David E. Cohn

Profiling Microdissected Epithelium and Stroma to Model Genomic Signatures for Cervical Carcinogenesis Accommodating for Covariates

This study is the first comprehensive, integrated approach to examine grade-specific changes in gene expression along the entire neoplastic spectrum of cervical intraepithelial neoplasia (CIN) in the process of cervical carcinogenesis. This was accomplished by identifying gene expression signatures of disease progression using cDNA microarrays to analyze RNA from laser-captured microdissected epithelium and underlying stroma from normal cervix, graded CINs, cancer, and patient-matched normal cervical tissues. A separate set of samples were subsequently validated using a linear mixed model that is ideal to control for interpatient gene expression profile variation, such as age and race. These validated genes were ultimately used to propose a genomically based model of the early events in cervical neoplastic transformation. In this model, the CIN 1 transition coincides with a proproliferative/immunosuppression gene signature in the epithelium that probably represents the epithelial response to human papillomavirus infection. The CIN 2 transition coincides with a proangiogenic signature, suggesting a cooperative signaling interaction between stroma and tumor cells. Finally, the CIN 3 and squamous cell carcinoma antigen transition coincide with a proinvasive gene signature that may be a response to epithelial tumor cell overcrowding. This work strongly suggests that premalignant cells experience a series of microenvironmental stresses at the epithelium/stroma cell interface that must be overcome to progress into a transformed phenotype and identifies the order of these events in vivo and their association with specific CIN transitions.

Meigs’ syndrome with an elevated CA 125 from benign Brenner tumors

BACKGROUND Meigs syndrome refers to solid, benign ovarian tumors, ascites, hydrothorax, and resolution of these signs after surgery. Meigs syndrome with an elevated CA 125 secondary to benign Brenner tumors is exceedingly rare. CASE A postmenopausal woman presented with a large pelvic mass, ascites, and a right pleural effusion. Serum CA 125 was 759 IU/mL. Ascitic fluid, pleural fluid, and fine needle aspiration of the mass were without evidence of malignancy. Exploratory laparotomy with total abdominal hysterectomy and bilateral salpingo-oophorectomy revealed benign Brenner tumors. Immunohistochemical staining for CA 125 showed immunoreactivity in the omentum only. Postoperatively, her signs and symptoms resolved completely and did not recur. CONCLUSION Cytologic or histologic confirmation of malignancy is imperative in patients with a pelvic mass, ascites, hydrothorax, and elevated CA 125 before initiating chemotherapy.

Genotypic and phenotypic progression in endometrial tumorigenesis: determining when defects in DNA mismatch repair and KRAS2 occur.

We set out to determine the relative timing of loss of DNA mismatch repair and KRAS2 mutation in endometrial tumorigenesis. We studied endometrial carcinoma (CA) and synchronous atypical endometrial hyperplasia (AEH), the premalignant precursor of endometrial cancer. Carcinoma and hyperplasia were investigated for loss of mismatch repair as evidenced by microsatellite instability (MSI) and for KRAS2 mutations. Endometrial cancers previously shown to be MSI‐positive were evaluated for KRAS2 codon 12 and 13 mutations. DNA was isolated from foci of AEH concomitant with, but physically remote from, the cancers by use of tissues prepared by laser capture microdissection (LCM). The AEH DNAs were then assessed for MSI and KRAS2 mutations. Of 210 endometrial CAs investigated, 51 (26%) were MSI‐positive, and among those, 21 (41%) arose concomitantly with AEH. Of 41 foci of AEH (mean, two foci per patient) investigated, 34 (83%) were MSI‐positive. KRAS2 mutations were seen in 5/51 (10%) MSI‐positive carcinomas. From the five patients informative for both KRAS2 mutation and MSI, 10 foci of AEH were available for investigation. All 10 AEH specimens (100%) were MSI‐positive, and six (60%) had the KRAS2 mutation present in the coexisting CA. The observation that some MSI‐positive AEH specimens lack the KRAS2 mutation seen in the coexisting CA supports a model in which loss of DNA mismatch repair precedes KRAS2 mutation. However, in addition to the absence of KRAS2 mutations in AEH, we discovered mutations in LCM hyperplasia and carcinoma specimens that were not present in the portion of the cancers originally investigated. These discordant genotypes suggest genetic heterogeneity in endometrial hyperplasia and concomitant cancer.

Radical hysterectomy for cervical cancer in obese women.

Objective To estimate the morbidity, adequacy of surgery, and survival of obese women undergoing radical hysterectomy and pelvic lymphadenectomy. Methods Patients with stage I and IIa cervical cancer and a body mass index (BMI) over 30 kg/m2 and absolute weight greater than 85 kg explored with the intent for radical hysterectomy between 1986 and 1998 were identified. Patient characteristics, surgical, pathologic, and follow-up data were extracted and survival curves were generated. Results Forty-eight obese women were identified who were explored for radical hysterectomy and pelvic lymph node dissection. The median BMI was 36 kg/m2, and the median weight was 95 kg. Thirty-five patients (73%) had stage Ib1 disease. Despite the obesity of the study group, none had severe comorbidity. The procedure was completed in 46 patients, and abandoned in two because of metastatic disease. For patients undergoing radical hysterectomy and pelvic lymph node dissection, median blood loss was 800 mL. No patient developed fistulas. Residual tumor was present in 26 (57%) hysterectomy specimens, and margins were without disease in 45 specimens (98%). A median of 26 pelvic lymph nodes were obtained per procedure, and six patients (13%) had positive nodes. Five-year overall and disease-free survival are 84% (95% confidence interval [CI] 70.9, 97.5) and 80% (95% CI 65.2, 93.8), respectively, at a median follow-up of 36 months. Conclusion In this carefully selected obese group, we demonstrate that radical hysterectomy and pelvic lymph node dissection can be performed with adequate surgical resection, acceptable morbidity, and excellent survival.

No evidence for BCL10 mutation in endometrial cancers with microsatellite instability.

Previous reports have suggested that the mononucleotide repeats in BCL10 frequently are mutated in both hematologic malignancies and solid tumors. We set out to determine whether these repeats, like simple repeat sequences in other genes, are a target for mutation in endometrial cancers with defective DNA mismatch repair. Primary endometrial cancers (n = 42) and endometrial cancer cell lines (n=5) with microsatellite instability (MSI) were investigated. BCL10 exons 2 and 3 were amplified by PCR and evaluated for mutation using denaturing high‐performance liquid chromatography (DHPLC) and single stand conformational variant (SSCV) analysis. Variants were directly sequenced. No BCL10 mutations were detected in exons 2 or 3 by DHPLC or SSCV. A polymorphism in exon 3 (638G→A) was seen in 4/42 (9.5%) MSI‐positive endometrial cancers and 0/5 MSI‐positive endometrial cancer cell lines. Thus, mutation in the mononucleotide repeat tracts of BCL10 is not a feature of endometrial cancers with defective DNA mismatch repair. Hum Mutat 17:117–121, 2001.