- Email: [email protected]
Apolipoproteins are highly expressed in malignant ovarian cyst fluids
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Abstracts / Gynecologic Oncology 125 (2012) S3–S167
Methods: An innovative Luminex multiplex platform was employed to systematically determine phosphorylation status of protein tyrosine kinases in a total of 69 protein lysates derived from normal human ovarian surface epithelial (HOSE) cells, ovarian tumors, and cancer cell lines. Significance Analysis of Microarrays (SAM) was performed to identify the signature of phosphorylated kinases with statistical significance. Profiling results were confirmed by using phosphor-specific kinase antibodies in immunoblot analysis of the profiled lysates and immunohistochemistry on formalin-fixed paraffin-embedded archived ovarian and fallopian tissues, as well as immunofluorescence of ovarian cancer cells growing as monolayer or 3D Matrigel cell cultures. Results: A signature of twenty-two phosphorylated protein tyrosine kinases was identified by SAM analysis of the profiling data. Spleen Tyrosine Kinase (SYK), a novel tyrosine kinase included in the signature, was found significantly phosphorylated in lysates from ovarian cancer tissues compared to normal tissues by both Western blot analysis and immunohistochemistry on 94 clinical ovarian tissues (P = 0.024). SYK phosphorylation was also identified in tubal intraepithelial carcinomas, the hypothesized precursors of high-grade serous ovarian carcinomas. However, SYK activation was not observed in ovarian cancer cell lines growing as attached monolayer cells, but was present when they grew as mouse xenografts or in 3D Matrigel in vitro cultures. Conclusions: We are the first to report that SYK, an extensively investigated tyrosine kinase in hematopoietic cells, is aberrantly phosphorylated and activated in ovarian cancer. SYK phosphorylation in ovarian cancer might be induced by extracellular stimuli that are exclusively present in the tumor microenvironment. These findings provide additional options in targeted therapy for ovarian cancer.
doi:10.1016/j.ygyno.2011.12.243
243 Identification of a subset of stage IV ovarian carinomas with improved overall survival P. Vaddadi1, H. Godoy1, J. Kesterson2, J. Tolentino1, P. Frederick1, N. duPont1, S. Lele1, K. Odunsi1. 1Roswell Park Cancer Institute, Buffalo, NY, 2 Penn State College of Medicine, Hershey, PA. Objective: Stage IV epithelial ovarian cancer (EOC) is relatively rare. Patients with stage IV EOC are classified based on parenchymal liver involvement or disease outside of the abdominal cavity. Compared to stage III EOC, stage IV EOC have worse outcomes despite similar patient characteristics, histology, tumor grade and initial chemotherapy response. The purpose of this study was to evaluate the impact of disease location in women with Stage IV EOC. Methods: After obtaining IRB approval, medical records of patients with FIGO stage IV EOC treated between 1991 and 2010 at Roswell Park Cancer Institute were reviewed. Clinical data abstracted included age at diagnosis, histologic subtype, tumor grade, Stage IV criteria (site of metastatic disease), surgical debulking status, baseline CA125, and chemotherapy agents. Optimal cytoreduction was defined as residual tumor less than 1 cm. Kaplan-Meier method and the log-rank test were used to calculate overall survival. The Cox proportional hazards regression model was used to identify independent variables associated with improved overall survival. Results: One hundred and thirteen patients met inclusion criteria and were available for analysis. Mean age at diagnosis was 62 years; median overall survival was 17.2 months. The majority of tumors were poorly differentiated and serous subtype (89% and
80%, respectively). Optimal tumor debulking was achieved in 51% of patients. Stage IV criteria was most often pleural effusions (69%, 78/ 113), followed by parenchymal liver disease (18%, 20/113) and supraclavicular or axillary lymph node metastases (13%, 15/113). Worse prognosis was associated with increasing age and suboptimal debulking status on univariate analysis. The median overall survival for patients with malignant pleural effusion was 19 months (range 1–186 months) versus 11 months (range 1– 205 months) for liver parenchymal disease (p b 0.05) . In the subset analysis, patients with pleural effusion were more likely to have an optimal debulking (p = 0.005) and improved overall survival compared to liver parenchymal disease. Conclusions: This study, one of the largest focusing on stage IV EOC, demonstrates the impact of disease location and debulking status on outcomes. These findings have important clinical implications affecting patient counseling and directing medical therapies. Therefore, we propose a substaging of stage IV EOC based on site of metastatic disease as patients with liver parenchymal disease have worse overall prognosis.
doi:10.1016/j.ygyno.2011.12.244
244 Apolipoproteins are highly expressed in malignant ovarian cyst fluids I. Podzielinski1, B. Saunders2, K. Kimbler1, K. Ferguson1, A. Branscum3, E. Fung4, P. DePriest1, J. Van Nagell1, F. Ueland1, A. Baron1. 1University of Kentucky Medical Center, Lexington, KY, 2Knoxville Gynecologic Cancer Specialists, Knoxville, TN, 3Oregon State University, Corvallis, OR, 4 Vermillion, Inc., Fremont, CA. Objective: Differentially expressed biomarkers may be useful risk assessment, early detection and diagnostic tests of epithelial ovarian cancer (EOC). The objective of this study is to identify differentially expressed biomarkers of epithelial ovarian tumors. Methods: Cyst fluids were collected from benign, borderline, and malignant ovarian tumors following surgical resection and interrogated by surface-enhanced laser desorption ionization time-offlight mass spectrometry (SELDI-TOF MS) and by enzyme-linked immunosorbent assay (ELISA). Wilcoxon rank-sum tests, logistic regression models, and receiver operating characteristic plots were used to assess whether a biomarker is associated with EOC. Spearman's rank order tests were used to assess whether correlations exist between biomarkers. Results: SELDI-TOF MS identified two high intensity peaks (m/z 8696 and 8825) in malignant ovarian cyst fluids as isoforms of apolipoprotein A2 (ApoA2). ELISA data further show that ApoA1, A2, B, C2, C3, and E cyst fluid concentrations are higher in malignant compared to benign or borderline ovarian tumors. These biomarkers are highly correlated with each other in benign and borderline cyst fluids, but less so in malignant cyst fluids. Multivariate logistic regression modeling demonstrates that ApoA2 and ApoE cyst fluid concentrations, age, and smoking are independent classifiers of malignant versus benign and borderline ovarian tumors, yielding 46.7% sensitivity, 95% specificity, and 89.6% test accuracy to discern malignant from benign and borderline tumors. Conclusions: Apolipoprotein A1, A2, B, C2, C3, and E cyst fluid concentrations are differentially expressed and dysregulated in malignant compared to benign and borderline ovarian tumors. Serum concentrations of these biomarkers may warrant investigation for the risk assessment, early detection, and/or diagnosis of EOC.
Abstracts / Gynecologic Oncology 125 (2012) S3–S167
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that improve screening effectiveness, survival, and the overall cost impact. Methods: Thirty seven thousand eight hundred and twenty-six women received 210426 screens from 1987–2011. Multiple comparisons in onefactor ANOVA were performed. Kaplan-Meier analysis evaluated survival. Results: Seventy screen-detected OVCAs had a 7 yr Kaplan Meier survival of 89.9+ 3.9% with high screening performance (Sensitivity/Specificity/ PPV/NPV: 85.4%/99%/14%/99.96%). Simple cysts have not demonstrated a risk of malignancy (Obstetrics & Gynecology 102:594–599) nor have septated cysts (Gynecologic Oncology 118:278–282) and can be followed without surgery with a 50% improvement in the PPV. For complex TVS abnormalities with both cystic and solid components, N97% of unilateral and bilateral ovarian abnormalities will resolve. The use of a morphology index is key to assessing if abnormal ovarian structures are resolving. Thus, serial ultrasound in conjunction with morphology index scores has the potential for improving the PPV by N70%. Using the average cost of treating Stage IIIC ($92,100 collections, Current Women's Health Reviews 5, 44–50) and the 54 early stage detections that screening prevented from progressing ($4.9 – 12.9 million saved), while including cost derived from the PPV, results in 148000–414000 screens at $30/screen that would balance screening expenses with savings from preventing progression to IIIC ovarian cancers. Conclusions: Many abnormalities discovered by TVS will show that they are resolving during serial surveillance using ultrasound with morphology indexing so that improvements in PPV result. Overall screening expenses are in balance with savings from preventing advanced disease. doi:10.1016/j.ygyno.2011.12.246
246 Patterns of recurrence and associated clinical factors in patients with advanced serous ovarian cancer who experience a CA125 negative recurrence K. Long, E. Tanner, M. Frey, N. Abu-Rustum, Y. Sonoda, G. Gardner, M. Leitao, R. Barakat, D. Levine, D. Chi. Memorial Sloan-Kettering Cancer Center, New York, NY.
doi:10.1016/j.ygyno.2011.12.245
245 Effective ovarian cancer (OVCA) screening using transvaginal ultrasound (TVS): Evolving improvements E. Pavlik, J. Hoff, R. Ware Miller, C. DeSimone, I. Podzielinski, J. Elder, F. Ueland, J. Van Nagell. University of Kentucky Medical Center/Markey Cancer Center, Lexington, KY. Objective: Because early stage ovarian cancer can be effectively treated, while prognosis remains grim for late stage disease, effective screening for early stage ovarian malignancies should benefit survival and cure. Current perceptions of TVS screening for OVCA have been negatively influenced by an overall low PPV or positive predictive value, lack of a survival advantage (JAMA 305:2295–2303) and cost/ prevalence relationships. The objective is examine modifications
Objective: To evaluate the clinical factors associated with CA125 negative recurrences in patients (pts) with advanced serous ovarian (OC), fallopian tube (FTC), and primary peritoneal carcinoma (PPC). Methods: Patient demographics, treatments, and outcomes were collected for all pts with stage IIIB-IV serous OC, FTC, and PPC who underwent primary cytoreductive surgery (CRS) at our institution from 2001–2010. Recurrences were classified as CA125 positive (pos) or negative (neg) based on criteria described by Rustin et al (CA125 N2x upper limit reference range or CA125 N2x nadir). All CA125 neg recurrences had either radiographic evidence of disease or biopsy proven disease. Standard statistical analysis and Kaplan-Meier survival analysis were utilized. Results: Of the 520 pts identified, 372 (71.5%) recurred. Fifty-eight pts (15.6%) had CA125 neg recurrences and 344 pts (84.4%) had CA125 pos recurrences. In the CA125 neg group, 12 pts (20.7%) presented with symptoms or abnormalities on physical exam, while 46 pts (79.3%) were diagnosed on surveillance computed tomography (CT). CA125 at initial diagnosis was significantly lower in the CA125 neg group (P b 0.01); however, there was no difference in nadir CA125 (P = 0.28). Univariate analysis was performed on the following factors: elevated CA125 at initial diagnosis, age, stage, tumor grade, carcinomatosis and ascites at initial diagnosis, residual disease after primary CRS, and prior intraperitoneal (IP) chemotherapy. The only factor associated with CA125 neg recurrence was IP chemotherapy: 34.5% of pts in the CA125 neg group had received IP therapy vs 18.8% of pts in the CA125 pos group (P = 0.01). At recurrence, pts in the
Abstracts / Gynecologic Oncology 125 (2012) S3–S167
Methods: An innovative Luminex multiplex platform was employed to systematically determine phosphorylation status of protein tyrosine kinases in a total of 69 protein lysates derived from normal human ovarian surface epithelial (HOSE) cells, ovarian tumors, and cancer cell lines. Significance Analysis of Microarrays (SAM) was performed to identify the signature of phosphorylated kinases with statistical significance. Profiling results were confirmed by using phosphor-specific kinase antibodies in immunoblot analysis of the profiled lysates and immunohistochemistry on formalin-fixed paraffin-embedded archived ovarian and fallopian tissues, as well as immunofluorescence of ovarian cancer cells growing as monolayer or 3D Matrigel cell cultures. Results: A signature of twenty-two phosphorylated protein tyrosine kinases was identified by SAM analysis of the profiling data. Spleen Tyrosine Kinase (SYK), a novel tyrosine kinase included in the signature, was found significantly phosphorylated in lysates from ovarian cancer tissues compared to normal tissues by both Western blot analysis and immunohistochemistry on 94 clinical ovarian tissues (P = 0.024). SYK phosphorylation was also identified in tubal intraepithelial carcinomas, the hypothesized precursors of high-grade serous ovarian carcinomas. However, SYK activation was not observed in ovarian cancer cell lines growing as attached monolayer cells, but was present when they grew as mouse xenografts or in 3D Matrigel in vitro cultures. Conclusions: We are the first to report that SYK, an extensively investigated tyrosine kinase in hematopoietic cells, is aberrantly phosphorylated and activated in ovarian cancer. SYK phosphorylation in ovarian cancer might be induced by extracellular stimuli that are exclusively present in the tumor microenvironment. These findings provide additional options in targeted therapy for ovarian cancer.
doi:10.1016/j.ygyno.2011.12.243
243 Identification of a subset of stage IV ovarian carinomas with improved overall survival P. Vaddadi1, H. Godoy1, J. Kesterson2, J. Tolentino1, P. Frederick1, N. duPont1, S. Lele1, K. Odunsi1. 1Roswell Park Cancer Institute, Buffalo, NY, 2 Penn State College of Medicine, Hershey, PA. Objective: Stage IV epithelial ovarian cancer (EOC) is relatively rare. Patients with stage IV EOC are classified based on parenchymal liver involvement or disease outside of the abdominal cavity. Compared to stage III EOC, stage IV EOC have worse outcomes despite similar patient characteristics, histology, tumor grade and initial chemotherapy response. The purpose of this study was to evaluate the impact of disease location in women with Stage IV EOC. Methods: After obtaining IRB approval, medical records of patients with FIGO stage IV EOC treated between 1991 and 2010 at Roswell Park Cancer Institute were reviewed. Clinical data abstracted included age at diagnosis, histologic subtype, tumor grade, Stage IV criteria (site of metastatic disease), surgical debulking status, baseline CA125, and chemotherapy agents. Optimal cytoreduction was defined as residual tumor less than 1 cm. Kaplan-Meier method and the log-rank test were used to calculate overall survival. The Cox proportional hazards regression model was used to identify independent variables associated with improved overall survival. Results: One hundred and thirteen patients met inclusion criteria and were available for analysis. Mean age at diagnosis was 62 years; median overall survival was 17.2 months. The majority of tumors were poorly differentiated and serous subtype (89% and
80%, respectively). Optimal tumor debulking was achieved in 51% of patients. Stage IV criteria was most often pleural effusions (69%, 78/ 113), followed by parenchymal liver disease (18%, 20/113) and supraclavicular or axillary lymph node metastases (13%, 15/113). Worse prognosis was associated with increasing age and suboptimal debulking status on univariate analysis. The median overall survival for patients with malignant pleural effusion was 19 months (range 1–186 months) versus 11 months (range 1– 205 months) for liver parenchymal disease (p b 0.05) . In the subset analysis, patients with pleural effusion were more likely to have an optimal debulking (p = 0.005) and improved overall survival compared to liver parenchymal disease. Conclusions: This study, one of the largest focusing on stage IV EOC, demonstrates the impact of disease location and debulking status on outcomes. These findings have important clinical implications affecting patient counseling and directing medical therapies. Therefore, we propose a substaging of stage IV EOC based on site of metastatic disease as patients with liver parenchymal disease have worse overall prognosis.
doi:10.1016/j.ygyno.2011.12.244
244 Apolipoproteins are highly expressed in malignant ovarian cyst fluids I. Podzielinski1, B. Saunders2, K. Kimbler1, K. Ferguson1, A. Branscum3, E. Fung4, P. DePriest1, J. Van Nagell1, F. Ueland1, A. Baron1. 1University of Kentucky Medical Center, Lexington, KY, 2Knoxville Gynecologic Cancer Specialists, Knoxville, TN, 3Oregon State University, Corvallis, OR, 4 Vermillion, Inc., Fremont, CA. Objective: Differentially expressed biomarkers may be useful risk assessment, early detection and diagnostic tests of epithelial ovarian cancer (EOC). The objective of this study is to identify differentially expressed biomarkers of epithelial ovarian tumors. Methods: Cyst fluids were collected from benign, borderline, and malignant ovarian tumors following surgical resection and interrogated by surface-enhanced laser desorption ionization time-offlight mass spectrometry (SELDI-TOF MS) and by enzyme-linked immunosorbent assay (ELISA). Wilcoxon rank-sum tests, logistic regression models, and receiver operating characteristic plots were used to assess whether a biomarker is associated with EOC. Spearman's rank order tests were used to assess whether correlations exist between biomarkers. Results: SELDI-TOF MS identified two high intensity peaks (m/z 8696 and 8825) in malignant ovarian cyst fluids as isoforms of apolipoprotein A2 (ApoA2). ELISA data further show that ApoA1, A2, B, C2, C3, and E cyst fluid concentrations are higher in malignant compared to benign or borderline ovarian tumors. These biomarkers are highly correlated with each other in benign and borderline cyst fluids, but less so in malignant cyst fluids. Multivariate logistic regression modeling demonstrates that ApoA2 and ApoE cyst fluid concentrations, age, and smoking are independent classifiers of malignant versus benign and borderline ovarian tumors, yielding 46.7% sensitivity, 95% specificity, and 89.6% test accuracy to discern malignant from benign and borderline tumors. Conclusions: Apolipoprotein A1, A2, B, C2, C3, and E cyst fluid concentrations are differentially expressed and dysregulated in malignant compared to benign and borderline ovarian tumors. Serum concentrations of these biomarkers may warrant investigation for the risk assessment, early detection, and/or diagnosis of EOC.
Abstracts / Gynecologic Oncology 125 (2012) S3–S167
S103
that improve screening effectiveness, survival, and the overall cost impact. Methods: Thirty seven thousand eight hundred and twenty-six women received 210426 screens from 1987–2011. Multiple comparisons in onefactor ANOVA were performed. Kaplan-Meier analysis evaluated survival. Results: Seventy screen-detected OVCAs had a 7 yr Kaplan Meier survival of 89.9+ 3.9% with high screening performance (Sensitivity/Specificity/ PPV/NPV: 85.4%/99%/14%/99.96%). Simple cysts have not demonstrated a risk of malignancy (Obstetrics & Gynecology 102:594–599) nor have septated cysts (Gynecologic Oncology 118:278–282) and can be followed without surgery with a 50% improvement in the PPV. For complex TVS abnormalities with both cystic and solid components, N97% of unilateral and bilateral ovarian abnormalities will resolve. The use of a morphology index is key to assessing if abnormal ovarian structures are resolving. Thus, serial ultrasound in conjunction with morphology index scores has the potential for improving the PPV by N70%. Using the average cost of treating Stage IIIC ($92,100 collections, Current Women's Health Reviews 5, 44–50) and the 54 early stage detections that screening prevented from progressing ($4.9 – 12.9 million saved), while including cost derived from the PPV, results in 148000–414000 screens at $30/screen that would balance screening expenses with savings from preventing progression to IIIC ovarian cancers. Conclusions: Many abnormalities discovered by TVS will show that they are resolving during serial surveillance using ultrasound with morphology indexing so that improvements in PPV result. Overall screening expenses are in balance with savings from preventing advanced disease. doi:10.1016/j.ygyno.2011.12.246
246 Patterns of recurrence and associated clinical factors in patients with advanced serous ovarian cancer who experience a CA125 negative recurrence K. Long, E. Tanner, M. Frey, N. Abu-Rustum, Y. Sonoda, G. Gardner, M. Leitao, R. Barakat, D. Levine, D. Chi. Memorial Sloan-Kettering Cancer Center, New York, NY.
doi:10.1016/j.ygyno.2011.12.245
245 Effective ovarian cancer (OVCA) screening using transvaginal ultrasound (TVS): Evolving improvements E. Pavlik, J. Hoff, R. Ware Miller, C. DeSimone, I. Podzielinski, J. Elder, F. Ueland, J. Van Nagell. University of Kentucky Medical Center/Markey Cancer Center, Lexington, KY. Objective: Because early stage ovarian cancer can be effectively treated, while prognosis remains grim for late stage disease, effective screening for early stage ovarian malignancies should benefit survival and cure. Current perceptions of TVS screening for OVCA have been negatively influenced by an overall low PPV or positive predictive value, lack of a survival advantage (JAMA 305:2295–2303) and cost/ prevalence relationships. The objective is examine modifications
Objective: To evaluate the clinical factors associated with CA125 negative recurrences in patients (pts) with advanced serous ovarian (OC), fallopian tube (FTC), and primary peritoneal carcinoma (PPC). Methods: Patient demographics, treatments, and outcomes were collected for all pts with stage IIIB-IV serous OC, FTC, and PPC who underwent primary cytoreductive surgery (CRS) at our institution from 2001–2010. Recurrences were classified as CA125 positive (pos) or negative (neg) based on criteria described by Rustin et al (CA125 N2x upper limit reference range or CA125 N2x nadir). All CA125 neg recurrences had either radiographic evidence of disease or biopsy proven disease. Standard statistical analysis and Kaplan-Meier survival analysis were utilized. Results: Of the 520 pts identified, 372 (71.5%) recurred. Fifty-eight pts (15.6%) had CA125 neg recurrences and 344 pts (84.4%) had CA125 pos recurrences. In the CA125 neg group, 12 pts (20.7%) presented with symptoms or abnormalities on physical exam, while 46 pts (79.3%) were diagnosed on surveillance computed tomography (CT). CA125 at initial diagnosis was significantly lower in the CA125 neg group (P b 0.01); however, there was no difference in nadir CA125 (P = 0.28). Univariate analysis was performed on the following factors: elevated CA125 at initial diagnosis, age, stage, tumor grade, carcinomatosis and ascites at initial diagnosis, residual disease after primary CRS, and prior intraperitoneal (IP) chemotherapy. The only factor associated with CA125 neg recurrence was IP chemotherapy: 34.5% of pts in the CA125 neg group had received IP therapy vs 18.8% of pts in the CA125 pos group (P = 0.01). At recurrence, pts in the