Robert F. Ozols

Cytogenetic studies in ovarian cancer

Cytogenetic studies of ovarian cancer have been conducted in the Medicine Branch, NCI, National Institutes of Health for 5 years. A total of 72 patients were studied by direct preparation and/or 1- to 3-day short-term culture of ascites (86 samples), pleural fluid (4 samples), and tumor (2 samples). Repeat examinations (1-24 months later) were performed in 7 of the 72 patients. Forty-four patients (62%) were successfully analyzed with banding techniques: 6 patients had adenocarcinoma, 7 had serous adenocarcinoma, 13 had serous papillary adenocarcinoma, 7 had serous papillary cystadenocarcinoma, 2 had mucinous adenocarcinoma, 6 had undifferentiated or poorly differentiated adenocarcinoma, 1 had clear cell adenocarcinoma, and 2 were not classified. Of these 44 patients, 29 had received prior chemotherapy, 14 were untreated, and in 1 patient the treatment status was unknown. Aneuploidy was observed in all patients and there was considerable variation in the chromosome numbers (even within single samples), often ranging from diploidy to triploidy to tetraploidy. All 44 patients had numerical abnormalities and 39 had structural abnormalities. The chromosomes most frequently involved in structural abnormalities (in decreasing order according to the number of patients involved) were #1, #3, #2, #4, #9, #10, #15, #19, #6, and #11; the least involved chromosomes were #21 and #5. Clone formation and the number of chromosomes involved in structural abnormalities increased with duration of disease and were more extensive in patients treated with chemotherapy than in patients treated with surgery alone. Our data did not show a deletion of chromosome #6 (6q-) to be specific for ovarian cancer.

Treatment of poor prognosis nonseminomatous testicular cancer with a “high‐dose” platinum combination chemotherapy regimen

A new intensive four drug combination chemotherapy regimen, termed PVeBV, consisting of cis‐platinum, vinblastine, bleomycin, and VP‐16, was administered to six previously untreated patients with poor prognosis advanced nonseminomatous testicular cancer and to four patients who had relapsed on primary platinum based regimens. The cis‐platinum was administered in 250 ml of 3% saline at twice the dose (40 mg/m2 IV days 1–5 every three weeks) used in other treatment schedules. All six previously untreated patients achieved a complete remission. Four achieved a complete remission with three cycles of PVeBV while the other two patients achieved a complete remission with an additional cycle of cisplatinum and VP‐16 at 200 mg/m2 IV × five followed by autologous bone marrow infusion. All four relapsed patients responded to PVeBV (two complete remissions and two partial remissions). There were no deaths associated with PVeBV therapy; however, myelosuppression was severe. There has been no renal toxicity (other than hypomagnesemia) observed with 35 cycles of high‐dose platinum therapy in previously untreated patients. These results indicate that PVeBV is a promising chemotherapy regimen for the treatment of poor prognosis testicular cancer patients. Furthermore, it appears that cis‐platinum can be administered at higher doses than previously used without an increase in renal toxicity if administered in hypertonic saline. The high‐dose cis‐platinum schedule, as used in PVeBV, warrants evaluation in other tumors which respond to standard‐dose platinum therapy.

Advanced ovarian cancer correlation of histologic grade with response to therapy and survival

In order to determine the prognostic and therapeutic importance of histologic grade for patients with advanced ovarian cancer, the pathologic specimens from 82 patients with Stage III‐IV disease (as defined by the International Federation of Gynecologists and Obstetricians (F.I.G.O.)) were reviewed and graded by two methods. A system based on cytologic detail using both the degree of anaplasia and the number of undifferentiated cells, (modified Broders Grades 1–4) was found to be particularly useful because it identified four groups with different survival outcomes as well as an apparent differential response to chemotherapy. Specifically, the overall improvement of survival in patients with Stage III‐IV disease observed in a prospective study of combination chemotherapy was related primarily to an increased survival of patients with Grade 2 and 3 lesions. Survival in Grade 1 patients was markedly better than for Grade 4 patients, but in neither case did survival appear to be influenced by the choice of chemotherapy. These observations suggest that prospective clinical trials assessing the efficacy of chemotherapy should employ cytologic grades as a separate stratification factor since chemotherapy for advanced disease may have to be tailored, in part, to the histologic grade.

Sarcoma arising in a residual testicular teratoma after cytoreductive chemotherapy.

A case of testicular teratoma metastasized to the retroperitoneum and after cytoreductive chemotherapy was noted to contain areas of frank sarcoma. Sarcomatous areas included embryonal rhabdomyosarcoma with a pattern of sarcoma botyroides, alveolar rhabdomyosarcoma, and fibrosarcoma. These areas differed markedly from areas of immature teratoma, which composed the remainder of the retroperitoneal lesion and which also characterized the primary tumor. These sarcomatous areas were characterized by numerous mitoses, marked cellular pleomorphism and diagnostic histologic, ultrastructural, and immunocytochemical features. Residual germ cell tumors following cytoreductive chemotherapy are traditionally categorized as teratoma only or teratoma with embryonal carcinoma or choriocarcinoma for therapeutic and prognostic reasons. This case does not conform to this simple categorization and raises serious questions concerning subsequent therapeutic decisions.

Thrombocytopenia and Extragonadal Germ-Cell Neoplasm

Excerpt To the editor: A report by Garnick and colleagues (1) has described three cases of idiopathic thrombocytopenia associated with extragonadal germ-cell tumors. We report an additional case in...

Current status of therapeutic modalities for treatment of gynecologic malignancies with emphasis on chemotherapy

THE GYNECOLOGIC NEOPLASMS are an intriguing group of diseases, with wide variation in biologic characteristics and natural histories. Despite this heterogeneity, the management of these diseases has historically been stereotypic. Therapy has almost exclusively involved surgery or radiotherapy or both. Nevertheless, there is reason to conclude that some patients with each of the gynecologic malignancies might benefit from systemic chemotherapy administered in concert with conventional surgical or radiotherapeutic management. Important prognostic factors crucial t.0 the identification of these patients are emphasized, and the current status of conventional therapies is examined. The present and potential roles of systemic chemotherapy are considered along with recommendations for future therapeutic research.

Chemotherapy in advanced disease

In 1981, approximately 17,000 new cases of ovarian carcinoma will be diagnosed and 11,200 of these women will die (approximately 6% of all female cancer deaths).’ Roughly one woman in 70 will develop this disease during her lifetime and only 25% will be diagnosed at a time when the disease is confined to the ovary. Furthermore, even in those patients with localized disease who have apparent complete resections or are rendered disease-free by pelvic irradiation, over one-third will eventually recur. As a result of the failure of local modalities to control disease in the vast majority of patients with ovarian adenocarcinoma, systemic chemotherapy has assumed a major role in disease management. Chemotherapy was originally used as second line treatment for radiation therapy failures, but is now commonly used as initial treatment for patients with advanced disease as well as an adjuvant to surgery for early stage disease (reviewed elsewhere in this series). In recent years, single alkylating agent chemotherapy has been frequently used for patients with bulky residual disease. Response rates of 33% to 65% can be anticipated with this form of therapy. Median survivals for all treated patients range from 1 O-l 4 months with median survivals of 17-22 months in those responding to treatment. Overall five year survivals range from O-9% with 16-22% of responders alive at five years.” Melphalan has been studied most thoroughly and is the standard single alkylating agent to which new drugs and combinations should be compared. Several non-alkylating agents also have significant activity in ovarian cancer. Adriamycin, hexamethylmelamine, and cis-platinum are of particular interest.9 In one prospective randomized trial, adriamycin, hexamethylmelamine and L-PAM achieved response rates of 29%, 33%, and 30%, respectively. In addition, hexamethylmelamine and cis-platinum are the only drugs thus far that have been useful as second line agents in patients failing initial therapy with alkylating agents. A summary of some of the active single agents is provided in Table 1. The relatively high response rates to various single agents has provided the impetus for today’s interest in combination chemotherapy. Combination chemotherapy has produced overall response rates which vary from 22-91% with complete remission rates of lo-69%. Unfortunately, many published reports are single arm studies of previously treated patients. Few combinations have been studied in randomized trials where differences in patient age, performance status, histologic grade, and amount of post-operative residual disease have been considered in assessing response rates. In many studies, it is likely that patient characteristics have a more important influence on survival than the chemotherapy regimen being tested. In addition, complete clinical responses are not always surgically confirmed and long term follow-up is often limited. Despite the problems in interpreting much of the published literature, there are several useful studies which show promise. Several combination chemotherapy studies appear to significantly increase response rates over those achieved with single agents. Successful prospective comparisons with single alkylating agents have employed the HexaCAF regimen (hexamethylmelamine, cyclophosphamide, methotrexate and 5fluorouracil);” AC (adriamycincyclophosphamide);6 and CHF (cyclophosphamide, hexamethylmelamine and 5-fluorouracil),4 and subsequently in a COG prospective trial randomizing non-optimal Stage III patients to receive AC, alkeran-h.examethylmelamine, or alkeran alone.8 Data from the Hexa-CAF study show a higher overall response rate (76% versus 54%), more complete responses (33% versus 16%), and a longer overall median survival (29 months versus 17 months). Recently cis-platinum has been included in a number of combination chemotherapy programs. These combinations have not been in use long enough to fully evaluate their effect on survival in comparison with currently established combination treatments or single agents. The

Therapeutic effect of a radiolabeled monoclonal antibody on human ovarian cancer xenograft in nude mice

The therapeutic value of 131I-OC125, a radiolabeled monoclonal antibody directed against a human ovarian tumor associated antigen CA125, was examined in an ascites forming intraperitoneal human ovarian carcinoma nude mouse model. Nude mice were injected intraperitoneally with NIH:OVCAR3 cells. Twenty-one days after tumor transplantation, groups of animals were injected intraperitoneally as follows: Group 1 with 200 microCi of 131I-OC125 (n = 20), Group 2 with 200 microCi of 131I (n = 17), Group 3 with 200 microCi of 131I-IgG (n = 21), Group 4 with 60 micrograms of OC125 (n = 18), and Group 5 was left untreated (n = 21). Survival of the tumor-bearing animals was used as the endpoint of the experiment. Mean survivals were found to be 52 +/- 18 days for the 131I-OC125 group, 53 +/- 16 days for the 131I-IgG group, 49 +/- 13 days for the 131I group, 47 +/- 24 days for the OC125 group, and 47 +/- 15 days for the untreated control. These results would indicate no therapeutic advantage of 131I-OC125 over controls in this animal model. However, other approaches using single as well as multiple radiolabeled monoclonal antibodies need to be tested in this model in order to definitely establish the efficacy of this treatment modality.

Glutathione Depletion with Buthionine Sulfoximine: Potential Clinical Applications

The effectiveness of chemotherapy in the treatment of many tumors is limited by two clinically distinct types of drug resistance. Tumors such as colon cancer, non-small lung cancer and malignant melanoma are inherently resistant to chemotherapy and response rates in these patients are low. In contrast, patients with tumors such as ovarian cancer and small cell lung cancer usually respond to the initial drug regimen but acquired drug resistance often develops and chemotherapy is of limited benefit in patients with recurrent or residual disease. A particularly clinically relevant feature of acquired drug resistance is the frequent development of a broad cross resistance to a wide variety of other drugs which is associated with the onset of resistance to the primary drug regimen.

Radioimaging of human ovarian carcinoma xenograft in nude mice

Human ovarian carcinomas in nude mice were radioimaged using a well-characterized antibody against a tumor-associated antigen (CA 125) and three transplantable human ovarian carcinoma tumor lines: NIH:OVCAR 3, NIH:OVCAR 5, and NIH:OVCAR 9. Radioiodinated monoclonal antibody OC125 was used in these studies. In order to establish the optimal conditions for imaging, tumor/blood ratios were determined. Gamma scintigraphy of nude mice bearing subcutaneous transplants of human ovarian carcinomas 3-4 days after 131I-OC125 administration demonstrated selective localization of the radiolabeled monoclonal antibody by these tumors without need for any background subtraction techniques.