered intravenously. These findings indicate the potential application of this hybrid gel as a mucoadhesive drug carrier amendable to use for intraperitoneal drug delivery and possible expansion for use on other mucosal surfaces of the female reproductive tract.

Survival analysis of endometrial cancer patients with positive lymph nodes.

OBJECTIVE: Patients with endometrial cancer with positive lymph nodes (International Federation of Gynecology and Obstetrics stage IIIC) have a substantially worse prognosis. This study investigates how tumor characteristics and adjuvant treatments influence overall survival (OS) in stage IIIC patients. METHODS: This multi-institution, institutional review board-approved study is a retrospective review of 116 patients with surgically staged endometrial cancer with positive lymph nodes treated from 1995 to 2008. The study cohort was evaluated using Kaplan-Meier estimates of OS and proportional hazard modeling. RESULTS: The 5-year OS for all patients was 51%. Administration of adjuvant therapy was associated with improved OS when compared with surgery alone (P = 0.007). Five-year OS was 40% for patients treated with surgery alone (n = 26), 50% with surgery and chemotherapy (n = 8), 58% with surgery and radiotherapy (n = 43), and 54% with surgery followed by both radiotherapy and chemotherapy (n = 39). Patients who received radiotherapy (n = 82) had improved OS (57%) when compared with patients who did not (n = 34, OS = 42%; P = 0.001). Radiotherapy was associated with improved OS for patients with endometrioid histology, high-grade tumors, and positive para-aortic lymph nodes. Patients with nonendometrioid histology and low-grade tumors who received radiotherapy had a similar OS as those who did not. High-grade tumors (P < 0.001), nonendometrioid histology (P = 0.004), and more than 2 positive lymph nodes (P = 0.01) were associated with a poorer OS. After controlling for patient demographics and tumor characteristics, patients with high-grade tumors and more than 2 positive lymph nodes had a poorer OS, whereas patients who received radiotherapy had improved OS. CONCLUSIONS: This large institutional study of patients with lymph node-positive endometrial cancer identified prognostic factors associated with a poor OS. Radiotherapy was associated with improved survival and may be specifically indicated for patients with endometrioid histology, high-grade tumors, and positive para-aortic lymph nodes. We recommend further investigation of adjuvant therapies in randomized clinical trials.

Characterization and evaluation of pre-clinical suitability of a syngeneic orthotopic mouse ovarian cancer model.

BACKGROUND/AIM: To develop and characterize the pre-clinical suitability of a syngeneic mouse epithelial ovarian cancer model in immunocompetent hosts. MATERIALS AND METHODS: ID8 mouse ovarian surface epithelium cells were implanted into the left ovarian bursa of C57BL/6 mice. Using conventional as well as ultrasound-based techniques and histopathological analysis, the tumor weights, volumes, metastases, ascites and vascularity were observed over a period of 16 weeks. RESULTS: Ovarian weights and volume increased 12- and 7-fold, respectively. Ultrasound measurements of ovarian ID8 tumors correlated with the actual size obtained following surgical excision. Ascites and metastasis were first observed at 12 weeks post-orthotopic implantation. Histopathological analysis indicated similarities between orthotopically-generated ovarian tumors and human ovarian tumors. However, there was less evidence of angiogenesis in this animal model. CONCLUSION: The development of this mouse model closely replicates characteristics seen in human ovarian cancer with feasibility of using ultrasound to assess tumor formation, progression and vascularization.

Familial clustering of endometrial cancer in a well-defined population.

OBJECTIVE: Using a genealogical database, we examined risk of endometrial cancer among family members of individuals with endometrial cancer. METHODS: We identified endometrial cancer cases in the Utah Population Database (UPDB), a computerized archive of genealogy data linked to the Utah Cancer Registry. We tested for excess relatedness and estimated relative risks (RR) among first-, second-, and third-degree relatives of endometrial cancer cases and stratified analyses by tumor histology and body mass index (BMI). RESULTS: We identified 3911 cases; 3546 were Type I cancers and 365 Type II cancers. The RR for all endometrial cancer cases and for cases with type I histology was significantly increased for first-, second-, and third-degree relatives. An almost three-fold risk was observed among first-degree relatives of individuals with Type I cancers and a 2.24-fold risk among second-degree relatives of Type I morbidly obese cases. The magnitude of endometrial cancer risk among relatives appeared to increase with case BMI. CONCLUSIONS: The elevated risks for endometrial cancer among first-, second-, and third-degree relatives support a genetic contribution to predisposition to endometrial cancer. The increased risk appears to be limited to Type I endometrial cancer. We observed increased risks for endometrial cancer among relatives of obese and morbidly obese Type I cases, which may be indicative of a synergistic relationship between underlying genetic propensity and shared environment. This study quantifies risk of developing cancer among relatives of patients with disease and provides the basis for further analysis of high risk pedigrees and gene identification for genetic etiologies of endometrial cancer.

Endometrial cancer--current state of the art therapies and unmet clinical needs: the role of surgery and preoperative radiographic assessment.

Endometrial carcinoma is the fourth most common cancer among women in the United States. Surgical pathologic staging has been the standard of care since 1988, which consists of analysis of collected peritoneal fluid, hysterectomy/oophorectomy, and pelvic and para-aortic lymphadenectomy. In 2005, it was further recommended that essentially all women with endometrial cancer who choose to undergo surgery have pelvic and para-aortic lymph node analysis. Despite this recommendation, there still remains controversy as to whether all patients with endometrial cancer should undergo full lymph node dissection. In this review, we assess the evidence surrounding this controversy and conclude that women with endometrial cancer should undergo complete lymphadenectomy at the time of surgery. Furthermore, we evaluate the evidence regarding laparoscopic surgical staging as a safe and effective alternative to the more invasive traditional laparotomy. Finally, for those patients who a gynecologic oncologist is not readily available to perform a complete lymph node dissection, we evaluate the various imaging studies and their utility as preoperative triage modalities.

Adjuvant radiotherapy and survival outcomes in early-stage endometrial cancer: a multi-institutional analysis of 608 women.

OBJECTIVE: The role of post-operative radiotherapy (RT) in women with early-stage, low to intermediate risk cancer of the uterine corpus remains controversial. The primary objective of this analysis was to evaluate the survival outcomes of women with early-stage endometrial cancer treated with surgery alone or surgery followed by RT. METHODS: Data from two institutions were collected from 1990 to 2003. The 608 eligible women had FIGO stage IA to IIA endometrial cancer and underwent primary surgery +/-RT. Univariate and multivariate analyses of pertinent variables were performed for the end points of disease-free survival (DFS) and overall survival (OS). RESULTS: The median age for all women was 64 years. RT was delivered to 133 women (22%). Unfavorable histologic grade (P < 0.0001) and stage (P < 0.0001) were significantly more prevalent in the adjuvant RT group. At a median follow-up of 5.2 years, 26 pelvic (11 vaginal) and 16 distant failures occurred along with 110 deaths (with no significant differences between women undergoing surgery alone or followed by RT). Adjuvant RT, younger age, and lower stage predicted for improved DFS and OS on multivariate analysis. Stratified analysis revealed that adjuvant RT conferred a survival benefit in women with stage IC or IIA disease. CONCLUSIONS: Adjuvant RT was associated with improved disease-free and overall survival in women with higher risk disease. Despite significantly worse disease characteristics among women in the adjuvant RT group, the analyzed end points were equivalent among the two groups. These findings suggest that adjuvant radiotherapy has a significant benefit in reducing mortality and disease progression in early-stage carcinoma of the uterine corpus.

Phosphatidylinositol 3-kinase inhibition by LY294002 radiosensitizes human cervical cancer cell lines.

PURPOSE: The phosphatidylinositol 3-kinase (PI3K) catalytic subunit is amplified in cervical cancers, implicating PI3K in cervical carcinogenesis. We evaluated the radiosensitizing effect of PI3K inhibition by LY294002 on clonogenic survival, growth characteristics, and gene expression in cervical cancer cell lines (HeLa and CaSki). EXPERIMENTAL DESIGN: Cervical cancer cells were treated separately and concurrently with the PI3K inhibitor LY294002 (10 micromol/L) and radiation (2 Gy) with serial analysis of cell count, apoptosis, and flow cytometry. PI3K inhibition was assessed by protein analysis of phosphorylated Akt. Clonogenic assays were done with varying doses of radiation and LY294002 and varied time points of administration of LY294002 proximate to the radiation dose. Surviving fractions and dose modification factors (DMF) were calculated. Each experiment was done in triplicate and analyzed using ANOVA regression analysis and Dunnett's t Test. Microarray gene expression analysis was done on the HeLa cell line. RESULTS: PI3K inhibition with LY294002 alone did not decrease cell survival. However, treatment with LY294002 significantly radiosensitized HeLa and CaSki cell lines with DMFs (1 log cell kill) of 1.95 and 1.37, respectively. Compared with post-irradiation, pretreatment produced more radiosensitization (P < 0.0001). DMFs were 2.2, 2.0, 2.0, and 1.2 for LY294002 added at 6, 2, and 0.5 hours before irradiation and 6 hours after irradiation, respectively. LY294002 pretreatment in irradiated HeLa cells led to altered gene expression. CONCLUSIONS: Although LY294002 alone did not produce cytotoxic effects, PI3K inhibition with LY294002 produced significant radiosensitization, showed significant time-dependent effects, increased apoptosis, and altered gene expression. These findings support future investigation of PI3K inhibitors in combination with radiation therapy for carcinoma of the cervix.

Does oncologic specialization influence outcomes following surgery in early stage adenocarcinoma of the endometrium?

OBJECTIVE: To evaluate treatment outcomes in women with early-stage endometrial cancer (FIGO IA, IB, IC, or IIA) surgically managed by a general gynecologist (GYN) or a gynecologic oncologist (GYO). METHODS AND RESULTS: 349 women treated from 1990-2003 were studied. Median follow-up was 3.7 years. Ninety-five were classified as high-intermediate risk (HIR: stages IB grade III, IC grade II or III, any stage IIA). 110 women received adjuvant radiotherapy. The GYO group had more unfavorable tumor characteristics based on stage and grade (P<0.0001), shorter follow-up (median 3.1 vs. 5.1 years, P=0.0002), and an absolute 12% less likelihood of receiving adjuvant radiotherapy (P=0.04). Local and distant failures were not significantly different. Overall survival favored GYN patients (P=0.02) with no difference in disease-specific survival (P=0.38). Multivariate analysis for disease-free survival revealed HIR disease (P=0.04) and GYO treatment (P=0.049) to be significant, with a trend for age

Detection of residual subclinical ovarian carcinoma after completion of adjuvant chemotherapy.

PURPOSE: We sought to test the hypothesis that the presence of telomerase activity in peritoneal washings of patients treated for ovarian carcinoma is a sensitive and specific indicator of the presence of residual disease. We hypothesized that this test, if added to second-look procedure protocols, could help determine whether residual disease is present or not in patients who have completed their adjuvant chemotherapy for ovarian carcinoma. EXPERIMENTAL DESIGN: Peritoneal washings were obtained from 100 consecutive patients undergoing a second-look procedure after treatment for ovarian carcinoma (cases) and from 100 patients undergoing surgery for benign gynecological conditions (controls). The washings were assayed for telomerase activity using the telomerase repeat amplification protocol. The results were compared to the histological and cytological findings. RESULTS: Among our 100 cases, 82 (82%) had either positive second-look procedures or expressed telomerase in their peritoneal washings. Fifty-three (53%) had positive second-look procedures, whereas 66 (66%) tested positive for telomerase. Twenty-nine of the 47 patients (62%) with negative second-look procedures tested positive for telomerase. Of the 53 patients with positive second-look procedures, 37 (70%) tested positive for telomerase. None of the 100 controls (0%) expressed telomerase in their peritoneal washings. CONCLUSIONS: Telomerase activity in peritoneal washings of patients treated for ovarian carcinoma and undergoing a second-look procedure may provide a means of increasing the sensitivity of such procedures for the detection of residual disease while maintaining a high level of specificity.