Alessandro Villanucci

UTERINE SARCOMA: TWENTY-SEVEN YEARS OF EXPERIENCE

PURPOSE A correlation of treatment for uterine sarcoma with outcome, prognostic importance of pathology, and clinical parameters. PATIENTS AND METHODS One hundred forty-one patients (median age: 56 years, range: 19-85 years) with a histologically verified uterine sarcoma were identified from a database compiled at the Royal Marsden Hospital and the University of Florence between 1974 and 2001. Seventy-two patients had leiomyosarcoma, 42 had mixed müllerian tumors, 22 had endometrial stromal sarcoma, 1 hemangiopericytoma, 1 rhabdomyosarcoma, and 3 patients had unspecified sarcoma. According to FIGO classification, Stage I, II, III, and IV tumors were identified in 71, 13, 31, and 26 patients, respectively. RESULTS At the time of analysis, 73.7% of patients were dead, and 26.3% were alive with a median survival of 2 years from initial diagnosis. Univariate analysis for cause-specific survival demonstrated statistical significance for histology (p = 0.02), grade (p = 0.003), stage (p = 0.007), and age (p = 0.02). Multivariate analysis demonstrated significant prognostic values for stage (p = 0.02) and histology (p = 0.05) only. Postoperative radiotherapy with a total dose higher than 50 Gy seems to be significant (p = 0.001) in reducing local recurrence. CONCLUSIONS Our data favor treatment for Stages I, II, and III of uterine sarcoma with radical surgery plus radical dose irradiation comprising both external beam radiotherapy and brachytherapy.

c-Kit Expression in Patients with Uterine Leiomyosarcomas: A Potential Alternative Therapeutic Treatment

Purpose: Uterine leiomyosarcomas are rare tumors characterized by their resistance to chemotherapy and radiation treatment. Surgery is the primary method of treatment, but for patients with unresectable disease, alternate therapeutic options are clearly warranted. According to initial observations of c-KIT expression, correlation with a bad prognosis, and the successful therapeutic possibility of STI571 in gastrointestinal stromal tumors, the data have encouraged us to study c-KIT expression in these tumors. Experimental Design: We analyzed the expression of c-KIT and genetic assessment of exon 11 of c-kit gene in 32 uterine leiomyosarcomas. Results: In 17 cases (53.1%), we observed a c-KIT expression in tumor cells. Of the 17 patients with distinct c-KIT-positive immunoreactivity, eight had I or II stage disease and nine had III or IV stage disease. Molecular genetic analysis of exon 11, analyzed by direct DNA sequencing, was performed for all of the c-KIT-positive uterine leiomyosarcomas. No mutations were found. Conclusion: The conventional chemotherapy in leiomyosarcomas appears to be ineffective for patients with metastatic or unresectable disease, and the management of these patients poses a special problem. In these women, new therapeutic strategies are warranted. The treatment with STI571 in leiomyosarcoma patients might be hypothesized, because uterine leiomyosarcomas also express c-KIT.

Utility of CDX-2 in distinguishing between primary and secondary (intestinal) mucinous ovarian carcinoma: an immunohistochemical comparison of 43 cases.

Primary and secondary mucinous tumors can involve the ovaries and have similar histologic appearances. The differential diagnosis is important for surgical and chemotherapeutic treatment and for the prognosis, but often it is extremely difficult. This article discusses an immunohistochemical panel that includes carcinoembryonic antigen (CEA), cytokeratin (CK) 7, CK20, CA125, CA19.9, and a new marker, CDX-2, for the distinction between primary ovarian mucinous carcinomas and metastatic (intestinal) ovarian tumors. Forty-three cases representing primary and secondary ovarian tumors were considered and consisted of 14 primary mucinous ovarian carcinomas (PMOCs) and 29 secondary (intestinal) ovarian tumors (SI-OTs). Fisher exact test was performed to evaluate the reliability of the respective antibodies to discriminate between PMOCs and SIOTs. CDX-2 was diffusely positive in all SIOTs and was expressed focally in 3 cases (21.42%) of PMOCs. CK7 was diffusely positive in 13 cases (44.82%) of SIOTs and in 13 cases (92.85%) of PMOCs. CK20 was diffusely positive in 17 cases (58.62%) of SIOTs and in 6 cases (42.85%) of PMOCs. CEA was diffusely positive in 28 cases (96.55%) of SIOTs and in 12 cases (85.71%) of PMOCs. CA19.9 was positive in all SIOTs and in 12 cases (85.71%) of PMOCs. CA125 was positive in 3 cases (10.34%) of SIOTs and in 4 cases (28.57%) of PMOCs. CK7 and especially CDX-2, a specific and sensitive marker, can aid pathologists in making a differential diagnosis (P = 0.003 and P < 0.0005, respectively), whereas CEA, CK20, CA125, and CA19.9 markers are not high enough to distinguish between primary and secondary mucinous ovarian tumors.

Correlation of Epidermal Growth Factor Receptor Expression with Tumor Microdensity Vessels and with Vascular Endothelial Growth Factor Expression in Ovarian Carcinoma

We analyzed in advanced ovarian serous G3 carcinoma the correlation between epidermal growth factor receptor (EGFR) overexpression and tumor angiogenesis and their relation with clinical outcome. Microvessel density (MVD) and vascular endothelial growth factor (VEGF) were statistically correlated with disease-free interval and death from disease both in univariate and multivariate analyses while EGFR expression was not correlated with clinical outcome. MVD was significantly associated with progression of disease during chemotherapy while VEGF and EGFR expression were not correlated with responsiveness to chemotherapy (Fisher’s exact test). VEGF expression was correlated with MVD (Fisher’s exact test). EGFR showed a trend to correlation with MVD. Further studies focusing on the use of angiogenesis inhibitors in addition to EGFR inhibitors on ovarian carcinoma cells may produce therapeutic strategies in the selection of tailored therapies in ovarian cancer patients.

HER-2/neu and bcl-2 in ovarian carcinoma: clinicopathologic, immunohistochemical, and molecular study in patients with shorter and longer survival.

The bcl-2 protein is a membrane protein involved in prolonging cell survival by inhibiting apoptosis. The HER-2 oncogene, which is located on chromosome 17 and encodes for a tyrosine-kinase growth factor receptor, is amplified and HER-2/neu is overexpressed in 25% to 30% of breast carcinomas. The authors analyzed the bcl-2 expression and the bcl-2 gene and HER-2/neu overexpression and amplification in FIGO stage IIIC, serous, G3, ovarian carcinomas obtained from living patients who had no evident disease 5 years after primary treatment compared with ovarian carcinomas obtained from patients, matched for stage, grade of differentiation, and treatment, who had died of progression of disease no later than 2 years after primary treatment. bcl-2 overexpression was statistically correlated with progression of disease during first-line chemotherapy (P=0.021). The HER-2/neu status was found not to correlate with progression of disease during first-line chemotherapy. Both bcl-2 and HER-2/neu expression were not statistically associated with the clinical outcome of ovarian cancer patients. Gene amplification of the HER-2/neu chromosome 17 was found in all the HER-2/neu, 3+ score, positive-staining ovarian carcinomas. None of the analyzed samples revealed a translocation t(14;18)(q32;q21) in the bcl-2 gene. The knowledge of additional prognostic or even predictive factors, such as bcl-2 expression, in patients with advanced ovarian carcinoma before the primary chemotherapeutic treatment may help in the management of patients who require a more tailored treatment. In addition, the gene amplification of the HER-2/neu suggests that HER-2 is a potential target for treatment in ovarian cancer.

COX‐2 and preoperative CA‐125 level are strongly correlated with survival and clinical responsiveness to chemotherapy in ovarian cancer

Background. CA‐125 is elevated in the serum of the majority of ovarian carcinoma patients. Cyclooxygenase‐2 is an enzyme whose synthesis is upgraded by several cytokines, growth factors, and tumor promoters. Methods. We analyzed cyclooxygenase‐2, preoperative CA‐125 levels, and CA‐125 levels during chemotherapy in 41 FIGO stage III, grade 3, ovarian serous carcinoma patients in relation to survival with a logistic regression. The correlation of cyclooxygenase‐2 expression and CA‐125 preoperative level with clinical responsiveness to chemotherapy was studied according to Fishers exact test. We compared 23 patients living with no evident disease five years after primary treatment to 18 patients who had died of progression of disease no later than two years after primary treatment. Results. Cyclooxygenase‐2 overexpression (p=0.014 and p=0.036) and preoperative CA‐125 level (p=0.012 and p=0.029) were found to be independent predictors of survival in univariate and multivariate analyses. Cyclooxygenase‐2 and CA‐125 level were correlated to responsiveness to chemotherapy (p=0.003 and p=0.036, respectively; Fishers exact test). The patients with a CA‐125 level <35 U/ml after two cycles of chemotherapy showed a longer survival (p=0.008). The median preoperative CA‐125 was 195 in high survival patients and 650 in low survival patients (p=0.004, Wilcoxon Mann–Whitney test). Conclusions. Cyclooxygenase‐2 overexpression and CA‐125 levels may help the management of ovarian cancer patients, permitting the selection of more aggressive and tailored first‐line therapy.

Estrogen and Progesterone Receptors Expression in Uterine Malignant Smooth Muscle Tumors: Correlation with Clinical Outcome

Abstract Uterine leiomyosarcomas are associated with a poor prognosis, although a considerable diversity in behavior may be found, and prolonged survival may occur. The aim of this study was to analyze the expression of estrogen (ER) and progesterone (PR) receptors in tumor specimens from uterine leiomyosarcomas, and to test their correlation with disease-free interval and cause-specific survival. This additional information may help the clinician differentiate between patients who have minimal risk of recurrence and those at greater risk of developing progressive disease. We examined specimens from 31 uterine leiomyosarcoma patients with clinical history and known follow-up. Disease-free interval and cause-specific survival rates were calculated according to the Kaplan-Meier method. According to univariate analysis, with Cox proportional hazards models, the ER expression (P=0.006 and P=0.016, respectively), PR expression (P=0.005 and P=0.016, respectively), and FIGO stage disease (P=0.011 and P=0.007, respectively) were independent predictors of the risk of recurrence and death from disease.

C-kit Expression in Uterine Leiomyosarcomas: An Immunocytochemical Study of 29 Cases of Malignant Smooth Muscle Tumors of the Uterus

Abstract Uterine malignant stromal tumors are rare neoplasms characterized by fatal prognosis. At the moment no effective systemic treatment is available for metas-tases or recurrent disease. The drugs employed in advanced neoplasms are ipos-famide, doxorubicin or epidoxorubicin, but the clinical response to chemotherapy is poor. Recent studies have shown that cells in gastrointestinal stromal tumors express a growth factor receptor with tyrosine kinase activity termed c-kit. Lately reports of efficacy of a specific anticancer drug with imatinib (STI571) based on specific molecular abnormalities of proto-oncogene C-kit present in gastrointestinal stromal tumors induced us to identify the C-kit phenotype also in uterine leiomyosarcomas. These data may be useful for treating metastatic uterine leiomyosarcomas with increased C-kit kinase activity.

Prognostic value of P-glycoprotein and proliferative index in advanced low grade serous ovarian carcinomas

Abstract The aim of this study was to test the prognostic value of p-glycoprotein expression and the proliferative index of tumor cells on the clinical response to chemotherapy, on the brief disease-free interval (<12 months) and on cause-specific survival in advanced ovarian carcinoma. We evaluated 83 ovarian carcinoma patients homogeneous for stage, type and grade histological. Brief disease-free interval and cause-specific survival rates (Kaplan-Meier method) were compared using the log rank test. Multivariate analysis (Cox proportional hazards models) was used to determine the independent effect of each variable on prognosis. In the uni-variate analysis, P-glycoprotein expression (P<0.0005) and proliferative index (P=0.0003 and P=0.0006) were independent predictors of survival and brief disease-free interval; residual disease was associated with survival (P=0.021). In multivariate analysis (Cox proportional hazards models), P-glycoprotein expression (P=0.001 and P=<0.0005) and proliferative index (P=0.081 and P=0.041) were independent predictors of brief disease-free interval and survival. P-glycoprotein expression (P<0.0005) and proliferative index (P=0.008) were associated with clinical response to chemotherapy.

P16INK4a Overexpression is Associated with Poor Clinical Outcome in Ovarian Carcinoma

Ovarian carcinoma in Europe and the United States is the fifth leading cause of death due to cancer among women. The tumor is usually diagnosed in advanced stages, and the survival rate at 5 years, despite surgical and chemotherapeutic treatment, is low. New therapeutic strategies are urgently needed for ovarian cancer patients. In recent years, studies have focused on gene therapy with adenoviral vector constructed to express protein products of tumor suppressor genes 1. The majority of gene therapy studies on ovarian carcinoma has focused on the p53 tumor suppressor gene 2. Modesitt et al.3 recently found that adenoviral-mediated expression of p16 was significantly more efficient than p53 as a growth inhibitor for the ovarian carcinoma cell l ines tested. Murphy,4 in a commentary on Modesitt’s study, made an interesting observation about the necessity of determining the ability of the p16 adenovirus to synergize with chemotherapeutic drugs and the importance of identifying drugs or therapies whose mechanism of action is not inhibited by p16. We have analyzed the P16INK4a immunohistochemical expression in 22 cases, III FIGO stage, ovarian carcinoma and correlated it with one of the most studied multidrug resistance phenotypes such as the MDR1 expression,5 with protein Rb, and also with the clinical outcome of the ovarian cancer patients. The specimens came from 22 women with Journal of Chemotherapy Vol. 16 n. 4 (411-413) 2004