Joshua P. Kesterson

The use of bevacizumab in refractory ovarian granulosa-cell carcinoma with symptomatic relief of ascites: a case report.

BACKGROUNDnThe potential role of bevacizumab in the treatment of ovarian granulosa-cell tumors has not been evaluated.nnnCASEnAn 82 year old woman with refractory ovarian granulosa-cell carcinoma was treated with bevacizumab with symptomatic relief of ascites.nnnCONCLUSIONnBevacizumab may have a role in the management of malignant ascites in the patient with refractory granulosa-cell carcinoma of the ovary which should be confirmed in a larger series of well selected patients.

Gene Expression Profiles in Stage I Uterine Serous Carcinoma in Comparison to Grade 3 and Grade 1 Stage I Endometrioid Adenocarcinoma

Background Endometrial cancer is the most common gynecologic malignancy in the developed countries. Clinical studies have shown that early stage uterine serous carcinoma (USC) has outcomes similar to early stage high grade endometrioid adenocarcinoma (EAC-G3) than to early stage low grade endometrioid adenocarcinoma (EAC-G1). However, little is known about the origin of these different clinical outcomes. This study applied the whole genome expression profiling to explore the expression difference of stage I USC (nu200a=u200a11) relative to stage I EAC-G3 (nu200a=u200a11) and stage I EAC-G1 (nu200a=u200a11), respectively. Methodology/Principal Finding We found that the expression difference between USC and EAC-G3, as measured by the number of differentially expressed genes (DEGs), is consistently less than that found between USC and EAC-G1. Pathway enrichment analyses suggested that DEGs specific to USC vs. EAC-G3 are enriched for genes involved in signaling transduction, while DEGs specific to USC vs. EAC-G1 are enriched for genes involved in cell cycle. Gene expression differences for selected DEGs are confirmed by quantitative RT-PCR with a high validation rate. Conclusion This data, although preliminary, indicates that stage I USC is genetically similar to stage I EAC-G3 compared to stage I EAC-G1. DEGs identified from this study might provide an insight in to the potential mechanisms that influence the clinical outcome differences between endometrial cancer subtypes. They might also have potential prognostic and therapeutic impacts on patients diagnosed with uterine cancer.

High Cumulative Doses of Pegylated Liposomal Doxorubicin Are Not Associated with Cardiac Toxicity in Patients with Gynecologic Malignancies

Purpose: The purpose of this study was to determine the cardiac safety of pegylated liposomal doxorubicin (PLD) in patients receiving high cumulative doses of PLD. Materials and Methods: A retrospective chart review of women with gynecologic malignancies treated at Roswell Park Cancer Institute from 2002 through 2007 who received cumulative doses of PLD ≧400 mg/m2 was performed. Results: Forty-two of 116 patients met the inclusion criteria. The mean age at initiation of PLD therapy was 63 years. The mean cumulative dose of PLD was 663.9 mg/m2 (range 400–1,524 mg/m2). The mean cumulative number of cycles of PLD given was 9.8 (range 5–25). Multigated acquisition (MUGA) scans were obtained in 93% (39/42) of patients prior to or immediately following their first dose of PLD. The mean baseline ejection fraction was 63% (range 49–76%). Follow-up MUGA scans were performed on 7 patients (17%). Two of these patients had a decrease in their ejection fraction, but of only 3 and 1%. The remaining 5 patients who had follow-up MUGA scans had an average increase in their left ventricular ejection fraction of 4% (range 1–9%). No patients developed clinical evidence of congestive heart failure while being treated with PLD. There were no treatment interruptions or discontinuations due to cardiac toxicity. Conclusion: Cumulative doses of PLD ≧400 mg/m2 are not associated with clinically evident cardiac toxicity in gynecologic oncology patients.

Microarray Analysis Reveals Distinct Gene Expression Profiles Among Different Tumor Histology, Stage and Disease Outcomes in Endometrial Adenocarcinoma

Background Endometrial cancer is the most common gynecologic malignancy in developed countries and little is known about the underlying mechanism of stage and disease outcomes. The goal of this study was to identify differentially expressed genes (DEG) between late vs. early stage endometrioid adenocarcinoma (EAC) and uterine serous carcinoma (USC), as well as between disease outcomes in each of the two histological subtypes. Methodology/Principal Finding Gene expression profiles of 20 cancer samples were analyzed (EACu200a=u200a10, USCu200a=u200a10) using the human genome wide illumina bead microarrays. There was little overlap in the DEG sets between late vs. early stages in EAC and USC, and there was an insignificant overlap in DEG sets between good and poor prognosis in EAC and USC. Remarkably, there was no overlap between the stage-derived DEGs and the prognosis-derived DEGs for each of the two histological subtypes. Further functional annotation of differentially expressed genes showed that the composition of enriched function terms were different among different DEG sets. Gene expression differences for selected genes of various stages and outcomes were confirmed by qRT-PCR with a high validation rate. Conclusion This data, although preliminary, suggests that there might be involvement of distinct groups of genes in tumor progression (late vs. early stage) in each of the EAC and USC. It also suggests that these genes are different from those involved in tumor outcome (good vs. poor prognosis). These involved genes, once clinically verified, may be important for predicting tumor progression and tumor outcome.

Tumor lysis syndrome associated with carboplatin and paclitaxel in a woman with recurrent endometrial cancer.

⁎ Corresponding author. Division of Gynecologic Oncology, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263, USA. Tel.: +1 716 845 5776; fax: +1 716 845 7608. E-mail address: Shashi.Lele@roswellpark.org (S. Lele). Tumor lysis syndrome (TLS) consists of a constellation of metabolic derangements including hyperuricemia, hyperkalemia, hyperphosphatemia, uremia, and hypocalcemia, usually triggered by cytotoxic chemotherapy. It results from the lysis of malignant cells with a resultant immense and rapid release of cellular contents from lysed neoplastic cells. TLS is rare in solid tumors [1]. Here we describe a patient who developed TLS after carboplatin and paclitaxel for recurrent endometrial cancer. A 60-year-old woman with a history of FIGO stage IIB uterine cancer receiving carboplatin and paclitaxel for recurrent endometrial cancer presented to the emergency room with shortness of breath. The patient had received carboplatin and paclitaxel 4 days previously. She admitted to a several day history of shortness of breath, weakness, and fatigue. Upon arrival she was hypotensive and tachycardic. Physical examination showed that the woman was in discomfort with decreased breath sounds at the lung bases and a diffusely tender abdomen. Laboratory evaluation revealed several abnormalities (Table 1). A CT scan showed bilateral atelectasis with consolidation at the lung bases and multiple mesenteric and peritoneal implants. The patient was given empiric antibiotics and intravenous hydration for suspected septicemia. Repeat lab values revealed worsening metabolic abnormalities consistent with TLS (Table 1). Despite aggressive interventions including dialysis and attempted correction of her metabolic and electrolyte derangements, her condition deteriorated and she died on hospital day 2. TLS is exceedingly rare in solid malignancies. In a review by Baeksgaard and Sørensen [1], they noted only 45 cases of TLS had been reported in patients with solid tumors. We are aware of only 5 reported cases occurring in gynecologic malignancies [1–3]. TLS results from the lysis of tumor cells with the release of their intracellular contents into the bloodstream. This leads to metabolic derangements including hyperuricemia, hyperphosphatemia, hyperkalemia, hypocalcemia, and elevated lactate dehydrogenase (LDH). These electrolyte abnormalities, if uncorrected, can lead to cardiovascular, renal, and neuromuscular compromise. Clinically, patients may present with acute renal failure, nausea, vomiting, diarrhea, anorexia, hematuria, cardiac arrhythmias, seizures, hypotension, and neuromuscular symptoms, including muscle cramps and paresthesia [4]. Our patient presented with shortness of breath, fatigue, and malaise. Laboratory evaluation revealed profound electrolyte disturbances. She required hemodialysis secondary to renal failure and metabolic derangements. Unfortunately, this patients condition deteriorated rapidly and she died 2 days after presentation and aggressive management. The mortality rate of TLS associated with solid tumors is 1 in 3 [1]. The optimal management of TLS is its prevention. Effective prevention involves recognition of those at risk with close monitoring and frequent assessment for electrolyte abnormalities. Patients at risk should receive aggressive hydration and diuresis with administration of an antihyperuricemic agent (e.g. allopurinol, rasburicase) [4]. We report a case of TLS in a patient receiving carboplatin and paclitaxel for recurrent endometrial cancer. Despite the infrequency of its occurrence in the gynecologic oncology setting, clinicians need to be aware of those at risk, its clinical and laboratory presentation, treatment, and prophylaxis because of its potential lethality.

Epithelioid sarcoma of the vulva in a 17-year-old pregnant woman.

Epithelioid sarcoma of the vulva is an extremely rare neoplasm with aggressive behavior and poor outcome. Herein, we report a case of vulvar epithelioid sarcoma presenting in a 17-year-old very early in her pregnancy. The patient presented with an asymptomatic nodule of the right labia majora of 1-year duration. Computerized tomographic scans showed enlarged inguinal lymph nodes and numerous lung nodules. Positron emission tomography was performed and revealed no suspicious lesions for metastatic disease. The patient underwent local excision of her vulvar lesion. On the basis of morphology and extensive immunohistochemistry, the lesion was classified as epithelioid sarcoma. The patient was referred to radiation therapy and upon evaluation, she was found to be in her sixth week of gestation. The patient continued with her pregnancy and underwent a lymph node dissection, which was positive. We review the literature of only the well-documented cases extensively studied by immunohistochemical analysis. We summarize the clinical presentation, clinical impression, treatment modalities, and outcomes of these cases. On account of the rarity of this disease in the vulva, there is no clear consensus on treatment modalities, but it seems that early aggressive surgical resection is the treatment of choice, with the role of adjuvant therapy to be determined.

Clinically aggressive primary solid pseudopapillary tumor of the ovary in a 45-year-old woman

We report the first case of primary solid pseudopapillary tumor of the ovary with aggressive behavior and fatal outcome in a 45-year-old woman. The patient presented with weight loss, decrease of appetite, and abdominal bloating for the last several weeks. Computed tomography scan revealed an ovarian mass, omental caking, complex ascites, and 2 hepatic lesions. The pancreas was unremarkable. Grossly, the ovarian mass showed severe capsular adhesion, and the cut surface was cystic and solid. On histologic examination, the tumor was composed of diffuse solid pseudopapillary and pseudocystic patterns. The neoplastic cells were uniform and round with very dispersed chromatin. The cytoplasm was faintly pink. There was mild atypia, but the mitotic rate was as high as 62 per 50 high-power field, and the Ki-67 was elevated at 20%. The tumor exhibited severe necrosis. Numerous foci of lymphovascular invasion were also seen. The tumor cells were positive for cytokeratin (focal) and for β-catenin (cytoplasmic and nuclear patterns). They were negative for chromogranin, synaptophysin, thyroglobulin, calcitonin, hepatocyte-paraffin 1, epithelial membrane antigen, calretinin, and α-inhibin. Electron microscopic study revealed nests of tumor cells with oval nuclei. The cytoplasm contained numerous pleomorphic mitochondria interspersed among short strands of rough endoplasmic reticulum. The tumor involved the fallopian tube, omentum, cul-de-sac, and abdominal wall. The pelvic washing was also positive for tumor cells. Despite chemotherapy, the patients condition had worsened, and she died of her disease 8 months after the initial diagnosis. We discuss the differential diagnosis of this tumor and the hypothesis of its origin.

Malignant mixed müllerian tumor of primary peritoneal origin

The aim of this study was to describe 2 cases of primary peritoneal malignant mixed müllerian tumor (MMMT). Two patients with primary peritoneal MMMT were examined for their clinical and pathologic features. We describe 2 cases of primary peritoneal MMMT in which the carcinomatous and mesenchymal components were readily identifiable, predominantly involving the peritoneum, with no ovarian involvement. The peritoneum and ovaries, with their common embryologic origin, likely account for the peritoneums ability to undergo a similar malignant transformation, with the resultant genesis of an MMMT of peritoneal origin.

Aldolase mRNA expression in endometrial cancer and the role of clotrimazole in endometrial cancer cell viability and morphology

Sir: Endometrial cancer (EC) is the most common gynecologic malignancy in developed countries. Recently, glycolytic enzymes have gained considerable attention in human cancers where glucose is the primary source of energy, and a high rate of glycolysis, which is the hallmark of cancer cells, provides the tumor with metabolic and survival advantages. Aldolase is an enzyme that is critical for the glycolytic pathway. Furthermore, an increased aldolase expression was found in various tumor types including cervical, endometrial, kidney, lung cancers and most recently in EC. An important regulator of glycolysis, namely clotrimazole (antifungal azole and calmodulin antagonist), was found to manipulate the binding of glycolytic enzymes to the cytoskeleton, which in turn modulates cell function, proliferation and differentiation. Herein, we evaluated cases of EC for aldolase mRNA expression and the effect of clotrimazole on EC cell lines. RNA was extracted from 70 patients with the diagnosis of endometrial adenocarcinoma. The expression of aldolaseC was determined using Taqman. qRTPCR gene expression Assay On Demand Probe ⁄ Primers (Applied Biosystems, Foster City, CA), with housekeeping gene GAPDH as an endogenous control. Samples were run, with three replicate assays for each gene in each sample. For each assay, the average GAPDH Ct (Cycle threshold) value in the TaqMan qPCR assay was subtracted from the Ct aldolaseC to obtain a DCt value (aldolaseC – GAPDH). Endometrial cancer cell lines including HEC1 and RL95 and colon cancer cell line (CT-26) (chosen as a control) were purchased from the American Tissue Culture Collection (ATCC, Manassas, VA) and they were cultivated according to the supplier’s recommendations. The cells were incubated in 5% CO2 at 37C in PBS containing 5 mM glucose in the absence and presence of 50uM clotrimazole (Sigma, St-Louis, Missouri). Clotrimazole was added to the cultures at different time points (1 h, 4 h, 8 h, 12 h, 18 h and 24 h). Untreated and clotrimazole treated cells were done in triplicate and washed one time with PBS and then harvested with trypsin. The cells were counted in a hemocytometer. Cell viability was determined by trypan blue dye exclusion. Transmission electron microscopy was done on the treated ⁄ and non-treated cells as described previously. For each assay, the average GAPDH Ct (Cycle threshold) value in the TaqMan qPCR assay was subtracted from the Ct of Aldolase to obtain a delta Ct value (Aldolase – GAPDH). Linear regression analyses were used to examine the association between the aldolaseC qRT-PCR levels and the patients’ clinicopathologic characteristics. Cox regression analyses were used to examine the relation of aldolaseC expression on survival. All statistical analysis was performed using the computing environment R (http://www.r-project.org/). The clinical and pathology data of the 70 patients with the qRT-PCR measurement are summarized in Table 1. High aldolaseC mRNA levels were positively associated with high nuclear and FIGO grades (P = 0.0566 each). Aldolase mRNA levels were not associated with tumor subtypes (P = 0.1057). We found that aldolaseC overexpression showed a potential predictive value for shorter overall survival. However, statistical significance threshold was not reached (P = 0.285), probably due to the relatively small sample size (70 in total). We found no evidence that aldolaseC mRNA levels to be associated with other patient outcomes such as recurrence. HEC1 and CT26 were successfully treated with clotrimazole resulting in detachment of cancer cells from the culture plates. Tryptan blue dye showed that clotrimazole induced time-dependent reduction in cell viability in CT26 cell line and HEC1 cell lines (Figure 1). Treatment of cells with clotrimazole affected the morphology of the cells as seen with examination by TEM. These same cells at the 4 h time point showed a greatly enlarged and highly vacuolated subcellular compartment and enlarged and swollen mitochondria with loss of cristae (Figure 2C–D). At the 24 h time point, cell death has occurred, which was evidenced by loss of integrity of the plasma membrane which resulted in cell rupture (Figure 2E,F). Our work showed that aldolaseC was overexpressed in a subset of human samples and in endometrial cancer cell lines. The overexpression of aldolaseC by tumor cells is an indication that human endometrial cancer, like other tumor types, depends on glycolysis for its energy supply to ensure its survival. Binding glycolytic enzymes to the cytoskeleton provides local ATP and it also affects cell structure which has led to the hypothesis that inhibition of glycolysis may severely abolish ATP generation in cancer cells leading to their death. Clotrimazole is an antifungal azole derivate that has been recognized as a calmodulin antagonist which induces inhibition of cell proliferation. Recent studies on melanoma, lung, and colon cancer cell lines showed that clotrimazole induces a significant dose-and time dependent reduction in aldolase levels, ATP and cell viability. Our Correspondence 1015

Prognostic factors in stages II/III/IV and stages III/IV endometrioid and serous adenocarcinoma of the endometrium

AIMSnTo explore and to compare the outcome of patients diagnosed with stage II/III/IV and stage III/IV endometrioid adenocarcinoma (EAC) with their serous carcinoma (USC) counterparts.nnnMATERIALS AND METHODSnA total of 107 patients (73 EAC and 34 USC) were evaluated. For statistical analysis, the following baseline variables were considered for their prognostic value: the patients age at presentation, the tumor size, the depth of myometrial invasion (MI), the lympho-vascular involvement (LVI) and the USC and the EAC subtypes (considered as binary variables). Disease free survival (DFS), death of disease (DOD) and overall survival (OS) were assessed using univariate and multiple Cox proportional hazards models.nnnRESULTSnIn univariate analysis, USC tends to recur more frequently than EAC (p = 0.004), a finding that disappeared in multivariate analysis. Furthermore, tumor histology had no significance in predicting the tumor outcomes. Among all of the prognostic factors and after adjusting for the aforementioned variables, MI ≥50% was the only independent factor in predicting DOD in stages II/III/IV (p = 0.009) and in stages III/IV (p = 0.004). MI was also an independent predictive factor for OS (p = 0.02) and early recurrences in stages III/IV. LVI was the only independent factor in predicting recurrences (p = 0.004) in stages II/III/IV but not in stages III/IV.nnnCONCLUSIONnBased on our study, tumor histology was not a significant factor in predicting disease outcome in stages II/III/IV and II/IV. Despite our limited sample size, we believe that our findings provide meaningful insights into the clinical study of endometrial cancer patients which in turn warrants further investigation.