Ram Eitan

Tumor microRNA expression patterns associated with resistance to platinum based chemotherapy and survival in ovarian cancer patients

BACKGROUND Ovarian cancer, the leading cause of gynecologic cancer deaths, is usually diagnosed in advanced stages. Prognosis relates to stage at diagnosis and sensitivity to platinum based chemotherapy. We aimed to assess the expression of microRNAs in ovarian tumors and identify microRNA expression patterns that are associated with outcome, response to chemotherapy and survival. METHODS Patients, who were surgically treated for ovarian cancer between January 2000 and December 2004 were identified. Patient charts were reviewed for clinicopathologic information, follow-up and survival. Total RNA was extracted from tumor samples and microRNA expression levels were measured by microarrays. Expression levels were compared between groups of samples and statistically analyzed. RESULTS Fifty-seven patients were identified to fit study criteria. Of them, 19 patients had stage I disease at diagnosis, and 38 patients, stage III. All patients received platinum based chemotherapy as first line treatment. 18 microRNAs were differentially expressed (p<0.05) between stage I and stage III disease. Seven microRNAs were found to be significantly differentially expressed in tumors from platinum-sensitive vs. platinum-resistant patients (p<0.05). Five microRNAs were associated with significant differences (p<0.05) in survival or recurrence-free survival. High expression of hsa-mir-27a identified a sub-group of patients with very poor prognosis. CONCLUSIONS We have found an array of tumor specific markers that are associated with response to platinum based first line chemotherapy. Expression of some of these miRNAs also correlated closely with prognosis. This approach can potentially be used to tailor chemotherapy and further management to specific patient needs.

Platinum-resistance in ovarian cancer cells is mediated by IL-6 secretion via the increased expression of its target cIAP-2

Ovarian carcinoma patients are initially responsive to platinum-based therapy, but eventually become refractory to treatment due to the development of platinum chemoresistance. Elevated levels of interleukin-6 (IL-6) in the sera and ascites of these patients predict poor clinical outcome. Our goal was to analyze the interaction between cisplatin and cisplatin-resistant ovarian cancer cells, and to identify means of circumventing platinum resistance. We studied ovarian carcinoma cell lines and cells drawn from ovarian carcinoma patients. Gene array analyses were performed on ovarian carcinoma cells upon treatment with cisplatin, and the results were validated by ELISA and Western blotting (WB). Cytotoxicity assays were performed on anti-IL-6 Ab-, IL-6-, and cellular inhibitor of apoptosis 2 (cIAP-2) siRNA-treated cells, following cisplatin addition. Our results revealed a highly significant increase in IL-6 and cIAP-2 mRNA and protein levels upon treatment with cisplatin. WB analysis of cisplatin-treated cells exhibited decreased cIAP-2 expression level following anti-IL-6 Ab addition. Furthermore, IL-6 by itself, significantly increased cIAP-2 levels in ovarian carcinoma cells. Finally, cytotoxicity assays showed sensitization to cisplatin following the addition of IL-6 and cIAP-2 inhibitors. In conclusion, cisplatin treatment of ovarian carcinoma cells upregulates IL-6 and cIAP-2 levels while their inhibition significantly sensitizes them to cisplatin. Here, we present cIAP-2 as a novel inducer of platinum resistance in ovarian carcinoma cells, and suggest an axis beginning with an encounter between cisplatin and these cells, mediated sequentially by IL-6 and cIAP-2, resulting in cisplatin resistance. Consequently, we propose that combining IL-6/cIAP-2 inhibitors with cisplatin will provide new hope for ovarian carcinoma patients by improving the current treatment.

Can parametrectomy be avoided in early cervical cancer? An algorithm for the identification of patients at low risk for parametrial involvement

AIMS To assess the rate of parametrial involvement in a large cohort of patients who underwent radical hysterectomy for cervical cancer and to suggest an algorithm for the triage of patients to simple hysterectomy or simple trachelectomy. METHODS Multicenter retrospective study of patients with cervical cancer stage I through IIA who underwent radical hysterectomy and pelvic lymphadenectomy. The patients were divided into 2 groups according to whether or not the parametrium was involved. The two groups were compared with regard to the clinical and histopathological variables. Logistic regression of the variables potentially assessable prior to definitive hysterectomy such as age, tumor size, lymph-vascular space invasion (LVSI) and nodal involvement was performed. RESULTS Five hundred and thirty patients had specific histological data on parametrial involvement and in 58 (10.9%) patients, parametria was involved. Parametrial involvement was significantly associated with older age, tumors larger than 2 cm, deeper invasion, LVSI, involved surgical margins, and the presence of nodal metastasis. By triaging patients with a tumor ≤ 2 cm and no LVSI, the parametrial involvement rate was 1.8% (2/112 patients). With further triage of patients with negative nodes, the rate of parametrial involvement was 0% (0/107 patients). CONCLUSION Using a pre-operative triage algorithm, patients with early small lesions, no LVSI and no nodal involvement may be spared radical surgical procedures and parametrectomy. Further prospective data are urgently needed.

Presentation, Diagnosis, and Treatment of Ovarian Torsion in Premenarchal Girls

STUDY OBJECTIVE To describe the clinical characteristics and treatment of ovarian torsion in premenarchal girls with surgically verified ovarian torsion. DESIGN AND PARTICIPANTS A retrospective cohort study design was used. The medical charts of all premenarchal girls with surgically verified ovarian torsion treated in a university-affiliated tertiary medical center from 1997 to 2012 were reviewed for clinical, treatment, and outcome data. RESULTS Thirty-two premenarchal girls were identified. Their median age was 9 years. There were 7 recurrences during the study period (17.9%), for a total of 39 cases. The main presenting symptoms were abdominal pain (92.3%) and nausea and vomiting (84.6%). Physical examination revealed abdominal tenderness in 25 cases (64.1%). Abdominal ultrasound, performed in 31 patients (38 cases), yielded pathologic findings in 28 (73.7%), mainly an enlarged ovary (11 cases, 28.9%). Doppler flow studies were abnormal in 15 cases. In 26 cases (68.4%), the tentative preoperative working diagnosis was ovarian torsion. Laparoscopy was performed in 26 cases, laparotomy in 10, and laparoscopy converted to laparotomy in 3 cases. Conservative management, mainly with additional cyst drainage or cystectomy, was used in 37 cases (95.2%) with oophoropexy in 5 cases. Two patients required oophorectomy because of a suspected neoplasm and severe ovarian necrosis. Pathologic examination demonstrated 5 simple cysts, 1 necrotic ovary, and 1 mature cystic teratoma. CONCLUSIONS Ovarian torsion in premenarchal girls is associated with nonspecific signs and symptoms. Abdominal ultrasound and Doppler imaging may assist in the diagnosis. Laparoscopy with conservative management is preferred. Owing to the high recurrence rate, oophoropexy may be considered.

Single-dose methotrexate injection for treatment of ectopic pregnancy in women with relatively low levels of human chorionic gonadotropin.

To evaluate potential risk factors at admission for failed single‐dose methotrexate injection in women with ectopic pregnancy.

Characteristics and Management of Ovarian Torsion in Premenarchal Compared With Postmenarchal Patients.

OBJECTIVE: To compare the clinical, ultrasonographic, and operative characteristics of premenarchal and postmenarchal patients with surgically verified ovarian torsion. METHODS: A retrospective cohort study of all patients with surgically verified ovarian torsion operated on at a single university-affiliated tertiary medical center during 1997–2013. Age at presentation, presenting symptoms, diagnostic studies, surgical procedure, and pathologic findings were analyzed. RESULTS: A total of 41 premenarchal and 208 postmenarchal patients were diagnosed with ovarian torsion during the study period. Median ages were 9 and 27 years, respectively. Median duration of symptoms before first presentation was longer among the premenarchal patients (24.0 compared with 8.0 hours, P<.001) as was the median interval from hospital admission to surgery (9.5 compared with 4.6 hours, P<.001). Premenarchal girls had a higher rate of restlessness, fever, and evidence of pelvic mass at presentation and a similar rate of ultrasonographic signs for torsion (78.5% compared with 73.1% P=.53). During surgery, a finding of a black–bluish ovary was more common in premenarchal girls (61.0% compared with 41.3%, P=.02). CONCLUSION: Ovarian torsion in premenarchal girls is associated with a longer interval from onset of symptoms and an increased rate of fever and pelvic mass at presentation compared with postmenarchal patients. These data may aid the physician in the evaluation of abdominal pain in premenarchal girls. LEVEL OF EVIDENCE: II

Risk factors for recurrence after Le Fort colpocleisis for severe pelvic organ prolapse in elderly women

INTRODUCTION We investigated parameters associated with recurrence after partial (Le Fort) colpocleisis surgery for severe pelvic organ prolapse (POP) in elderly women. METHODS A retrospective cohort study included all women who underwent partial colpocleisis in a single tertiary center from February 2007 through July 2013 for stage 3 or 4 triple compartment prolapse. Inclusion criteria were age over 60, sexually inactive, medical comorbidities, increased risk for comprehensive reconstructive pelvic surgery, and refusal or failure to use a pessary as a conservative non-surgical treatment. Exclusion criteria were post-menopausal bleeding, pelvic malignancy, and the desire to preserve coital function. RESULTS The study group included 47 women of mean age 77.3 ± 8.2 (range 61-91 years). All had medical comorbidities. Fourteen patients (29.8%) had undergone previous hysterectomy. All patients underwent partial colpocleisis and perineorrhaphy. Seven women (14.9%) underwent mid-urethral sling for urinary incontinence. Mean follow-up was 14.8 ± 10.3 months (range, 2-37 months) and mean hospitalization, 3.5 ± 1.5 days (range, 2-9 days). There were no intraoperative complications. Postoperative complications comprised lower urinary tract infection (n = 2). Objective cure (according to vaginal examination) was 80.9% (38/47), and subjective (according to symptoms), 91.5% (43/47). No patient regretted the loss of sexual function. The main reasons for prolapse recurrence were statistically significant longer post-operative vaginal length and wider genital hiatus. CONCLUSIONS Objective and subjective cure rates of Le Fort colpocleisis for the treatment of severe POP were high with low morbidity. Parameters associated with prolapse recurrence were longer postoperative vaginal length and wider genital hiatus.

The significance of paracardiac lymph-node enlargement in patients with newly diagnosed stage IIIC ovarian cancer.

OBJECTIVE Extra-abdominal metastases in epithelial ovarian cancer (EOC) are relatively rare. Interpreting computed tomography (CT) scans, during initial work-up, little attention is focused on enlargement of paracardiac lymph nodes (PCLN) and their significance is not clear. We aimed to examine whether the presence of PCLN during initial diagnosis of EOC influences prognosis. METHODS A retrospective study comparing patients with stage 3 EOC who were diagnosed with PCLN on CT scan during initial evaluation to stage 3C patients without PCLN. Scans were reviewed by a single radiologist for peritoneal involvement, distal metastases and presence of PCLN. Disease status at diagnosis, results of surgery, chemotherapy and response, disease-free interval (DFI) and overall survival (OS) were recorded. RESULTS Thirty one patients with stage 3C EOC with PCLN on initial CT scan were included and compared with 41 controls. There was no significant difference between groups in abdominal optimal cytoreduction rate. Lower rates of complete response (CR) to initial treatment were detected in the study group (45.2% vs. 78.0%, p=.004). In survival analysis, the DFI for patients with PCLN was shorter (median 9.0 vs. 24.0 months, p=.0097) and overall survival was shorter (median 31.7 vs. 61.3 months, p=.001). Multivariate analysis showed that PCLN was significantly associated with a lower rate of CR, a shorter DFI and a shorter OS. CONCLUSION The presence of enlarged PCLN at presentation appears to be associated with poor prognosis in stage 3C EOC. Further attention should be given to detection and follow-up of such findings when considering treatment.

The counseling and management of young healthy BRCA mutation carriers.

Abstract Although more than 15 years have elapsed since the discovery of the BRCA1 and BRCA2 genes and the associated increased risk of breast and ovarian cancers in mutation carriers, our understanding of the syndrome is still evolving. With the accumulation of knowledge, more questions arise regarding the proper approach to mutation carriers diagnosed as having cancer. Moreover, the number of questions regarding the recommended management methods for healthy carriers and the potential risk-reducing measures is increasing constantly. In this review, we discuss these issues and summarize contemporary recommendations.

Laparoscopic adnexal transposition: novel surgical technique.

Abstract Treatment of some cancers diagnosed at an early stage with expectation of prolonged survival has permitted the consideration of salvaging the reproductive and hormonal function of premenopausal female patients. When radiation to the pelvic area is part of treatment, this will almost always result in ovarian failure. To protect the ovaries, an oophoropexy may be performed, which involves moving the ovaries away from the radiation field. This procedure may be performed via laparoscopy. Some women undergoing laparoscopic radical hysterectomy may also be candidates for laparoscopic transposition. Because failure rates are still reported to be high, we developed a novel technique to mobilize the adnexa, which we present in this paper and attached movie. After separating the adnexa from the uterus and developing the infundibulopelvic (IP) ligament, a retroperitoneal tunnel is developed from the pelvis to the transposition opening laterally. The adnexa are moved through this tunnel, avoiding torsion of the vessels, and are brought through the opening back into the peritoneum. The adnexa are now fixed securely to the posterolateral abdominal wall with nonabsorbable sutures. Several issues permit better results using this technique. The IP ligament remains retroperitoneal and itself is outside the field of radiation. There is no kinking of the ovarian blood supply on the peritoneal fold. The location of the transposition is way above the field of radiation, preventing scatter injury. Even if one or both of the sutures fail, placement of the ovary will not change because of the peritoneum it has been brought through. This and the final location of the IP ligament retroperitoneally may enforce the ovary to it outside of the radiation field and prevent possible migration of the ovary back to the pelvis. This technique has advantages, which may offer the ovaries a better chance to resume hormonal function.