Suspicious axillary lymph nodes in patients with unremarkable imaging of the breast.

OBJECTIVE: The aim of this study was to evaluate the pathological findings and the method of tissue harvesting in those patients who have both suspicious axillary lymph nodes and normal imaging of the breast. STUDY DESIGN: From January 2005 to June 2008 all female patients who underwent opportunistic screening mammography and ultrasound examination of the breast and the axilla, and who were found to have suspicious axillary lymph nodes seen on ultrasound examination, were retrospectively analysed. Tissue harvesting was done by fine needle aspiration, core needle biopsy, or open biopsy. RESULTS: Out of approximately 7500 screened patients, 51 were found to have suspicious axillary lymph nodes on ultrasound with unremarkable breast ultrasound and mammography. Histopathology and/or cytology of these lymph nodes showed 33 benign and 18 malignant results. Of the malignant results only 1 case was an occult invasive lobular breast carcinoma detected afterwards on breast magnetic resonance imaging. Eleven cases were non-Hodgkin lymphomas, 4 were malignant melanomas, and 2 were metastases from the lower genital tract. Diffuse cortical thickening and complete loss of echo texture were the only features on ultrasound predicting malignancy. Palpation and mean size of the evaluated lymph nodes had no predictive value for malignancy. In the 33 cases of non-malignant pathology 9 patients showed patterns of specific infectious disease, including 4 patients with tuberculosis. CONCLUSION: Suspicious lymph nodes of the axilla seen on ultrasound rarely indicate occult breast cancer but show a variety of other malignancies and generalised infectious disease requiring further treatment. Fine needle aspiration and/or core needle biopsy are both sufficient methods for clarification in the majority of cases.

Phase II study of weekly docetaxel in patients with recurrent or metastatic endometrial cancer: AGO Uterus-4.

OBJECTIVE: The aim of this phase II multicenter study was to evaluate the safety, toxicity and efficacy of docetaxel administered weekly as first line chemotherapy in patients with recurrent or metastatic endometrial cancer. PATIENTS AND METHODS: Thirty five patients with recurrent or metastatic endometrial cancer without previous chemotherapy were enrolled to receive three 6-week cycles of docetaxel 35 mg/m(2)/week with 2-week breaks between the cycles. Therapy response was evaluated after every 6-week cycle, and therapy was continued in case of at least stable disease. Final therapy response was evaluated after three 6-week cycles of docetaxel. RESULTS: Thirty five patients with a median age of 65 years (range, 37-80 years) were evaluable for toxicity assessment, one patient presented with severe anaphylactic reaction during the second application of docetaxel and therapy was discontinued. Subsequently, this patient received doxorubicin-cisplatin combination chemotherapy. Another patient was initially documented with uterine papillary serous cancer but secondarily confirmed as uterine carcinosarcoma. Thus, 33 patients were assessable for response. Overall response rate was 21% (3 PR and 4 CR). Three patients showed stable disease. Median TTP and OAS were 12 weeks and 43 weeks, respectively. Therapy with weekly docetaxel was well tolerated; in particular, no grade 3 or 4 hematological toxicities occurred. CONCLUSION: Docetaxel weekly has a favorable toxicity profile, is well tolerated and shows encouraging activity in patients with advanced endometrial cancer.

Endometrial cancer.

Radical surgery including complete pelvic and para-arortic lymph node dissection (LND) is both the main therapeutic effort and the decisive staging procedure in patients with invasive endometrial cancer (EC) and should be performed in specialized institutions. Vaginal cuff brachytherapy holds little serious side effects and may be beneficial in preventing vaginal recurrences. External irradiation treatment no longer has a routine indication in primary therapy. The omission of retroperitoneal staging (LND) at primary surgery does not indicate adjuvant radiotherapy but rather second-effort surgery removing pelvic and para-aortic lymph-nodes. External radiotherapy should be reserved for fully staged patients with residual non-resectable tumor manifestation and/or nodal involvement in relation to the extent of tumor involvement and surgical intervention. Hormonal and cytotoxic therapy is experimental in the adjuvant setting. The first step in palliative systemic treatment should be the administration of endocrine therapy when the tumor expresses progesterone receptors and tumor manifestations are not acutely life-threatening. In other cases or when endocrine treatment fails chemotherapy may be considered, which is often limited due to its toxicity. Preferably, palliative hormonal and/or chemotherapy should be administered in controlled clinical trials.

GnRH antagonists in the treatment of gynecological and breast cancers.

Approximately 80% of human ovarian and endometrial cancers and 50% of breast cancers express GnRH and its receptor as part of an autocrine regulatory system. After binding of its ligand the tumor GnRH receptor couples to G-protein alphai and activates a variety of intracellular signaling mechanisms. (1) Through activation of a protein tyrosine phosphatase, autophosphorylation of growth factor receptors is reverted leading to an inhibition of mitogenic signaling and reduced cell proliferation. (2) Through activation of nuclear factor kappa B antiapoptotic mechanisms are induced protecting tumor cells from apoptosis induced, for example, by doxorubicin. (3) Through activation of the Jun kinase pathway AP-1 is induced, leading to cell cycle arrest in the G0/G1 phase. It seems reasonable to speculate that this system enables the tumor cell to reduce proliferation and to activate repair mechanisms while being protected simultaneously from apoptosis. Interestingly, GnRH antagonists show the same activity in this system as agonists, indicating that the dichotomy GnRH agonist-GnRH antagonist defined in the pituitary gonadotrope is not valid for the tumor GnRH system. Recently, a second type of GnRH receptor, specific for GnRH-II, has been identified in ovarian and endometrial cancers, which transmits significantly stronger antiproliferative effects than the GnRH-I receptor. GnRH antagonists have agonistic effects on this type II receptor. In animal models of human cancers, GnRH antagonists had stronger antitumor effects than GnRH agonists. Therefore, we performed a phase II clinical trial with the GnRH antagonist, cetrorelix (10 mg/day), in patients with ovarian or mullerian carcinoma refractory to platinum chemotherapy. Of 17 evaluable patients treated with cetrorelix, 3 obtained a partial remission (18%) which lasted for 2 to 6 months. Furthermore, 6 patients experienced disease stabilization (35%) for up to 1 year. In this very refractory patient population (median number of prior chemotherapies = 3) these results are quite remarkable when compared with palliative chemotherapy. In addition, cytotoxic GnRH analogs have been developed, where for example doxorubicin was covalently coupled to GnRH analogs. These compounds have superior antitumor effects in cancers expressing GnRH receptors as compared with native doxorubicin and allow for a targeted cytotoxic chemotherapy of gynecologic and breast cancers.

Luteinizing hormone-releasing hormone induces nuclear factor kappaB-activation and inhibits apoptosis in ovarian cancer cells.

More than 80% of human ovarian cancers express LHRH and its receptor as part of a negative autocrine mechanism of growth control. This study was conducted to investigate whether LHRH affects apoptosis in ovarian cancer. EFO-21 and EFO-27 ovarian cancer cells were treated with LHRH agonist Triptorelin or with cytotoxic agent Doxorubicin in the absence or presence of Triptorelin. Apoptotic cells were quantified by flow cytometry. Expression of nuclear factor kappa B (NFkappaB) was assessed by RT-PCR and immunoblotting. For determination of Triptorelin-induced NFkappaB activation, cells were transfected with a NFkappaB-secreted alkaline phosphatase reporter gene plasmid (pNFkappaB-SEAP) and cultured for 96 h with or without Triptorelin. The causal relation between Triptorelin-induced NFkappaB activation and Triptorelin-induced protection against apoptosis was investigated using SN50, an inhibitor for nuclear translocation of activated NFkappaB. Apoptosis induction by Triptorelin was never observed. Treatment with Doxorubicin (1 nmol/L) for 72 h increased the percentage of apoptotic cells in EFO-21 and EFO-27 ovarian cancer cell lines to 31% or 34%, respectively. In cultures treated simultaneously with Triptorelin (100 nmol/L), the percentage of apoptotic cells was reduced significantly, to 17% or 18%, respectively (P < 0.001). RT-PCR and immunoblotting experiments showed that NFkappaB subunits p50 and p65 were expressed by ovarian cancer cell lines EFO-21 and EFO-27. When EFO-21 or EFO-27 cells were transfected with pNFkappaB-SEAP and subsequently treated with Triptorelin (100 nmol/L), NFkappaB-induced SEAP expression increased 5.3-fold or 4.7-fold, respectively (P < 0.001). Triptorelin-induced reduction of Doxorubicin-induced apoptosis was blocked by SN50-mediated inhibition of NFkappaB translocation into the nucleus. We conclude that LHRH induces activation of NFkappaB and thus reduces Doxorubicin-induced apoptosis in human ovarian cancer cells. This possibility to protect ovarian cancer cells from programmed cell death is an important feature in LHRH signaling in ovarian tumors, apart from the inhibitory interference with the mitogenic pathway.

Docetaxel is effective in the treatment of metastatic endometrial cancer.

BACKGROUND: Systemic treatment of endometrial carcinoma with distant metastases is currently performed, inter alia, with anthracyclines, platinum, paclitaxel, if osfamid or progestins. This is the first report presenting experience in treatment of metastatic endometrial carcinoma with docetaxel. CASE REPORT: A 69-year-old women with adenocarcinoma of the endometrium was treated with primary combined radiotherapy. Two years later disseminated bilateral pulmonary metastases were detected and the patient was submitted to chemotherapy with epirubicin. After three cycles of chemotherapy with epirubicin examinations revealed metastatic progression. Thus, chemotherapy was changed to docetaxel. RESULTS: After three cycles of chemotherapy with docetaxel examinations revealed remission of the described pulmonary metastases more than 50%. A further three cycles of chemotherapy with docetaxel lead to continuing shrinkage of the detectable metastases to less than 25% of the original size. Because of various side effects, like increasing fatigue and asthenia, uncomfortable acral paresthesia and allergic skin reactions, the patient refused to continue chemotherapy. CONCLUSION: We conclude that docetaxel may be an active agent in patients with metastatic endometrial cancer, but care should be taken to minimize side-effects.

Early detachment of colon carcinoma cells during CD95(APO-1/Fas)-mediated apoptosis. I. De-adhesion from hyaluronate by shedding of CD44.

Ligation of CD95 (APO-1/Fas) cell surface receptors induces death in apoptosis-sensitive cells. Induction of apoptosis in adherent gamma interferon-stimulated HT-29 and COLO 205 colon carcinoma cells by cross-linking CD95 with anti-APO-1 monoclonal antibody resulted in detachment of the cells from hyaluronate starting about 1 h after antibody exposure. Loss of adhesion was paralleled by a substantial reduction of the multifunctional cell surface adhesion molecule CD44. As evidenced by cycloheximide treatment, this effect was not caused by impaired protein synthesis. Depletion of surface CD44 was also not due to membrane blebbing, since cytochalasin B failed to inhibit ascension from hyaluronate. Instead, ELISA and time kinetics showed increasing amounts of soluble CD44 in the supernatant of CD95-triggered cells. SDS-PAGE revealed that soluble CD44 had an apparent molecular mass of about 20 kD less than CD44 immunoprecipitated from intact cells. Thus, CD95-triggering induced shedding of CD44. Shedding is a novel mechanism operative in early steps of CD95-mediated apoptosis. Shedding surface molecules like CD44 might contribute to the active disintegration of dying epithelial cells in vivo.

In situ detection of enterocytic apoptosis in normal colonic mucosa and in familial adenomatous polyposis.

Physiological regeneration of colonic epithelium entails proliferation at the crypt base and cell loss by shedding or cell death. The aim of this study was to localise and assess the rate of apoptosis in normal and neoplastic colonic epithelium with respect to zones of proliferation. Familial adenomatous polyposis (FAP) was chosen as a model to study neoplastic transformation of colonic mucosa at an early stage. Apoptotic cells were detected in situ by TdT-mediated biotin-dUTP nick end labelling (TUNEL) in parallel to cells in cycle determined by Ki-67 immunohistochemistry using the monoclonal antibody MiB-1. By detection of genomic fragmentation, two different patterns of enterocytic apoptosis emerged: (a) apoptotic bodies being engulfed by adjacent epithelial cells, and (b) apoptotic cells with only subtle morphological changes being extruded into the gut lumen. The engulfment pattern was seen predominantly in the crypts of the normal colonic mucosa and, although very rare, was clearly confined to the basal proliferation compartment. The extrusion pattern was restricted to the luminal mucosal surface. Adenomas of FAP showed highly increased numbers of apoptotic bodies, which were scattered throughout the transformed mucosa. Both patterns of apoptosis were topographically intermingled although the extrusion pattern prevailed at the luminal adenoma surfaces. Whereas cells in cycle were somewhat more numerous in the upper parts of the crypts, apoptosis occurred with increased frequency at sites beneath the proliferation maximum suggesting an inverted direction of epithelial cell migration in adenomas. These results suggest two distinct routes towards enterocytic apoptosis in the colonic mucosa leading to engulfment or extrusion of dying cells. Adenomatous transformation of colon epithelium is associated with a considerable increase of the cellular turnover rate and with a severe disturbance of the microtopographical localisation of birth and death of enterocytes.

Microwave irradiation of paraffin-embedded tissue sensitizes the TUNEL method for in situ detection of apoptotic cells.

Apoptosis is a morphologically distinct form of programmed cell death that plays an important role in the growth regulation of a variety of tissues and also in the elimination of self-reacting immunocompetent cells. Several techniques for the qualitative and quantitative detection of this process have been established; recently, an in situ nick end-labelling technique based on the detection of DNA fragmentation, which is a molecular characteristic of apoptotic cell death, was described. Applying this method to paraffin sections of human tissues, sensitivity was observed to be inconsistently low with regard to the expected number of apoptotic cells. In the present study we show that irradiation of the tissue sections in 10 mM citrate buffer, pH 6.0, by microwaves at 750 W considerably enhances the sensitivity of this nick end-labelling technique.