Ritonavir blocks AKT signaling, activates apoptosis and inhibits migration and invasion in ovarian cancer cells.

BACKGROUND: Ovarian cancer is the leading cause of mortality from gynecological malignancies, often undetectable in early stages. The difficulty of detecting the disease in its early stages and the propensity of ovarian cancer cells to develop resistance to known chemotherapeutic treatments dramatically decreases the 5-year survival rate. Chemotherapy with paclitaxel after surgery increases median survival only by 2 to 3 years in stage IV disease highlights the need for more effective drugs. The human immunodeficiency virus (HIV) infection is characterized by increased risk of several solid tumors due to its inherent nature of weakening of immune system. Recent observations point to a lower incidence of some cancers in patients treated with protease inhibitor (PI) cocktail treatment known as HAART (Highly Active Anti-Retroviral Therapy). RESULTS: Here we show that ritonavir, a HIV protease inhibitor effectively induced cell cycle arrest and apoptosis in ovarian cell lines MDH-2774 and SKOV-3 in a dose dependent manner. Over a 3 day period with 20 muM ritonavir resulted in the cell death of over 60% for MDAH-2774 compared with 55% in case of SKOV-3 cell line. Ritonavir caused G1 cell cycle arrest of the ovarian cancer cells, mediated by down modulating levels of RB phosphorylation and depleting the G1 cyclins, cyclin-dependent kinase and increasing their inhibitors as determined by gene profile analysis. Interestingly, the treatment of ritonavir decreased the amount of phosphorylated AKT in a dose-dependent manner. Furthermore, inhibition of AKT by specific siRNA synergistically increased the efficacy of the ritonavir-induced apoptosis. These results indicate that the addition of the AKT inhibitor may increase the therapeutic efficacy of ritonavir. CONCLUSION: Our results demonstrate a potential use of ritonavir for ovarian cancer with additive effects in conjunction with conventional chemotherapeutic regimens. Since ritonavir is clinically approved for human use for HIV, drug repositioning for ovarian cancer could accelerate the process of traditional drug development. This would reduce risks, limit the costs and decrease the time needed to bring the drug from bench to bedside.

Second neoplasms in survivors of endometrial cancer: impact of radiation therapy.

OBJECTIVE: To evaluate the association of radiotherapy to subsequent second cancers in endometrial carcinoma survivors. METHODS: Subjects with endometrial cancer as their first malignancy were identified from the Surveillance, Epidemiology and End Results (SEER) database from 1973 to 2004 and were divided into radiation (R) and No Radiation (NR) groups. Person years at risk (PYR), observed (O) and expected (E) counts and SIR (standardized incidence ratio) were determined. (%) increase in relative risk (RR) for R vs. NR group was calculated using Poisson regression. Absolute Excess Risk (AER) was 'O' minus 'E' per 10,000 PYRs. RESULTS: Of 90,502 subjects 31,643 (34.9%) were in R and 52,182 (57.6%) in NR. The radiation status of 6677 (7.3%) was unknown. In the R group 4203 developed second cancers vs. 5563 in NR group; relative risk for R group-1.25 (95% CI 1.20 to 1.29). A total of 17.11 excess tumors were observed in R group (AER). The relative risk increased with latency of exposure and peaked at (>10 years), being 40% (p<0.001). The statistically significant (%) increase in RR for individual organs was as follows: urinary bladder (124%), vagina (88%), vulva (83%), sarcoma (70%), colon and rectum (43%) and lung (29%). CONCLUSION: In the largest study reporting on association of radiotherapy to subsequent second neoplasms in endometrial cancer survivors, the increased risk of second cancers was most pronounced in the field of exposure and was affected by latency since exposure.

Radiation-associated endometrial cancer.

OBJECTIVE: To compare prognostic variables and survival of radiation-associated endometrial cancers with sporadic second endometrial cancers. METHODS: Patients with primary cancers of pelvic organs (urinary system, colorectal, cervix, vulva, and vagina) were identified from the Surveillance, Epidemiology, and End Results (SEER) database between 1973 and 2005. Among these patients, those who received pelvic radiation and subsequently developed endometrial cancer formed the radiation-associated endometrial cancers cohort (cases), whereas those who did not receive pelvic radiation but subsequently developed endometrial cancer formed the sporadic second endometrial cancers cohort (controls). Comparisons between radiation-associated endometrial cancers and sporadic second endometrial cancers used chi, t tests, Kaplan-Meier, and cox proportional hazards analysis. RESULTS: In 205 radiation-associated endometrial cancer patients and 1,001 sporadic second endometrial cancer patients, the mean age of diagnosis was 65 years and 68 years, respectively (P<.001). The mean latency between primary pelvic organ cancer and second endometrial cancer was 110 months for the radiation-associated endometrial cancers and 77 months for the sporadic second endometrial cancers (P=.03). The lesions in the radiation-associated endometrial cancers cohort (compared with sporadic second endometrial cancers) were far more likely to be nonendometrioid histology (76.2% compared with 51%, P<.001), poorly differentiated (58% compared with 28%, P<.001), and advanced stage (International Federation of Gynecology and Obstetrics III and IV [corrected] combined) (43% compared with 16%, P<.001). The 5-year survival rate for radiation-associated endometrial cancers and sporadic second endometrial cancers was 27.1% and 57.1%, respectively (P<.001). In multivariable analysis, after controlling for age, race, histology, stage, grade, and treatment, the hazard ratio for death of radiation-associated [corrected] endometrial cancers was 1.4 (95% ((CI)) [corrected] 1.2-3.6; P=.002). CONCLUSION: The radiation-associated endometrial cancers carry a grave prognosis because they are more likely to be nonendometrioid, poorly differentiated advanced stage cancers. The longer latency and extensive spread at diagnosis among radiation-associated endometrial cancers may suggest a possible delay in clinical presentation and diagnosis. LEVEL OF EVIDENCE: II.

Carboplatin and paclitaxel adjuvant chemotherapy in primitive neuroectodermal tumor of the uterine corpus.

Primitive neuroectodermal tumor of the uterine corpus (PNET) is rare and appears to have an aggressive clinical course. We report on a postmenopausal woman with optimal surgically cytoreduced advanced-stage PNET in which adjuvant combination chemotherapy with platinum and taxane agents was unsuccessful in extending her disease-free survival.

A comparison of younger vs older women with vulvar cancer in the United States.

OBJECTIVE: The purpose of this study was to compare the prognostic variables and survival of younger (< 50 years) to that of older (> or = 50 years) women with vulvar cancer. STUDY DESIGN: Subjects with invasive squamous cell carcinoma of the vulva were identified from the limited use Surveillance, Epidemiology, and End Results (SEER) Program 1988-2005. Comparisons between younger and older women were accomplished with chi(2) and t-tests. Survival analysis was accomplished with Kaplan-Meier for univariate analysis and Cox proportional hazards model for multivariate analysis. RESULTS: A total of 6965 patients met inclusion criteria, of whom 1345 patients (19.3%) were younger and 5620 patients (80.7%) were older. The 5-year survival was 87.5% for younger women and 52.5% for older women (P < .001). After data were controlled for race, stage, grade, and surgical treatment, older patients had a hazard ratio of 3.9 (95% CI, 3.2-4.7) for death. CONCLUSION: A striking survival difference exists between younger and older women with squamous cell vulvar cancer, which supports the view that etiopathogenesis of this disease may vary between age groups.

Prognostic significance of keratinization in squamous cell cancer of uterine cervix: a population based study.

PURPOSE: To determine the influence of keratinization on prognosis in squamous cell cancer (SCC) of the uterine cervix. METHODS: Patients with keratinized squamous cell carcinoma (KSCC) and non-keratinized squamous cell carcinoma (NKSCC) of the cervix were identified from the Limited Use SEER database from 1988 to 2004. A subgroup of patients who did not have radiation or surgery formed the basis to study the natural history of the disease. Data were analyzed using Pearson Chi-square, Student's T tests. Kaplan-Meier and Cox Regression Proportional Hazards survival analysis was conducted in SPSS and SEER-Stat software. RESULTS: The KSCC group had 3,102 and the NKSCC had 3,751 patients with mean age being 51 and 49 years, respectively (P = 0.001). In general, patients with KSCC were more likely to have advanced stage (FIGO III and IV) disease while patients with NKSCC were more likely to have poorly differentiated neoplasms (P < 0.001). The prevalence of lymph node metastasis remained similar in both histology types (P > 0.05). Overall, the 5-year survival in KSCC was 63.4% as compared to 65.3% in the NKSCC group (P = 0.04). Patients treated by surgery had no difference in survival; however, patients treated by radiation had a median survival in KSCC of 33 months (n = 928, 95% CI 27.7-38.3) as compared to 38 months (n = 1,140, 95% CI 32.1-43.8) in NKSCC (P = 0.03). A total of 165 KSCC and 147 NKSCC patients did not receive treatment. Within this subgroup, the median survival was 10 months (95% CI 5.93-14.07) as compared to 28 months (95% CI 17.9-38.0; P = 0.001) respectively for the two cohorts. In multivariate analysis stage, treatment status, nodal metastasis and keratinization were independent predictors of survival (P < 0.05). CONCLUSION: This is the largest study reporting on the prognostic importance of keratinization in SCC. KSCC may be less radiosensitive and associated with shorter overall survival. Also, in the natural history of the SCC, keratinization signifies striking reduction in survival.

Lymphadenectomy and ovarian preservation in low-grade endometrial stromal sarcoma.

OBJECTIVE: To report the impact on overall survival of lymphadenectomy and ovarian preservation in patients with endometrial stromal sarcoma. METHODS: Data were extracted from the Surveillance, Epidemiology, and End Results Program from 1988 to 2005. Kaplan-Meier and Cox proportional hazards analyses were used to identify possible predictors for survival. RESULTS: Nine hundred seventy women were reported with endometrial stromal sarcoma. The 384 women with low-grade endometrial stromal sarcoma had a younger age, earlier stage, and longer survival than the 320 women with high-grade lesions. Among the low-grade endometrial stromal sarcoma patients, the incidence of extrauterine disease was 25%, and lymph node metastasis was 7%. Univariable and multivariable analysis demonstrated lymph node metastasis and ovarian preservation were not significant prognostic factors for survival. CONCLUSION: In low-grade endometrial stromal sarcoma, the risk of extrauterine spread and lymph node metastasis merit consideration for surgical staging. Neither lymph node metastasis nor ovarian preservation seems to affect the excellent overall survival of these patients. LEVEL OF EVIDENCE: II.

Image-guided percutaneous cryotherapy for the management of gynecologic cancer metastases.

OBJECTIVE: To report the clinical response to image-guided percutaneous cryotherapy (IPC) for the palliative management of localized metastases in patients with gynecologic malignancies. METHODS: Institutional review board approval and patient consent were obtained. Gynecologic oncology patients were identified from our institution's cryotherapy database from August 2003 to August 2007. Cryotherapy was performed with 2.4 mm diameter probes (Endocare, Irvine, CA) with ultrasound or computerized tomography (CT) guidance under conscious sedation and local anesthesia. Follow-up was conducted by imaging studies and clinical encounters, using Response Evaluation Criteria in Solid Tumors (RECIST criteria). RESULTS: Twenty-eight ablation sessions were performed for 41 metastatic foci in 15 patients with gynecologic malignancies. Twelve patients had prior chemotherapy and 5 patients had prior radiation. Median follow-up was 317.5 days (range 95-1189). Median post-procedure pain score: 3/10 (range 0-5). Mean initial tumor size was 2.6 cm in maximal diameter. Median reduction in tumor diameter at 1 month was 21.4% (range 2-67.4%), at 3 months was 43.6% (range 16-80.4%), at 6 months was 54.7% (range (16.6-88.9%) and at 9 months was 58.2% (range 32-88.9%). Ten patients received concurrent chemotherapy, 8 had progression of disease at other sites and 2 had stable disease, while the cryotherapy site improved. One of 5 patients who had cryotherapy in the previously irradiated zone had recurrence. A liver capsule hematoma developed as an immediate complication in one patient and an enterocutaneous fistula developed in another. CONCLUSION: IPC is a well-tolerated, effective tool for local control of isolated metastatic foci as a single-modality treatment and for local control of symptomatic metastases in select patients undergoing systemic therapy for the management of gynecologic malignancies.

A population-based analysis of 788 cases of yolk sac tumors: A comparison of males and females.

Yolk sac tumors (YST) are a rare and aggressive germ cell tumor. The objective of this study is to compare the patient characteristics and survival of YST in males and females. Demographic and clinicopathologic information were obtained from the Surveillance, Epidemiology, and End Results Program from 1973 to 2003. Statistical analysis was performed using Independent-sample t-test, chi(2) test, Kaplan-Meier methods and Cox proportional hazards regression. Seven hundred eighty-eight patients were identified, 451 (57%) were males and 337 (43%) were females. The mean age at diagnosis was similar in males and females. The age at diagnosis showed a bimodal distribution with an increased incidence in the first 4 years of life and during the 2nd to 4th decade of life. The most common site of the primary tumor was gonadal, namely testis 336 (42.6%) and ovary 257 (32.6%). Among the extragonadal sites, tumor site of origin differed in males and females. The 5-year survival of extragonadal YST (66%) was worse than gonadal YST (86%) (p < 0.05). The overall median survival for the cohort was 87 months. This was similar in males (81 months) and females (91 months) (p > 0.05). As the year of diagnosis progressed from 1973 to 2003, survival of both males and females with YST consistently improved. The bimodal age distribution of YST generates the hypothesis that sex steroids may play a role in selected YST. Although the overall survival in all YST patients has improved over the past few decades, the primary sites of origin differ in males and females and impact prognosis.

The prevalence and prognostic impact of lymph node metastasis in malignant germ cell tumors of the ovary.

BACKGROUND: The purpose of this study is to report the prevalence and prognostic importance of lymph node metastasis in malignant germ cell tumors of the ovary (OGCT). METHODS: Demographic and clinicopathologic information were abstracted from the Surveillance, Epidemiology, and End Results Program (SEER) from 1988 to 2004. Patients with a histologic diagnosis of OGCT after surgical resection were included. The study population was divided into Cohort A (lymph node metastasis absent) and Cohort B (lymph node metastasis present). Statistical analysis using Fisher's Exact Test, Kaplan-Meier survival methods, and Cox regression proportional hazards were performed. RESULTS: In 613 patients with lymphadenectomy, the prevalence of lymphnode metastasis was 18.1% (111/613). In dysgerminoma, malignant teratoma and mixed germ cell tumors including pure non-dysgerminoma histology, the lymphnode metastasis was present in 28%, 8% and 16% patients respectively (p<0.05). Age, race, grade and extent of lymph node dissection influenced lymph node involvement but this was statistically not significant. Five year survival in Cohort A was 95.7% compared to 82.8% in Cohort B (p<0.001). After controlling for age, race, stage, grade and histology, multivariate analysis revealed the presence of lymph node involvement as an independent predictor of poor survival with a hazards ratio of 2.87 (95% CI 1.439-5.725; p<0.05). CONCLUSIONS: Prevalence of lymph node metastasis varies according to histology in OGCT and is an independent predictor of poor survival in these patients. These findings highlight the value of lymphadenectomy and may be helpful in creating risk stratification models for individualization of adjuvant therapies.

The effects of combining docetaxel and cyclooxygenase-2 inhibitors on proliferation and apoptosis in epithelial ovarian cancer.

In-vitro studies have shown that taxanes can upregulate cellular cyclooxygenase-2 expression. The purpose of this study is to evaluate the effects of the combination, cyclooxygenase-2 inhibitor and docetaxel, on epithelial ovarian cancer cells. Four epithelial ovarian cancer cell lines (MDAH-2774, SKOV3, OVCAR and CaOV-3) were treated with the specific cyclooxygenase-2 inhibitor NS398 (10 or 100 mumol/l) and docetaxel (0.1, 1 or 10 mumol/l) in various combinations. Apoptosis in the ovarian cancer cells was assessed using TUNEL assay. Multiplex reverse transcription-PCR was used to determine mRNA levels of cyclooxygenase-2, bcl-2 and bax. Treatment of all epithelial ovarian cancer cells with docetaxel resulted in significant apoptotic death. Concurrent treatment of MDAH-2774, SKOV3 and OVCAR cells with docetaxel and NS398 resulted in the reduction of the taxane-induced apoptosis. Similar reduction was seen when the cells were exposed to NS398 for 4 h before docetaxel treatment. Conversely, treating the MDAH-2774 and SKOV3 cells with docetaxel followed by NS398 resulted in a significant increase in apoptosis compared with treatment with the taxane alone. bax mRNA levels were significantly reduced in SKOV3 cells treated concurrently with NS398 and docetaxel; bcl-2 mRNA levels showed no change. When combining docetaxel and a cyclooxygenase-2 inhibitor in the treatment of ovarian cancer cells, the sequencing of the drugs seems to have an important influence on the overall outcome. Using the cyclooxygenase-2 inhibitor before or concurrently with the taxane will result in a reduction of cellular apoptotic death. This might be due to a reduction in the expression of the proapototic gene bax.

The effects of the inhibition of inducible nitric oxide synthase on angiogenesis of epithelial ovarian cancer.

OBJECTIVE: The release of nitric oxide by tumor cells, through the stimulation of inducible nitric oxide synthase expression, may play a critical role in ovarian cancer progression. In this study we have sought to determine the effects of inhibiting inducible nitric oxide synthase on angiogenesis that was induced by 2 ovarian cancer cell lines, SKOV and MDAH2774. STUDY DESIGN: Real-time polymerase chain reaction and enzyme-linked immunosorbent assay techniques were used to determine the expression levels of inducible nitric oxide synthase and vascular endothelial growth factor in the ovarian cancer cell lines in response to treatments with L-NAME, an inhibitor of nitric oxide synthase, and SNAP, and nitric oxide donor. Ovarian cancer-induced angiogenesis was assessed in vitro with an established assay that is based on the ability of human umbilical vein endothelial cells to form a tubular network in response to angiogenic agents. RESULTS: SKOV and MDAH2774 cell lines exhibited over-expression of inducible nitric oxide synthase and have high baseline nitric oxide levels. This was associated with high levels of vascular endothelial growth factor production and angiogenesis induction. Treatment of the ovarian cancer cell lines with L-NAME significantly reduced vascular endothelial growth factor levels production and completely inhibited angiogenesis. In contrast, treatment with SNAP significantly increased vascular endothelial growth factor levels and increased angiogenesis in both cell lines. CONCLUSION: Our data suggest that the inhibition of inducible nitric oxide synthase may form a basis for a novel therapeutic treatment option for ovarian cancer therapy.

A population-based study of racial and ethnic differences in survival among women with invasive cervical cancer: analysis of Surveillance, Epidemiology, and End Results data.

OBJECTIVE: The incidence of cervical cancer is higher in Hispanic than in non-Hispanic or African American women in the United States, but few studies have examined differences in survival between these groups. The objective of this study was to examine racial/ethnic differences in survival after diagnosis with invasive cervical cancer in a population-based sample of patients while adjusting for patient and tumor characteristics and treatment types. METHODS: We identified 7267 women (4431 non-Hispanic Caucasians, 1830 Hispanic Caucasians, and 1006 non-Hispanic African Americans) diagnosed with primary invasive cervical cancer from 1992 to 1996 (with follow-up through 2000) from the Surveillance, Epidemiology and End Results (SEER) Program. Kaplan-Meier and Cox proportional hazards survival methods were used to assess differences in survival by race/ethnicity. RESULTS: After adjusting for age at diagnosis, histology, stage, first course of cancer-directed treatment (surgery and radiation therapy), and SEER registry, Hispanic Caucasian women were at 26% decreased risk of death from any cause (hazard ratio (HR) = 0.74, 95% confidence interval (CI): 0.66-0.83) and non-Hispanic African American women were at 19% increased risk of death (HR = 1.19, 95% CI: 1.06-1.33) compared to non-Hispanic Caucasian women over the follow-up period. CONCLUSION: Analysis of population-based SEER data indicates significant survival differences by race/ethnicity for women with invasive cervical cancer. Hispanic Caucasian women in SEER had improved survival compared to non-Hispanic Caucasian or non-Hispanic African American women.

Expression of cyclooxygenase-2 in advanced stage ovarian serous carcinoma: correlation with tumor cell proliferation, apoptosis, angiogenesis, and survival.

OBJECTIVE: Cyclo-oxygenase-2 seems to be involved at various steps in the processes of tumor progression. The objective of this study was to examine the relationship between cyclo-oxygenase-2 expression and tumor proliferation, apoptosis and angiogenesis in patients with advanced stage high-grade ovarian carcinoma. STUDY DESIGN: Specimens from 118 patients with high-grade and advanced stage (III, IV) serous ovarian carcinoma were evaluated by immunohistochemistry for cyclo-oxygenase-2, Ki-67, vascular endothelial growth factor, and bcl-2 expression. Tumor microvessel density was assessed with CD34 immunostaining. We investigated the relationships between cyclo-oxygenase-2 expression and clinicopathologic characteristics, tumor angiogenesis (tumor microvessel density and vascular endothelial growth factor expression), and tumor proliferation and apoptosis. The effect of cyclooxygenase-2 expression on patient survival was determined. RESULTS: There was a significant positive correlation between cyclo-oxygenase-2 expression in tumor cells and markers of tumor proliferation and angiogenesis. In univariate survival analysis, high cyclo-oxygenase-2 and high Ki-67 expression showed a significant impact of on patient survival (P < .001). In multivariate regression analysis, only Ki-67 expression retained its significance as an independent poor prognostic factor (death hazard ratio, 2.0; 95% CI, 1.2-3.3; P < .001). CONCLUSION: Expression of cyclo-oxygenase-2 correlates with tumor proliferation and tumor angiogenesis but not with apoptotic markers (bcl-2 expression) in high-grade, advanced-stage serous ovarian carcinoma.

Expression of Cox-2, CD34, Bcl-2, and p53 and survival in patients with primary peritoneal serous carcinoma and primary ovarian serous carcinoma.

The objective of this study was to compare the immunohistochemical profile and clinical course of primary peritoneal serous carcinoma (PPC) and primary ovarian serous carcinoma (OSC). These entities are virtually indistinguishable morphologically, but their differential molecular and clinical features are incompletely characterized. Twenty-nine cases of high-grade, high-stage PPC and 96 cases of stage matched OSCs were compared. PPC was identified based on the criteria proposed by the Gynecologic Oncology Group. The tumors were staged according to International Federation of Gynecology and Obstetrics criteria for ovarian cancer and graded according to World Health Organization criteria. Expression of Cox-2, CD-34, bcl-2, and p53 was compared in the two tumors and correlated with clinical data including stage, age, race, and overall survival. Although the median survival, using Kaplan-Meier test, of patients with OSC (1060 days, 35.3 months) was longer than those with PPC (708 days, 23.6 months) the difference was not statistically significant. However, Cox-2 expression was correlated with microvessel density in PPC (p=0.026) and OSC cases (p=0.005), and high expression of Cox-2 correlated with lower survival rate in OSC cases (p=0.045) but not in PPC cases (p=0.12). These findings, coupled with the morphologic overlap existing between OSC and PPC, support the view that they represent related pathologic entities.

Survival of women diagnosed with malignant, mixed mullerian tumors of the ovary (OMMMT).

OBJECTIVE: To analyze the survival of women with malignant, mixed mullerian tumors of the ovary (OMMMT) compared to women with epithelial ovarian cancer (EOC). METHODS: Data from the Surveillance, Epidemiology and End Results (SEER) Program on 14025 women diagnosed with primary invasive ovarian cancer between 1988 and 1997 were used for this analysis (382 had OMMMT). Differences in distribution of prognostic variables by histological type were compared using a chi-square test. Multivariable survival models were fit using Cox proportional hazards regression analysis to compare risk of death for OMMMT compared to EOC. Analyses were also performed using cases with OMMMT compared to high-grade EOC only. RESULTS: Women with OMMMT were older at diagnosis and were more likely to have primary surgery compared to women with EOC. The majority of women in either histological group had advanced-stage disease at diagnosis. Women with OMMMT had a significant increased risk of death from any cause whether being compared to all women with EOC (HR = 1.69, 95% CI = 1.50,1.90) or to women with high-grade EOC only (HR = 1.58, 95% CI = 1.40,1.79). Women with advanced-stage OMMMT were at a 60% increased risk of death compared to women with advanced-stage, high-grade EOC, after adjustment for other variables of interest (adjusted HR = 1.60, 95% CI = 1.40,1.84). There was no difference in risk of death for these two groups of women with early-stage disease. CONCLUSION: OMMMT is a rare malignancy compared to EOC and had a significantly worse prognosis compared to EOC.