P.J. Frederick

Efficacy of Levo-1-Methyl Tryptophan and Dextro-1-Methyl Tryptophan in Reversing Indoleamine-2,3-Dioxygenase-Mediated Arrest of T-Cell Proliferation in Human Epithelial Ovarian Cancer

It has been reported that levo-1-methyl tryptophan (L-1MT) can block indoleamine-2,3-dioxygenase (IDO) expressed by human dendritic cells (DC), whereas dextro-1-methyl tryptophan (D-1MT) is inefficient. However, whether L-1MT or D-1MT can efficiently reverse IDO-induced arrest of human T-cell proliferation has not been clarified. Here, we show a marked immunosuppressive effect of IDO derived from INDO-transfected 293 cell, IDO+ ovarian cancer cells, and monocyte-derived DCs on CD4+ Th1 cells, CD8+ T cells, and natural killer cells derived from peripheral blood, ascites, and tumors of ovarian cancer patients. We found that, whereas L-1MT and D/L-1MT can restore proliferation of tumor-derived and peripheral blood T-cell subsets, D-1MT does not effectively restore IDO-induced arrest of T-cell proliferation. Although D-1MT inhibited kynurenine production at high concentrations, L-1MT was more effective in abrogating kynurenine generation and tryptophan depletion, whereas tryptophan was completely depleted by IDO even in the presence of high amounts of D-1MT. Together, the results indicate that, whereas the generation of tryptophan metabolites (kynurenines) by IDO is important in mediating suppression of T-cell proliferation, the degree to which tryptophan depletion is restored by 1MT is also critical in overcoming IDO-induced arrest of T-cell proliferation.

Current and Emerging Clinical Applications of Multispectral Optoacoustic Tomography (MSOT) in Oncology

Accurate detection and characterization of cancers are key for providing timely intervention and effective treatments. Current imaging technologies are particularly limited when it comes to detecting very small tumors in vivo, i.e., very early cancers or metastases, differentiating viable tumor from surrounding dead tumor tissue, and evaluating tumor metabolism within tissue. Optoacoustic imaging offers potential solutions to these imaging problems because of its ability to image optical absorption properties of both intrinsic tissue chromophores and exogenous contrast agents without the involvement of ionizing radiation. Optoacoustic imaging uses pulsed laser to induce localized thermoelastic expansion that generates acoustic waves detectable by an ultrasound transducer. To date, multispectral optoacoustic tomography (MSOT) has primarily been used in preclinical research; however, its use in translational and clinical research is expanding. This review focuses on current and emerging applications of optoacoustic imaging for molecular imaging of cancer using both exogenous and endogenous contrast agents and sheds light on potential future clinical applications. Clin Cancer Res; 22(14); 3432–9. ©2016 AACR.

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 (n = 11) relative to stage I EAC-G3 (n = 11) and stage I EAC-G1 (n = 11), 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.

Assessment of risk factors for 30-day hospital readmission after surgical cytoreduction in epithelial ovarian carcinoma.

Objective: To evaluate factors that place epithelial ovarian cancer (EOC) patients at increased risk for hospital readmission. Methods: A retrospective review of patients diagnosed with EOC undergoing surgical cytoreduction at the University of Alabama at Birmingham from 2001 to 2008 was performed. Patients who required readmission were identified. Demographic data, comorbidities, surgical data including bowel resections, and hospital length of stay were evaluated. Results: A total of 207 patients were identified. The mean age at diagnosis was 64 years (range, 32-89 years), 58% had optimal debulking (n = 120), and the mean number of comorbidities was 1.3 (range, 0-6). Readmission within 30 days of discharge occurred in 33 (16%) of 207 patients. The readmission group had a statistically higher number of comorbidities (1.75 vs 1.01, P = 0.025). The most common reasons for readmission were small bowel obstruction/ileus, wound complications, and thromboembolic events. Conclusions: The most common reason for readmission after cytoreductive surgery for EOC is small bowel obstruction/ileus. Studies assessing postoperative disease management programs including nursing telephone follow-up, administration of outpatient intravenous fluids, and continuation of antithrombotic agents may offer opportunities to reduce readmissions.

Evaluation of the National Surgical Quality Improvement Program Universal Surgical Risk Calculator for a gynecologic oncology service

Objectives The National Surgical Quality Improvement Program is aimed at preventing perioperative complications. An online calculator was recently published, but the primary studies used limited gynecologic surgery data. The purpose of this study was to evaluate the performance of the National Surgical Quality Improvement Program Universal Surgical Risk Calculator (URC) on the patients of a gynecologic oncology service. Study Design We reviewed 628 consecutive surgeries performed by our gynecologic oncology service between July 2012 and June 2013. Demographic data including diagnosis and cancer stage, if applicable, were collected. Charts were reviewed to determine complication rates. Specific complications were as follows: death, pneumonia, cardiac complications, surgical site infection (SSI) or urinary tract infection, renal failure, or venous thromboembolic event. Data were compared with modeled outcomes using Brier scores and receiver operating characteristic curves. Significance was declared based on P < 0.05. Results The model accurately predicated death and venous thromboembolic event, with Brier scores of 0.004 and 0.003, respectively. Predicted risk was 50% greater than experienced for urinary tract infection; the experienced SSI and pneumonia rates were 43% and 36% greater than predicted. For any complication, the Brier score 0.023 indicates poor performance of the model. Conclusions In this study of gynecologic surgeries, we could not verify the predictive value of the URC for cardiac complications, SSI, and pneumonia. One disadvantage of applying a URC to multiple subspecialties is that with some categories, complications are not accurately estimated. Our data demonstrate that some predicted risks reported by the calculator need to be interpreted with reservation.

Uterine Neoplasms, Version 1.2018: Clinical practice guidelines in oncology

Endometrial carcinoma is a malignant epithelial tumor that forms in the inner lining, or endometrium, of the uterus. Endometrial carcinoma is the most common gynecologic malignancy. Approximately two-thirds of endometrial carcinoma cases are diagnosed with disease confined to the uterus. The complete NCCN Guidelines for Uterine Neoplasms provide recommendations for the diagnosis, evaluation, and treatment of endometrial cancer and uterine sarcoma. This manuscript discusses guiding principles for the diagnosis, staging, and treatment of early-stage endometrial carcinoma as well as evidence for these recommendations.

Oxaliplatin is a safe alternative option for patients with recurrent gynecologic cancers after hypersensitivity reaction to Carboplatin.

Objective The aim of this study was to determine the tolerability and efficacy of oxaliplatin in patients with recurrent gynecologic malignancies after carboplatin hypersensitivity reactions in comparison with conventionally used cisplatin. Methods Forty-six patients were treated with platinum-based chemotherapy from 2006 to 2011 and developed hypersensitivity reactions to carboplatin. Oxaliplatin was administered to 27 patients; 19 patients received cisplatin. Clinicopathologic variables, toxicity, and time-to-failure were analyzed retrospectively using descriptive statistics, Fisher exact, and independent sample permutation t tests. Results The median number of carboplatin cycles and cumulative dose before reaction were similar in the oxaliplatin and cisplatin groups, respectively (6 vs 7.5 cycles, P = 0.93; 980 [662] mg vs 686 [579.6] mg, P = 0.49). Non–life-threatening hypersensitivity reaction to oxaliplatin developed in 2 of 27 patients. No reactions to cisplatin occurred. The median number of oxaliplatin/cisplatin cycles was 6 in both groups. Complete response to therapy was 34.6% (oxaliplatin) and 31.6% (cisplatin); stable disease was seen in 50.0% and 36.8% of oxaliplatin- and cisplatin-treated patients, respectively (P = 0.46). Exposure to oxaliplatin resulted in less neurotoxicity than cisplatin (25.9% vs 68.4%, P = 0.01). The median number of prior chemotherapy lines in both groups was 2. The median time-to-failure was 10.8 months in oxaliplatin group and 9.8 months in cisplatin group (P = 0.86). Conclusions Salvage therapy with oxaliplatin after hypersensitivity reaction to carboplatin is associated with excellent tolerability and time-to-failure comparable to cisplatin. When further administration of carboplatin is precluded, oxaliplatin represents a safe and effective treatment strategy in the platinum-sensitive relapse setting. The significantly lower neurotoxicity profile makes it an attractive alternative to cisplatin.

Stress and burnout among gynecologic oncologists: A Society of Gynecologic Oncology Evidence-based Review and Recommendations

Burnout in physicians is a significant problem in all fields of medicine. A 2008 survey of members of the American College of Surgeons (ACS) and a 2014 survey of members of the Society of Gynecologic Oncology (SGO) reported that physician burnout occurs in 32% to 40% of gynecologic oncologists and surgeons This article describes the risk factors responsible for burnout in gynecologic oncologists and other physicians and the consequences of burnout and explores potential solutions. Data from the oncology, trauma, and surgical literature have shown that physicians treating themost acutely ill patients have 40% or greater prevalence of burnout. At the individual level, burnout is indicative of emotional exhaustion and stress, depersonalization in relationships with coworkers, detachment from patients, a sense of inadequacy or low personal accomplishment, mental illness, substance abuse, and risk of suicide. In the SGO survey, 33% of respondents screened positive for depression, 11% took medication for depression, and 14% experienced panic attacks. The ACS survey corroborated these findings, reporting that 30% of surgeons screened positive for symptoms of depression. Substance abuse was identified in 15% of gynecologic oncologists; there was a positive screen for alcohol abuse and suicidal ideation. The SGO survey reported that only 9% of respondents had sought psychiatric care in the previous 12months, and 45%were reluctant to seek psychiatric care. Suicide is a significant problem among all physicians who experience burnout; suicide rates are higher among female physicians. In both the SGO survey and the ACS survey, 13% to 14% of respondents reported suicidal ideation. At the professional level, physician burnout impacts patient care as shown by suboptimal patient outcomes, increased medical errors, increased liability claims, and inappropriate prescriptions. Because few studies have specifically assessed burnout in gynecologic oncologists, much of what is understood about burnout has been extrapolated from a variety of other physician specialties. Risk factors for burnout: Job stress is one of the most important factors associated with physician burnout. Gynecologic oncologists with a low perception of internal locus of control and increased anxiety with end-of-life care have greater work-related stress. Loss of a sense ofmeaning fromwork has been shown to increase the risk of physician burnout. Changing interests and career drift can develop over time. Gynecologic oncologists who devote most of their time and effort to patient care and surgery may find that they derive more job satisfaction and meaning in research and be unable to do so. The difficulty balancing career with family/personal life is a key factor contributing to burnout. In the AGS survey, worklife balance issues predicted burnout equally in both sexes, but the effect was more pronounced among female physicians. Modern home computer technology has a major affect on work-life balance in that physicians have 24-hour access to patient records, shared communication with colleagues, and on-demand educational resources. Risk factors for burnout in the AGS survey were having younger children between the ages of 5 and 21 years, income based on patient care billing, and working at least 60 hours per week. The SGO survey reported that independent risk factors associated with burnout were low mental quality of life, depression, being stressed and overwhelmed, suicidal ideation, alcohol abuse, and reluctance to seek care. The findings of a large study among US physicians assessing work-home conflict in dual-career relationships reported that female physicians were more likely to report signs or symptoms of burnout than male physicians. Copyright

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

Claudin7 and moesin in endometrial Adenocarcinoma; a retrospective study of 265 patients

BackgroundMetastasis is the main cause of death in cancer and is a multistep process. Moesin (MSN), a member of the ezrin-rdixin-moesin family and Claudin7 (CLDN7), a tight junction protein, both play a role in tumor cell metastasis. Previously, we found an over-expression of MSN and under-expression of CLDN7 at the mRNA level in uterine serous carcinoma in comparison to uterine endometrioid adenocarcinoma. The purpose of this study is to determine the protein expression of MSN and CLDN7 in endometrial cancer (EC) and to evaluate their prognostic value. Two hundred sixty-five patients with EC were retrieved from the archives. MSN and CLDN7 immunostaining were performed on the tissue paraffin sections. The expression of each antibody was reported and then correlated with clinicopathological prognostic factors including age, tumor grade, tumor stage, lympho-vascular involvement, depth of myometrial invasion, overall survival (OS), disease free survival (DFS) and death of disease (DOD).ResultsMSN and CLDN were expressed in 46% and 52% of overall cases. We observed an association between MSN+ staining and tumor grade, and serous and clear cell carcinoma subtypes (p < 0.001 each). There was an association between CLDN7+ staining and low tumor grade and endometrioid adenocarcinoma subtype (p < 0.001 and 0.001 respectively). However, no association between MSN and CLDN7 expression and outcome including OS, DOD, and DFS was found.ConclusionA significant prognostic value of MSN and CLDN7 in predicting disease outcomes in patients with EC was not demonstrated. Nevertheless, the high percentage of EC cases with MSN and CLDN7 immunoexpression, and their association with tumor grade and subtypes, suggests that these proteins might play a role in tumorigenesis of endometrial adenocarcinomas. Future studies are needed to shed light on their mechanistic properties in EC cells.