2003 Annual Meeting
ABSTRACT 1
Prediction of Optimal Versus Suboptimal Cytoreduction of Advanced Stage Serous Ovarian Cancer Using MicroarraysBy Invitation
Andrew Berchuck, M.D.
Edwin S. Iversen, Ph.D.
Johnathan M. Lancaster, M.D.
Holly K. Dressman, Ph.D.
Michael West
Joseph R. Nevins, Ph.D.
Jeffrey R. Marks, Ph.D.
OBJECTIVE: To define gene expression patterns associated with optimal versus suboptimal debulking of advanced stage serous ovarian cancers.
STUDY DESIGN: RNA from 44 advanced serous ovarian cancers (19 optimal, 25 suboptimal) was interrogated using Affymetrix U133A microarrays that contain over 22,000 genes. Genes were screened on the basis of their association with debulking status to obtain the top 120 differentially expressed genes. These genes were then used to develop a predictive model for debulking status, which was subjected to out-of-sample cross validation.
RESULTS: We found that patterns of expression of 32 genes can distinguish between optimal and suboptimal debulking with 72.7% predictive accuracy. Analysis of the data based on clusters of coordinately expressed genes resulted in only a marginal improvement in predictive accuracy (75%).
CONCLUSIONS: These data support the hypothesis that favorable survival associated with optimal debulking of advanced ovarian cancers is due, at least in part, to the underlying biological characteristics of these cancers.
DISCUSSANT: Jonathan S. Berek, M.D.
ABSTRACT 2
Regulation of Expression of Tissue Plasminogen Activator and Plasminogen Activator Inhibitor-1 by Dichloroacetic Acid in Human Fibroblasts from Normal Peritoneum and AdhesionsBy Invitation
Michael P. Diamond, M.D.
Eslam ElHammady, M.D.
Rona Wang, M.D.
Michael Kruger, M.S.
Ghassan Saed, Ph.D.
OBJECTIVE(S): As part of our ongoing studies to understand the biologic mechanisms of wound repair which lead to postoperative adhesions, we have identified characteristics of an adhesion phenotype which differ between fibroblasts obtained from human normal peritoneum and adhesions. In this study we sought to examine whether stimulation of aerobic metabolism would alter differential expression of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1), thereby creating a milieu likely to be less favorable to postoperative adhesion development. To examine this issue we have utilized a compound, dichloroacetic acid (DCA), which stimulates the pyruvate dehydrogenase complex, causing pyruvate to be metabolized in the Krebs cycle rather than being converted into lactate, thereby switching anaerobic to aerobic metabolism.
STUDY DESIGN: Human fibroblasts from normal peritoneum and adhesions were cultured in the absence or presence of DCA (100 µg/ml) for 24 h, under normal and hypoxic (2% O2) conditions. Real time RT/PCR of tPA, PAI-1, and a housekeeping gene β-actin was performed using mRNA extracted from all treatment points.
RESULTS: DCA stimulated normal peritoneal fibroblast tPA mRNA expression under hypoxic conditions. In adhesion fibroblasts, DCA treatment enhanced tPA mRNA expression under both normoxic and hypoxic conditions. PAI-1 mRNA expression was unaltered by DCA in normoxic normal peritoneal fibroblasts, but during culture under hypoxic conditions, DCA reduced PAI-1 mRNA expression. Similarly, in adhesion fibroblasts, DCA reduced PAI-1 mRNA expression under both normoxic and hypoxic conditions. As a result, in normal peritoneal fibroblasts under hypoxic conditions, and in adhesion fibroblasts under normoxic and hypoxic conditions, DCA greatly increased the tPA/PAI-1 ratios.
CONCLUSION(S): These findings confirm that fibroblasts from adhesions are characterized by reduced tPA and increased PAI-1 production. These observations are extended to show the stimulation of oxidative metabolism by DCA increases tPA expression under hypoxic conditions. DCA reduces PAI-1 production by hypoxic normal peritoneal fibroblasts and adhesion fibroblasts under hypoxic conditions. The resultant increases in the tPA/PAI-1 ratios would favor development of a fibrinolytic milieu, which would be expected to potentially limit postoperative adhesion development. Thus regulation of metabolic activity of peritoneal cells may provide a target for future interventions for reduction of development of postoperative adhesions, particularly as it relates to healing of peritoneal sites which previously had adhesions. (e.g. sites of potential adhesion reformation).
DISCUSSANT: Robert S. Schenken, M.D.
ABSTRACT 3
RAS/RAF Mutation and Defective DNA Mismatch Repair in Endometrial CancersBy Invitation
David G. Mutch, M.D.
Matthew A. Powell, M.D.
Mary Ann Mallon, B.S.
Paul J. Goodfellow, Ph.D.
OBJECTIVES: Defective DNA mismatch repair is a common genetic abnormality in both colon cancers and endometrial cancers. Cancers with defective DNA mismatch repair have the so-called mutator phenotype and accumulate genetic errors at an increased rate. An early mutational target in cells with defect DNA mismatch repair may be the RAS/RAF pathway. Colon cancers often have KRAS2 mutations and if not KRAS2 mutations, may have BRAF mutations. This study investigated the spectrum and frequency of mutations in BRAF and KRAS2 in endometrial carcinomas based on mismatch repair status.
STUDY DESIGN: 441 endometrial cancer patients were properly staged, graded and evaluated for mismatch repair status. These patients were then stratified by the degree of microsatellite instability (MSI) observed in their tumors. 146 of selected tumors were then evaluated for KRAS2 and BRAF mutations based on their MSI.
RESULTS: 146 endometrioid endometrial cancers were evaluated for KRAS2 and BRAF mutations. Thirty-five (24%) had activating KRAS2 mutations but only a single BRAF mutation was identified in an MSI-positive cancer. Twenty-four of 81 (29.6%) MSI high cancers in which the MLH1 repair gene was methylated had KRAS2 mutations. When compared to the other groups this approached statistical significance (P=0.06). KRAS2 mutation status was associated with increasing age at diagnosis (P=0.02).
CONCLUSIONS: In spite of many similarities between colon and endometrial cancers, the mechanism of the development of endometrial cancers appears to be different than colon cancers in that BRAF is not affected by a mismatch repair problem since only KRAS2 mutations were seen. In addition, increasing age appears to lead to an increased likelihood that such a mutation will occur.
DISCUSSANT: David M. Gershenson, M.D.
ABSTRACT 4
Manipulation of the Pill Free Interval in Oral Contraceptive Pill Users: The Effect on Follicular SuppressionBy Invitation
William D. Schlaff, M.D.
Anne M. Lynch, M.D.
Heather D. Hughes, M.S.P.H.
Marcelle I. Cedars, M.D.
Deborah L. Smith, M.D.
OBJECTIVES: Compare follicular suppression produced by three different oral contraceptive regimens differing by treatment in the pill-free interval.
STUDY DESIGN: In a university setting, 54 women were randomized to receive either 20µg ethinyl estradiol + 100µg levonorgestrel followed by 7 pill free days, 20µg ethinyl estradiol + 150µg desogestrel followed by 2 days of placebo then 10µg ethinyl estradiol for 5 days, or 28 days of 20µg ethinyl estradiol plus 150µg desogestrel. Follicular suppression was evaluated by serial ultrasounds as well as serum and urinary hormone levels during a two month study period. Data were analyzed by non-parametric statistical tests.
RESULTS: There was a significant difference in follicle count between the 3 groups (P=0.0065). Women treated with a 7 day pill free interval were the least suppressed. Estrogen levels were more variable, and led to an observation that overweight (body mass index >25) was associated with reduced follicle suppression (RR=1.6, 95% CI 1.0, 2.7) and higher estrogen levels (RR=5.3, 95% CI 1.3, 21).
CONCLUSIONS: Contraceptive pill users treated with a 7 day pill free interval demonstrate less follicular suppression than women supplemented with either estrogen alone or estrogen plus progestin. Overweight women were less suppressed than women of normal weight.
DISCUSSANT: Abbey B. Berenson, M.D.
ABSTRACT 5
The Effects of Dexamethasone and Betamethasone on SP-B mRNA Expression in Human Type II Pneumocytes and Human Lung Adenocarcinoma CellsBy Invitation
Susan M. Ramin, M.D.
Alex C. Vidaeff, M.D.
Larry C. Gilstrap, III, M.D.
Karen D. Bishop, B.S.
Gaye N. Jenkins, B.S.
Joseph L. Alcorn, Ph.D.
OBJECTIVE: To compare the effect of a single 48 hours exposure to betamethasone or dexamethasone in the NCI-H441 cell line and in human type II pneumocytes.
STUDY DESIGN: NCI-H441 cells were exposed 48 hours to varying concentrations of betamethasone or dexamethasone (10-10 to 10-7 M) alone or in combination with dibutyryl cAMP (1mM). Likewise, human type II pneumocytes were exposed 48 hours to varying concentrations of betamethasone or dexamethasone (10-9 to 10-7 M) alone or in combination with dibutyryl cAMP (1mM). The measured outcome was the stimulatory effect on SP-B gene transcription as expressed by SP-B mRNA accumulation. The experiment was conducted three times, in parallel with control. SP-B mRNA was determined at control level and 48 hours after exposure by QRT-PCR.
RESULTS: A similar dose-dependent response in SP-B mRNA expression was seen with both betamethasone and dexamethasone. In human type II pneumocytes, the inductive profile of SP-B mRNA after 48 hours exposure to betamethasone or dexamethasone was similar to that seen in the NCI-H441 cells.
CONCLUSION: Dexamethasone and betamethasone achieved similar dose-response patterns of SP-B expression in vitro.
DISCUSSANT: James G. Quirk, M.D., Ph.D.
ABSTRACT 6
In Utero Hematopoietic Stem Cell Transplantation Using Haploidentical Donor Adult Bone Marrow in a Canine ModelBy Invitation
Karin J. Blakemore, M.D.
Catherine Hattenburg, M.S.
Gail Stetten, Ph.D.
Karin Berg, M.D.
Sarah South, Ph.D.
Kathleen Murphy, Ph.D.
Richard Jones, M.D.
OBJECTIVE: Chimerism can be achieved in a canine model of in utero bone marrow transplantation (BMT) using >=1x108 CD34+ haploidentical donor cells/kg without graft-versus-host-disease (GVHD).
STUDY DESIGN: In utero BMT was performed by ultrasound-guided intraperitoneal infusion in 30 to 41 day canines using CD34+ selected cells from paternal BM at doses of 1.3x108 to 2.5x1010 CD34+ cells/kg. A method for marking control littermates was developed using intraperitoneal ethiodol. Postnatal studies included histologic, FISH canine Y probe and PCR-based chimerism analyses.
RESULTS: Term survival was 86-100% for transplants 34 days versus 14% and 43% at 30 and 31 days. Microchimerism (<1%) was demonstrated in tissues from 4 informative litters including thymus, liver, skin, spleen, and intestine. Neither gestational age nor donor CD34 cell dosage altered the level of engraftment in these experiments. There was no evidence of GVHD.
CONCLUSION: In utero BMT in a canine model achieves microchimerism using high CD34+ cell doses.
DISCUSSANT: Charles J. Lockwood, M.D.
ABSTRACT 7
An Unexpected Effect of Glucocorticoids on Stimulation of c-fms Proto-Oncogene Expression in Choriocarcinoma Cells Expressing Little Glucocorticoid ReceptorBy Invitation
Setsuko K. Chambers, M.D.
Christina M. Ivins, B.A.
Barry M. Kacinski, M.D., Ph.D.
Richard B. Hochberg, Ph.D.
OBJECTIVE: To determine the mechanism by which glucocorticoids (GC) stimulate c-fms proto-oncogene expression in JAR choriocarcinoma cells, reported to lack the GC receptor (GR).
STUDY DESIGN: GC action on c-fms was tested using ligand binding assays, Northern and Western blotting, immunohistochemistry, quantitative reverse-transcriptase polymerase chain reaction (RTPCR), and nuclear run-off experiments.
RESULTS: Dex stimulated c-fms (EC50 = 1nM) in JAR cells in a specific manner. Both RU486 and actinomycin D inhibited dex stimulation, suggesting receptor-mediated and transcriptionally regulated actions. Neither cytosol or whole cell binding assays, nor immunohistochemistry detected GR in JAR cells. However, Southern blot analysis of RT-PCR products revealed levels of GR mRNA in JAR cells approximately 100-fold lower than in HeLa controls. In all but one clone among several JAR clones tested, there was concordance between presence or absence of GR mRNA and GC sensitivity.
CONCLUSION: Some JAR cells contain low levels of GR, which mediate dex stimulation of c-fms expression. Such sensitivity to circulating GCs confers a survival advantage to these cells by stimulating the c-fms related invasive behavior so characteristic of choriocarcinomas.
DISCUSSANT:Michele Follen, M.D., Ph.D.
ABSTRACT 8
Accuracy of Pelvic Examination in the Assessment of Operable Cervical Cancer PatientsBy Invitation
Mitchel S. Hoffman, M.D.
Richard J. Cardosi, M.D.
William S. Roberts, M.D.
James V. Fiorica, M.D.
Edward C. Grendys, Jr., M.D.
David Griffin, M.D., Ph.D.
OBJECTIVE: To determine whether pelvic examination identifies factors which suggest the need for radiotherapy following radical hysterectomy for cervical cancer.
STUDY DESIGN: Observational, 7/1/00 - 12/31/02. Sixty-seven stage 1B-2A cervical cancer patients undergoing primary surgical treatment. Assessments made on pelvic examination were compared to pathologic findings. Data were analyzed using descriptive statistics, calculation of sensitivities, specificities, positive and negative predictive values, and determination of odds ratios.
RESULTS: The overall spectrum of small to large tumors (<1-8 cm) and cervices (2.5-8 cm) correlated well with examination (r = 0.77 - 0.88). Accuracy of examination was approximately 50% for tumor diameter (+/- 25%), 85% for cervical diameter (+/- 25%), 80% for outer-third invasion, 80% for endophytic growth, and 90% for vaginal involvement. The likelihood for adjuvant radiotherapy had a significant association with the number of at-risk examination variables present.
CONCLUSIONS: For women undergoing radical hysterectomy for stage 1B-2A cervical cancer, the presence of multiple high-risk factors found on pelvic examination is significantly associated with indications for adjuvant postoperative radiotherapy.
DISCUSSANT: Paul B. Underwood, M.D.
ABSTRACT 9
Continent Ileocolonic Urinary Reservoir (Miami Pouch): The University of Miami Experience Over 15 YearsBy Invitation
Manuel A. Peñalver, M.D.
Emery M. Salom, M.D.
Luis E. Mendez, M.D.
Dana Schey, M.D.
Nicholas Lambrou, M.D.
Noor Kassira, M.S.
Orlando Gomez-Marvin, M.Sc., Ph.D.
OBJECTIVES: A patient with a recurrent central pelvic malignancy after radiation will require urinary diversion as part of the reconstructive phase of the pelvic exenteration. The aim of our study is to assess the result of our 15-year experience with a continent ileocolonic urinary reservoir-the Miami pouch.
STUDY DESIGN: Since 1988, all patients who received a continent ileocolonic urinary reservoir in the Division of Gynecologic Oncology, University of Miami School of Medicine, were included in the study. Parameters evaluated during the study period include functional outcomes, early and late perioperative complications, and their management.
RESULTS: A total of 90 patients were identified from February 1988 to December 2002. Seventy-eight (87%) had a recurrent central pelvic malignancy and 82 patients (91%) had received radiation prior to the Miami Pouch procedure. The non-reservoir related morbidities were fever (76%), wound complication (30%), pelvic collection (12%), ileus/small bowel obstruction (12%), and postoperative mortality (11%). The most common reservoir related complications were urinary infection (40%), ureteral stricture (20%), and difficulty with self-catheterization (18%). In our study the overall complication rate directly related to the Miami pouch was 53%. Conservative management resolved over 80% of these cases. The rate of urinary continence achieved in our patients was 93% during our 15-year experience with the Miami pouch.
CONCLUSION: The Miami pouch is a good alternative for continent urinary diversion during exenteration or radiation induced damage. The rate of major complications requiring aggressive surgical intervention is acceptable. The majority of all postoperative complications (80%) can be corrected utilizing conservative techniques associated with less mortality than reoperation and thus should be employed first. The technique is simple and effective in high-risk previously irradiated women with a high rate of functional success and a profound advantage for a woman’s psychosocial well being.
DISCUSSANT: Peter E. Schwartz, M.D.
ABSTRACT 10
Predictive Value of the Clinical Diagnosis of Lower Genital Tract Infection in WomenBy Invitation
Daniel V. Landers, M.D.
Harold C. Wiesenfeld, M.D.
R. Phillip Heine, M.D.
Marijane A. Krohn, Ph.D.
Sharon L. Hillier, Ph.D.
OBJECTIVE: We hypothesized that diagnostic approaches to lower genital tract infections are inaccurate and proposed this study to evaluate typical approaches.
STUDY DESIGN: Clinical diagnoses were made using symptoms, direct observation, wet mount, vaginal pH and amines in 598 women with genital complaints. Laboratory testing for N. gonorhoeae, yeast, T. vaginalis, C. trachomatis and bacterial vaginosis by Gram stain.
RESULTS: The most frequent symptoms were vaginal discharge (64%), change in discharge (53%), malodor (48%) and pruritis (32%). The infection rates were 46% bacterial vaginosis, 29% yeast, 12% trichomoniasis, 11% chlamydia or gonorrhea and 21% with no infection. The presenting symptoms did not predict laboratory diagnosis. Clinical signs and symptoms with office-based tests and microscopy improved the accuracy of diagnoses. Amsel’s clinical diagnosis of bacterial vaginosis was the most sensitive at 92%. The sensitivity of wet mount diagnosis of trichomoniasis was 62%, yeast by microscopy, 22% and mucopus for predicting gonorrhea and/or chlamydia, 30%.
CONCLUSION: Presenting symptoms alone should not be used to direct treatment where resources permit more complete evaluation with office-based testing including microscopy. Treatment failures or diagnostic uncertainty should prompt specific laboratory testing.
DISCUSSANT: Ronald S. Gibbs, M.D.
ABSTRACT 11
The Obstetric Vesicovaginal Fistula: Characteristics of 899
Patients from Jos, Nigeria
By Invitation
L. Lewis Wall, M.D., D.Phil.
Jonathan A. Karshima, FWACS
Carolyn Kirschner, M.D.
Steven D. Arrowsmith, M.D.
OBJECTIVES: To describe the characteristics of women presenting
with obstetric vesicovaginal fistulas at a hospital in north central
Nigeria.
STUDY DESIGN: Retrospective record review of all women seen
with vesicovaginal fistulas at Evangel Hospital in Jos, Plateau State,
Nigeria, between January, 1992, and June, 1999.
RESULTS: A total of 932 fistula cases were identified, of which 899
(96.5%) were temporally associated with labor and delivery. The
"typical patient" was small and short (44 kg and <150 cm); had
been married early (15.5 years) but was now divorced or separated;
was uneducated, poor, and from a rural area; had developed her fistula
as a primigravida during a labor that lasted at least 2 days and
which resulted in a stillborn fetus.
CONCLUSIONS: Obstetric vesicovaginal fistula is extremely common
in north central Nigeria. A complex interaction involving multiple
biological and socioeconomic factors appears to predispose
young women to this devastating childbirth injury.
DISCUSSANT: Mary Lake Polan, M.D., Ph.D.