Guus Fons

Validation of tissue microarray technology in endometrioid cancer of the endometrium

Aim: To validate tissue microarray (TMA) for endometrial cancer by comparing immunohistochemical staining results of triplicate core biopsies on TMA with the results of full-section analysis. Methods: The study material consisted of slides and selected tissue blocks of 41 patients with endometrioid cancer of the endometrium. A TMA was constructed. Both the TMA and the slides were stained with the same antibodies against progesterone receptor (PR), oestrogen receptor, p53 and epithelial membrane antigen (EMA). Concordance between results was expressed as the κ statistic. Results: Concordance between the staining results of TMA and whole slides was good for PR (κ = 0.69), oestrogen receptor (κ = 0.78), p53 (κ = 0.81) and EMA (κ = 0.72). Concordance between the results on TMA and slides depends on the number of assessable cores per tumour. Three assessable cores per case result in outcomes that are at least 94% similar to those achieved using conventional tissue sections with a two-class scoring system. This is independent of focal or diffuse staining patterns. Conclusion: TMA is a useful tool for further analysis of the molecular pathways in endometrial cancer. The effect of selection has to be taken into account when the prognostic value of protein expression on TMA is determined.

Adjuvant radiotherapy in patients with vulvar cancer and one intra capsular lymph node metastasis is not beneficial

AIM OF THE STUDY The aim of the study was to analyze the benefit from adjuvant radiotherapy in patients with vulvar cancer and a single positive node without extra capsular spread. MATERIALS AND METHODS The study population comprised data of 75 patients with vulvar cancer and one lymph node metastasis. The patients were treated in three different university centers in Amsterdam, Groningen and Rotterdam between 1984 and 2005. RESULTS Out of 75 patients, 31 (41%) were treated with adjuvant radiotherapy. Both disease-free survival (DFS) and disease-specific survival (DSS) were comparable between the groups who did and who did not receive adjuvant radiotherapy (HR 0.98, 95% CI 0.45-2.14, p=0.97 and HR=1.02, 95% CI 0.42-2.47, p=0.96). CONCLUSION We could not demonstrate any beneficial effect of adjuvant radiotherapy in the group of patients with one intra capsular metastasis.

Prognostic value of bilateral positive nodes in squamous cell cancer of the vulva.

Objectives: The aim of the current study was, first, to determine whether laterality of lymph node metastases has prognostic significance, independent of the number of lymph node metastases. Second was to determine the prognostic significance of extracapsular spread irrespective of the number of lymph node metastases. Methods: Data on 134 patients with stage III/IVA vulva cancer from 1982 till 2004 and treated with curative intent in either the Academic Medical Centre in Amsterdam or the Mercy Hospital for Women in Melbourne were reviewed. The impact of the number of lymph node metastases, extracapsular spread, and bilateral existence of lymph node metastases on survival was determined. Results: The bilateral presence of lymph node metastases is not a significant predictor for survival if a correction is made for the number of lymph node metastases (hazards ratio, 1.31; 95% confidence interval, 0.68-2.51; P = 0.420). If extracapsular spread is put into the model as well, this is the only parameter of prognostic significance in multivariate analysis (hazards ratio, 5.27; 95% confidence interval, 2.60-10.67; P < 0.001). The five-year survival of patients with extracapsular spread is only 31%, which is considerably lower than the 80% survival of patients with only intracapsular metastases. Conclusions: In conclusion, there is growing evidence that bilateral existence of lymph node metastases is not a sufficient variable to qualify stage. Extracapsular spread, however, seems to be the most valuable lymph node-associated prognostic factor for survival.

Validation of tissue microarray technology in vulvar cancer

The aim of the study was to validate tissue microarray (TMA) for vulvar cancer by comparing immunohistochemical staining results of triplicate core biopsies on TMA with the results of full section analysis. The study material consisted of slides and selected tissue blocks from 40 patients with vulvar cancer. A TMA was constructed with 3 cores/case. Both the TMA and the slides were stained with the same antibodies against COX-2, Caspase-3, epidermal growth factor receptor, p16INK4, Cyclin D1, and Ki67. For COX-2, 2 different scoring systems were applied. Agreement in the readings between TMA and slides was expressed in total agreement and κ. Expression patterns of antibodies can be reproduced on TMA with good reliability (κ 0.68 to 0.75) for Ki-67, p16INK4, COX-2, Cyclin D1, and epidermal growth factor receptor in comparison with whole slides. For Caspase-3 agreement is only slight with a κ of 0.40. The majority of discordant cases for COX-2 and Ki67 were negative on slide and positive on TMA. For epidermal growth factor receptor and Caspase-3 an opposite pattern was found. For COX-2, the use of an alternative scoring system resulted in a decrease of κ from 0.68 to 0.21. Agreement between results on TMA and slides depends on the distribution of the protein in the cancer tissue and on the scoring system used.

Identification of potential prognostic markers for vulvar cancer using immunohistochemical staining of tissue microarrays.

The aim of this study is to determine immunohistochemical markers with prognostic significance for disease-specific survival in patients with squamous cell cancer of the vulva. The study material consisted of slides and paraffin blocks of 50 vulvectomy specimens. A tissue microarray was constructed and stained with 16 antibodies. The impact of lymph node metastases, size of tumor, vascular space involvement, and the marker expression on disease-specific survival was calculated. In univariate analysis lymph node metastases, tumor size more than 4 cm, vascular space involvement, strong cyclooxygenase 2 expression, and absent Caspase 3 expression were significantly associated with disease-specific survival. In a multivariate analysis, poor disease-specific survival is independently associated with absent Caspase 3 expression (hazard ratio, 0.2; 95% confidence interval, 0.04-0.97; P = 0.045). Five-year survival was 86% in patients with tumors positive for Caspase 3 (n = 20) and drops to 64% in patients with Caspase 3-negative tumors (n = 30). In this test set, cyclooxygenase 2 and Caspase 3 seem to be immunohistochemical markers with prognostic significance for vulva cancer. The results have to be validated.

Laparoscopy to Predict the Result of Primary Cytoreductive Surgery in Patients With Advanced Ovarian Cancer: A Randomized Controlled Trial

Purpose To investigate whether initial diagnostic laparoscopy can prevent futile primary cytoreductive surgery (PCS) by identifying patients with advanced-stage ovarian cancer in whom > 1 cm of residual disease will be left after PCS. Patients and Methods This multicenter, randomized controlled trial was undertaken within eight gynecologic cancer centers in the Netherlands. Patients with suspected advanced-stage ovarian cancer who qualified for PCS were eligible. Participating patients were randomly assigned to either laparoscopy or PCS. Laparoscopy was used to guide selection of primary treatment: either primary surgery or neoadjuvant chemotherapy followed by interval surgery. The primary outcome was futile laparotomy, defined as a PCS with residual disease of > 1 cm. Primary analyses were performed according to the intention-to-treat principle. Results Between May 2011 and February 2015, 201 participants were included, of whom 102 were assigned to diagnostic laparoscopy and 99 to primary surgery. In the laparoscopy group, 63 (62%) of 102 patients underwent PCS versus 93 (94%) of 99 patients in the primary surgery group. Futile laparotomy occurred in 10 (10%) of 102 patients in the laparoscopy group versus 39 (39%) of 99 patients in the primary surgery group (relative risk, 0.25; 95% CI, 0.13 to 0.47; P < .001). In the laparoscopy group, three (3%) of 102 patients underwent both primary and interval surgery compared with 28 (28%) of 99 patients in the primary surgery group ( P < .001). Conclusion Diagnostic laparoscopy reduced the number of futile laparotomies in patients with suspected advanced-stage ovarian cancer. In women with a plan for PCS, these data suggest that performance of diagnostic laparoscopy first is reasonable and that if cytoreduction to < 1 cm of residual disease seems feasible, to proceed with PCS.

Assessment of promising protein markers for vulva cancer.

Objectives: To validate the results of a previous study with the tissue microarray technology showing that cyclooxygenase 2 (COX-2) overexpression and absent caspase 3 expression are associated with poor disease-specific survival in univariate analysis. Methods: The study group comprised 80 consecutive patients with vulva cancer treated in the period from 1999 to 2003 in a university hospital. A tissue microarray with 3 tumor tissue cores per patient was constructed and stained with antibodies against COX-2, caspase 3, epidermal growth factor receptor, p16INK4, cyclin D1, and Ki-67. The impact of the expression of these protein markers and selected clinicopathologic variables on disease-specific as well as disease-free survival was measured. Cox proportional hazard model was used for both univariate and multivariate analyses. Results: In multivariate analysis, lymph node metastases and strong COX-2 expression were related to disease-free (hazard ratio [HR], 8.33, 95% confidence interval [CI], 2.97-23.36; P < 0.001; and HR, 6.42; 95% CI, 2.33-17.72; P < 0.001) and disease-specific survival (HR, 6.04; 95% CI, 2.12-17.19; P = 0.001; and HR, 5.11; 95% CI, 1.82-14.36; P = 0.002). In the present series, no association was found between caspase 3 expression and survival. Conclusion: The prognostic significance of COX-2 overexpression was confirmed. In contrast, in the present series, no relation was found between caspase 3 expression and survival.

Regarding "reasons for diagnostic delay in gynecological malignancies".

To the Editor: W read with interest the wellconducted study by Vandborg et al about ‘‘delay in gynecological malignancies.’’ This is an important issue because analyzing the type of delay and the reasons for delay can hopefully help us in defining strategies to prevent long delay and, as a consequence, to diagnose and treat at an earlier stage of the disease. From the study by Vandborg et al, it seems obvious that vulvar cancer has the longest delay, mainly caused by patients’ delay. However, we feel that the methodology as used for this study has some flaws where the authors try to define patients’ delay in vulvar cancer. The definition as used by the authors for patients’ delay was: ‘‘time from recognition of symptom until first consultation with a health professional.’’ The specificity of this definition might be too low for vulvar cancer because most patients with vulvar cancer experience a (very) long history of aspecific symptoms like vulvar itching and pain due to lichen sclerosis of the vulva. At that time, even when the general practitioner examines the patient carefully, there is no obvious vulvar cancer present yet. We are in doubt if strategies to make patients more aware of these symptoms will result in earlier diagnosis of vulvar cancer. We all know many patients that we follow every 6 months for lichen sclerosis of the vulva where no suspicion is found, but 6 months later, the patient presents with an obvious cancer. We are more concerned about the long ‘‘system delay’’ of 56 days. In a series of 14 patients, an average increase of 50% of tumor size was measured during a mean waiting time until operation of 4 weeks. This finding suggests that vulvar cancer is a very fast-growing tumor as soon as it is clinically detectable. In that context, 56 days between primary referral and the date of surgery seems to be too long. We feel that we, as physicians, can more effectively influence the system delay than the patients’ delay.