Abstracts Presented for the Thirty-Third Annual Meeting of the Society of Gynecologic Oncologists

Gynecologic Oncology 84, 479 –536 (2002) doi:10.1006/gyno.2001.6565, available online at http://www.idealibrary.com on

ABSTRACTS Abstracts Presented for the Thirty-Third Annual Meeting of the Society of Gynecologic Oncologists The Fontainebleau Hilton, Miami Beach, Florida, March 16 –20, 2002

significantly prolongs the duration of progression-free survival. Whether ultimate survival of this patient population is improved remains to be determined.

PLENARY SESSION I—SUNDAY, MARCH 17, 2002 Moderators: Abstracts 1–5, Vicki Baker; Abstracts 6 –9, Thomas Wright, Jr. 1. Phase 3 Randomized Trial of 12 versus 3 Months of Single-Agent Paclitaxel in Patients with Advanced Ovarian Cancer Who Attained a Clinically Defined Complete Response to Platinum/Paclitaxel-Based Chemotherapy. A Southwest Oncology Group and Gynecologic Oncology Group Trial. Maurie Markman, P. Y. Liu, Sharon Wilczynski, Bradley J. Monk, Larry Copeland, and David Alberts. City of Hope National Medical Center, Duarte, California; Cleveland Clinic Foundation, Cleveland, Ohio; Ohio State University Health Center, Columbus, Ohio; Southwest Oncology Group Statistical Center, Seattle, Washington; UC Irvine Medical Center, Orange, California; and University of Arizona Cancer Center, Tucson, Arizona. 1 Objectives. We wished to determine if continuing the cycle-specific cytotoxic agent paclitaxel for an extended period of time in women with advanced ovarian cancer who had achieved a clinically defined complete response to a platinum/paclitaxel-based chemotherapy regimen could prolong the time of subsequent progression-free survival and possibly favorably impact ultimate survival. Methods. Patients entered into this phase 3 trial were randomized to receive either 3 or 12 cycles of single-agent paclitaxel (initially 175 mg/m 2 over 3 h) administered every 28 days. Patients were then followed without further therapy and observed for progression-free survival (PFS, primary study end point) and overall survival. Due to a higher rate of early withdrawal in the 12-cycle arm, secondary to the development of peripheral neuropathy, the dose of paclitaxel in both arms was decreased to 135 mg/m 2. Results. As of 09/06/01, a total of 277 patients (262 evaluable), well-balanced for prognostic factors, had entered the trial, with a total of 54 PFS events having developed among 222 patients with follow-up data. With the exception of peripheral neuropathy there were no major differences in toxicity between the study regimens. The median PFS were 21 and 28 months in the 3- and 12-cycle paclitaxel arms, respectively. One-sided P values from an unadjusted log-rank test and an adjusted Cox model analysis (for stratification factors) were 0.0035 and 0.0023, respectively, both in favor of the 12-cycle arm. The Cox model adjusted 3-cycle vs 12-cycle paclitaxel progression hazard ratio was estimated to be 2.31 (99% confidence interval of 1.08 – 4.94). With a protocol-specified early termination boundary of P ⫽ 0.005, these findings led the SWOG Data and Safety Monitoring Committee to discontinue the trial. As of the date of study closure there was no difference in overall survival between treatment arms. Conclusion. Application of 12 cycles of single-agent paclitaxel administered to women with advanced ovarian cancer who have attained a clinically defined complete response to initial platinum/paclitaxel-based chemotherapy 1

Please note that each abstract’s author affiliations are in alphabetical order and do not necessarily correspond with the presented author order. 479

2. The Association of Hemoglobin with Survival in Advanced Cervical Carcinoma Patients Treated with Cisplatin and Radiotherapy. William E. Winter III, G. Larry Maxwell, Tian Cunqiao, G. Scott Rose, Gillian Thomas, and Jay W. Carlson. GOG Statistical Office, Buffalo, New York; Toronto-Sunnybrook Regional Cancer Center, Toronto, Canada; and Walter Reed Army Medical Center, Washington, DC. Objective. The purpose of this study was to confirm that hemoglobin (Hb) levels during treatment with cisplatin and radiotherapy are associated with disease recurrence and survival in patients with advanced cervical cancer and to explore whether there is an interval during treatment in which the association of low hemoglobin and poor outcome is particularly significant. Methods and Materials. An ancillary data review of 501 patients receiving cisplatin and radiotherapy in two prospective trials conducted by the Gynecologic Oncology Group (GOG 120 and GOG 165) was performed. Demographic data, pathologic information, treatment-related factors, and Hb values at baseline and during each week of therapy were collected. Statistical analysis was performed using multivariate regression and the log-rank test. Results. Two hundred and eight-five of 501 patients (57%) and 216 of 501 patients (47%) were diagnosed with stage II and stage III/IV disease, respectively. Hb levels progressively declined throughout treatment in all patients. Hb values were greater at baseline and during therapy in patients who were disease-free. In univariate analyses, lower hemoglobin levels were significantly associated with age ⬍60 years, decreased performance status, advanced stage, and increased tumor size. After controlling for performance status, stage of disease, tumor size, and duration of radiotherapy, mean Hb values during treatment were predictive of disease recurrence (P ⫽ 0.002). The pretreatment Hb level was not significant when Hb levels during treatment were included in the regression model. When the treatment course was divided into early, middle, and late periods, multivariate regression analysis revealed that Hb values during the late treatment period were the most predictive of disease recurrence (P ⫽ 0.006). The 5-year progression-free survivals (PFS) for stage III/IV patients with mean Hb values during treatment with ⱖ12 and ⬍10 g/dl were 64 and 31%, respectively (P ⫽ 0.002). Conclusions. The Hb level during combined radiotherapy and cisplatin was an independent predictor of treatment outcome in advanced cervical carcinoma. Hb levels in the last part of treatment are the most predictive of disease recurrence and survival. Prospective studies are underway to determine if raising hemoglobin levels will affect outcome in cervical cancer patients treated with curative intent. 3. Functional Overexpression of Erythropoietin Receptor in Gynecologic Malignancies. John W. McBroom, Tom C. Krivak, G. Scott Rose, Geza Acs, Michael J. Birrer, and Ajay Verma. National Cancer Institute, Rockville, Maryland; Uniformed Services University of the Health Sciences, Bethesda, Maryland; University of Pennsylvania Medical Center, Philadel0090-8258/02 $35.00 © 2002 Elsevier Science (USA) All rights reserved.

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phia, Pennsylvania; and Walter Reed Army Medical Center, Washington, DC. Objective. Erythropoietin (EPO) and its receptor (EPOR) stimulate the growth and survival of erythroblasts and erythrocytic leukemia cells. Since recombinant human EPO (rhEPO) is utilized in the management of anemia associated with treatment of gynecologic malignancies, we sought to determine the functional expression of EPOR in ovarian and cervical malignancies. Methods. Benign immortalized surface ovarian epithelial cell lines (ISOE80 and ISOE120), ovarian cancer cell lines (SKOV3 and OVCAR3), and a cervical cancer cell line (HELA) were maintained in culture. EPOR expression was determined in cell protein extracts via Western blotting using polyclonal anti-EPOR antibodies. Fluorescence-activated cell sorting (FACS) analysis of EPOR expression in HELA and SKOV3 cells was performed using monoclonal anti-human EPOR–phycoerythrin conjugate. HELA, SKOV3, and OVCAR3 cell lines were examined for immunohistochemical (IHC) staining of EPOR. IHC localization was performed on benign and malignant cervical and ovarian specimens. Functional EPOR signaling was explored by determining rhEPO-induced Jak-2 phosphorylation in the HELA and SKOV3 cell lines using anti-JAK-2 antibodies. Results. Western blot and FACS analysis of ovarian and cervical carcinoma cell lines revealed EPOR overexpression in the malignant but not in the benign cell lines. IHC staining for EPOR in cervical and ovarian tissue revealed absent to low levels in normal and increased levels in malignant tissue. Exposure of cervical and ovarian cancer cell lines to rhEPO resulted in activation of the Jak-2 signaling pathway, demonstrating functionality of the EPOR. A phospho-Jak-2 blocking peptide confirmed the specificity. Conclusion. In this study, we show that EPOR is overexpressed in human ovarian and cervical carcinoma cell lines and clinical biopsies. We also demonstrate that activation of EPOR by rhEPO can initiate potent cell survival signaling pathways in human cervical and ovarian cancer cell lines. The recent demonstration of elevated EPOR expression in breast, endometrial, and brain carcinomas, along with these data in ovary and cervical cancer, raises the concern that EPO treatment may stimulate cancer cells in a manner similar to its effects on erythroblasts. Our findings suggest that the current practice of rhEPO administration to cancer patients to support hemoglobin levels may warrant further investigation. 4. Ovarian Preservation May Be Considered in Young Patients with EarlyStage Leiomyosarcoma of the Uterus. Robert L. Giuntoli II, Connie S. Dimarco, Daniel S. Metzinger, Stephen S. Cha, Jeff A. Sloan, Gary L. Keeney, and Bobbie S. Gostout. Mayo Clinic, Rochester, Minnesota; and University of Louisville, Louisville, Kentucky. Objective. Multivariate analysis of clinical outcomes in patients with leiomyosarcoma (LMS) of the uterus demonstrates ovarian preservation to be associated with significantly improved survival. This case– control investigation further evaluates the impact of ovarian conservation on survival of women with LMS of the uterus. Methods. Using the ICD 9 codes for LMS and malignant neoplasm of the uterus, a medical record search of the years 1976 to 1999 identified 285 potential study subjects. Charts were retrospectively reviewed and relevant clinical and pathologic data extracted. Stage was assigned using 1988 FIGO criteria for endometrial adenocarcinoma. Grade was assigned using Broder’s four-level system. The case group was composed of 32 patients who had ovarian preservation. The control group (matched for age, stage, and grade) was selected from study patients with documented bilateral salpingooophorectomy. Survival curves were generated using the methods of Kaplan and Meier. P values ⬍0.05 were consider significant. Results. Median ages at diagnosis were 39 and 43 years for the cases and controls, respectively. Median follow-up of survivors was 9.1 years for the cases and 13.5 years for the controls. A majority of subjects were stage I (86% cases and 83% controls). Grade 1 was assigned to 46% of the cases and 43% of the controls. Grade 3 lesions were noted in 33% of the cases and 37% of the controls. Adjuvant therapy was given to 13 and 30% of the cases and controls, respectively. Univariate analysis demonstrated no difference in recurrence or disease-specific survival between the cases and the controls. Conclusions. Although LMS

is a hormonally responsive tumor, ovarian preservation does not appear to adversely impact prognosis. In young patients with LMS confined to the uterus, removal of the ovaries may not be necessary. 5. Hormone Replacement Therapy Formulations and Risk of Epithelial Ovarian Carcinoma. Anita S. Sit, Francesmary Modugno, Joel L. Weissfeld, Sarah L. Berga, and Roberta B. Ness. Department of Obstetrics & Gynecology & Reproductive Sciences, Magee-Womens Hospital, Pittsburgh, Pennsylvania; and Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania. Objective: Hormone replacement therapy (HRT) has been inconsistently linked to ovarian cancer. Estrogen formulations in HRT vary in their effects on estrogen-sensitive target tissues, such as the ovary. The aim of the study is to evaluate the impact of various HRT formulations and their characteristics of use on the risk of epithelial ovarian carcinoma (EOC). Methods. We assessed the association between the use of HRT and the risk of invasive EOC in women participating in a population-based, case– control study in the Delaware Valley from 1994 to 1998. Cases aged 45 or above at diagnosis (n ⫽ 484) were compared to community controls (n ⫽ 926) frequency matched by age and area of residence. Information on HRT formulation, timing, and duration was obtained by in-person interview by trained interviewers. HRT formulations were classified as opposed (estrogen ⫹ progestin) or unopposed (estrogen alone). They were further categorized according to the estrogen component as either conjugated equine estrogen (CEE), the most common formulation, or estrogen other CEE as non-CEE. Multivariate unconditional logistic regression analyses were used to adjust for age at diagnosis, number of live births, use of oral contraceptives, family history of ovarian carcinoma, and history of tubal ligation. Results. Overall, no association between any HRT use and EOC was found (OR ⫽ 0.94, 95% CI ⫽ 0.74, 1.19). Both unopposed non-CEE (OR ⫽ 0.52 95% CI ⫽ 0.25, 1.10) and progestin-only formulations (OR ⫽ 0.86 95% CI ⫽ 0.47, 1.58) appeared moderately associated with a reduced risk, although the results did not reach statistical significance. However, use of unopposed non-CEE was associated with a significant decrease in risk among hysterectomized women (OR ⫽ 0.17, 95% CI ⫽ 0.04, 0.82) but not among women with an intact uterus (OR ⫽ 1.14, 95% CI ⫽ 0.44, 2.98; P for interaction ⫽ 0.049). No significant differences in EOC risk were observed for other HRT formulations. Conclusions. Our results did not suggest an altered risk of EOC and the overall use of HRT. Variations in HRT formulation in combination with individual risk factors such as hysterectomy may confer differing risk of EOC in relation to HRT. Future research efforts will be needed to investigate the effects of different estrogen formulations and ovarian cancer risk. 6. Endometriosis and Its Treatment with Danazol or Lupron in Relationship to Ovarian Cancer. Carrie Cottreau, Roberta B. Ness, and Marc Goodman. University of Hawaii, Honolulu, Hawaii; and University of Pittsburgh, Pittsburgh, Pennsylvania. Objective. We sought to determine the impact on ovarian cancer risk of two drugs used to treat endometriosis: the synthetic androgen danazol and the anti-androgenic, gonadotropin-releasing hormone agonist leuprolide (Lupron). Methods. Pooled data from two case– control studies conducted between 1993 and 1999 in the region around Philadelphia and in Hawaii/Los Angeles were used to examine the relationships among endometriosis, endometriosis treatments, and ovarian cancer. One thousand three hundred and seventy-three cases of ovarian cancer and 1980 population-based, age-matched controls were interviewed. Odds ratios relating endometriosis, and its treatment with danazol or leuprolide, to ovarian cancer were calculated by logistic regression after adjustment for gravidity, oral contraceptive duration, education, and family history of ovarian cancer. Results. A minority of women had a diagnosis of endometriosis including 195 (9.8%) cases and 195 (14.2%) controls. Eight cases and 7 controls used leuprolide and 12 cases and 5 controls used danazol. Women with a diagnosis of endometriosis were 1.5-fold more likely than those without endometriosis to have ovarian cancer. Although at least 1 month of leuprolide use marginally elevated the risk of ovarian cancer (OR 1.4, 95% CI

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS 0.5–3.9), this was mostly because women using leuprolide generally had endometriosis. Restricting the analysis to include only women with endometriosis, the association between leuprolide and ovarian cancer diminished (OR 1.2, 95% CI 0.4 –3.8). In contrast, danazol use substantially increased the risk of ovarian cancer (OR 3.6, 95% CI 1.2–10.4) and the elevation persisted for danazol users who had endometriosis (OR 2.3, 95% CI 0.8 – 6.9), albeit nonsignificantly. Conclusions. Endometriosis increased the risk of ovarian cancer, as has been found previously. Beyond the impact from endometriosis, danazol, but not leuprolide, elevated ovarian cancer risk. Although numbers of exposed women were small, these novel data support the hypothesis that androgens play a role in ovarian cancer. They also raise concerns that the use of danazol in the treatment of endometriosis may put women at risk for developing ovarian cancer. 7. Margin Distance and Other Pathologic Prognostic Factors in Vulvar Carcinoma: A Multivariate Analysis. John K. Chan, Huyen Pham, Valerie E. Sugiyama, Mai Gu, Joanne Rutgers, Kathryn Osann, Michael L. Berman, and Philip J. Disaia. Long Beach Memorial Hospital, Orange, California; and University of California, Irvine, Orange, California. Objectives. To determine the importance of margin status and other surgical and pathologic factors involved with the survival of patients with squamous cell carcinoma of the vulva. Methods. All patients with vulvar carcinoma diagnosed between 1984 and 2000 were identified from tumor registry databases at two Southern California hospitals. Data for analysis were collected from hospital charts and clinic follow-up records. All slides were rereviewed by two pathologists to determine the margin distance and other pathological factors. Kaplan–Meier survival and logistic regression analyses were used to determine predictors of outcome. Results. Ninety patients (median age 69) were diagnosed with vulvar carcinoma, including 28 with FIGO surgical stage I disease, 20 with stage II, 26 with stage III, and 16 with stage IV disease. Twenty-seven (30%) patients underwent radical deep excisions and 63 (70%) had radical vulvectomies. Eighteen (20%) patients received postoperative tailored radiotherapy to the groins and/or the perineum to prevent local regional recurrence. The 3-year cumulative survival rates of stage I, II, III, and IV patients were 92, 73, 63, and 20%, respectively (P ⬍ 0.00005). Eleven stage I and 10 stage II patients died from other causes and none died from vulvar carcinoma. Increasing tumor margin distance was significantly associated with decreasing local recurrence (P ⫽ 0.006). In fact, none of the 29 patients with a pathologic margin distance ⱖ8 mm had local vulvar recurrence. Of the 61 women with a surgical margin ⬍8 mm, 13 (21%) had a local/ regional recurrence. Moreover, women with ⱖ3 positive groin nodes had a significantly higher rate of disease recurrence than patients with ⬍3 metastatic groin nodes (P ⬍ 0.00005). Lastly, age, stage, tumor size, thickness, depth, grade, lymphovascular space invasion, and margin status were all significant independent predictors for survival in our multivariate analysis. The median follow-up period was 48 months (range 1–187). Conclusions. Surgical margin distance is an important predictor of local vulvar recurrence. Our results demonstrate that a 1-cm tumor-free surgical margin on the vulva leads to a high rate of local regional control. Furthermore, age, stage, tumor size, thickness, depth, grade, lymphovascular space invasion, and margin status are all significant independent predictors for survival. 8. Pelvic Exenteration and Quality of Life. A. Peter M. Heintz, Marrion A. Van Eijkeren, and Evelien J. Roos. University Medical Center Utrecht, Utrecht, The Netherlands. Objective. To determine the quality of life (qol) after pelvic exenteration in patients treated at the University Medical Center Utrecht. Methods. All records (n ⫽ 62) of the patients who underwent an exenteration between January 1989 and January 2000 were reviewed. All patients who were alive on the first of January 2000 and who were able to fill in a questionnaire (n ⫽ 29) received two questionnaires to assess their qol, general health level, symptoms, functioning, and sexuality: the EORTC QLQ30 version 3.0, and QLQ-OV 28. Twenty-five of them responded. Survival was estimated according to the

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Kaplan–Meier life table. Results. Disease-free survival and survival after 5 years were 46 and 42%, respectively. The mean age of the interviewed population was 75 years (range 20 –77). The exenteration group had on the items “general health,” “qol,” and “emotional functioning” a score equal to the general population and to women with cervical cancer (70 vs 72– 65). However, the exenteration group, especially those ⬍57 years, scored lower on the items physical functioning (71 vs 86 – 84), social functioning (67 vs 91–75), and role functioning (65 vs 83), which means that they functioned less well in their work, hobbies, and other daily activities. The exenteration group reported more fatigue, sleeplessness, and constipation, but not more pain than healthy women. They found it difficult to cope with disease and treatment and they had a worsened body image. Only 8 patients were sexually active. Five of them had a neovagina. The exenteration had a huge influence on the sexual life of all patients: sexual activity, the role of sexuality in their lives, and the influence of the operation on sex life scored negative in the whole group, but the worst in the total exenteration group. The exenteration patients did not experience a negative influence of the operation on the relation with their partner. Conclusions. Survival and disease-free survival do not differ from most reported results of exenterative surgery. The general qol and health level are experienced as equal to the healthy population. However, body image and sexual life are negatively influenced by the procedure. Our results support a positive attitude toward this serious option for women with a local regional recurrence of pelvic cancer.

9. Ethnic Differences in Incidence, Treatment, and Survival: SEER Analysis of 1175 Cases of Uterine Sarcoma. Sandra E. Brooks, Min Zhan, Timothy R. Cote, Kristen H. Kjerulff, and Claudia R. Baquet. National Institute of Health, Bethesda, Maryland; and University of Maryland School of Medicine, Baltimore, Maryland. Objective. To compare uterine sarcoma in black and white women by incidence, histology, treatment, and survival. Methods. We defined uterine sarcomas as primary uterine malignancies diagnosed as leiomyosarcoma, carcinosarcoma, high-grade endometrial stromal sarcoma, adenosarcoma, and sarcoma not otherwise specified. We used cases from the population-based SEER program to compare uterine sarcoma among black and white women ⬎35 years old. Using data from 1993 to 1997, we compared race-specific age-adjusted incidences, histologic distributions, extent of disease, and likelihood of receiving therapy. Using data from 1973 to 1997, we compared race-specific survival. Results. During the period 1993–1997, 1175 women aged ⬎35 were diagnosed with uterine sarcoma, 963 (82%) of whom were white and 212 (18%) of whom were black. The age-adjusted incidence for blacks was twice that of whites (7.9/10 5 vs 3.7/10 5 ). Differences in uterine sarcoma incidence existed for leiomyosarcoma (1.6/10 5 for blacks vs 0.9/10 5 for whites, P ⬍ 0.01) and carcinosarcoma (4.7/10 5 for blacks vs 1.7/10 5 for whites, P ⬍ 0.001), but not other histologic types. Racial differences in stage distribution existed for stage II disease only, with 4% of whites and 10% of blacks aged 35– 64 assigned to stage II (P ⫽ 0.013) and 10% of whites and 18% of blacks aged ⬎65 assigned to stage II (P ⫽ 0.024). Whites were more likely to have cancer-directed surgery recommended and completed [92% vs 86% (P ⫽ 0.006)]. Specifically, black women aged 35– 64 underwent fewer hysterectomies (P ⫽ 0.04) and black women ⬎75 underwent fewer lymph node dissections (P ⫽ 0.02) than white women. The differences in use of radiation therapy were not statistically significant. The overall 5-year causespecific survival rate for black women with uterine sarcoma was 22% lower than for white women [0.40 (SE 0.035) vs 0.51 (SE 0.02), P ⫽ 0.05], with the differences in survival being largest for black women with regional (stage II) disease [0.22 (SE 0.43) vs 0.40 (SE 0.026) P ⬍ 0.001]. Conclusions. Carcinosarcoma and leiomyosarcoma occurred more frequently in black women than in white women, but black women were less likely to undergo hysterectomy and node dissection. Differences in stage distribution and 5-year survival were greatest for stage II disease. Less definitive therapy may partially explain the lower cause-specific survival of blacks with uterine sarcoma.

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PLENARY SESSION II—MONDAY, MARCH 18, 2002 Moderators: Abstracts 10 –12, William McGuire; Abstracts 13–15, Gilliam Thomas 10. Risk of Hormone-Related Cancers after Ovarian Stimulation for in Vitro Fertilization in a Cohort of 26,428 Women. Curt W. Burger, Helen Klip, and Flora E. Van Leeuwen. Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; and Netherland Cancer Institute, Amsterdam, The Netherlands. Objective. To study the long-term risk of gynecologic cancer in women after in vitro fertilization (IVF). Concerns have been raised that the use of fertility drugs may lead to a long-term increase in the risk of hormone-related cancers. Methods. We examined cancer risk in a large Dutch cohort of women who had at least one IVF treatment (n ⫽ 18,298). The unexposed group consisted of 6320 women who were diagnosed with subfertility disorders but never received IVF. All women received a risk factor questionnaire (response rate 66.9%). Furthermore, specific data on cause of subfertility and details of fertility treatment were collected from medical records. Cancer incidence was ascertained through linkage with the population-based Netherlands Cancer Registry. Results. Sixty-eight breast cancers were observed among the exposed cohort whereas 61.8 were expected during a median follow-up period of 5.5 years [standardized incidence ratio (SIR) ⫽ 1.1 95% confidence interval (CI) 0.9 to 1.4]. In the unexposed cohort, the SIR for breast cancer was 1.0 (95% CI 0.7 to 1.4; based on 41 observed cases). Nine ovarian cancer cases were observed in the exposed cohort (SIR ⫽ 1.2; 95% CI 0.5–2.2) versus six in the unexposed cohort (SIR ⫽ 1.3; 95% CI 0.5–2.9). In the exposed cohort, we found an increased risk for uterine cancer compared to the general population rates (SIR ⫽ 3.8; 95% CI 1.6 –7.5; based on 8 observed cases). In the unexposed cohort, we observed 4 cases of uterine cancer (SIR ⫽ 2.4; 95% CI 0.7– 6.1). Conclusion. These findings suggest no increased risks for breast cancer and ovarian cancer in women exposed to IVF compared to general population rates. The increased risk for uterine cancer is being further explored in multivariate analyses. 11. Prophylactic Oophorectomy in Patients at Risk for Hereditary Ovarian Carcinoma. Richard R. Barakat, Martee L. Hensley, Dharmendra Bhaskaran, Poonam Rastogi, Beata Korytowsky, Jeff Boyd, Mark Robson, and Kenneth Offit. Memorial Sloan-Kettering Cancer Center, New York, New York. Objective. To improve decision-making for the management of women at risk for hereditary ovarian carcinoma (HOC), we aimed to determine the incidence of occult primary cancers, the subsequent risk of developing primary peritoneal cancer, and the costs of prophylactic oophorectomy (PO). Methods. Between 2/95 and 6/00, we performed 180 POs. Eighty-two of 180 patients had known genetic testing. Of these, 53 (65%) had pathogenic BRCA1 or BRCA2 mutations. Two patients were members of an HNPCC kindred. Surgical procedures included laparoscopically assisted vaginal hysterectomy/BSO (9 patients), bilateral salpingo-oophorectomy (BSO) combined with breast surgery (9), and total abdominal hysterectomy/BSO (3); 131 underwent laparoscopic PO (L-PO) alone. Total direct medical charges incurred from preadmission testing to 60 days post-PO were determined for the first 124 consecutive patients who underwent L-PO only. Charges were converted to direct medical costs. Results. The mean age for all patients was 50 (range 30 –74 years). The mean operative time for patients undergoing L-PO alone was 73 min. Ten operative complications occurred in 9 (6.9%) patients: uterine perforation (3) and 1 each of hemorrhage, conversion to laparotomy/wound cellulitis, cystotomy, bowel obstruction, enterocolitis, and metabolic abnormality. Thirty-two patients (24.4%) who had only L-PO required a 1-day admission for persistent nausea, urinary retention, pain, or anxiety. Pathological evaluation of the adnexa for all 180 cases revealed 3 cases (1.7%) of occult

carcinoma, 2 involving the ovary and 1 the fallopian tube. In addition, there were 3 cases (1.7%) of metastatic breast cancer to the ovaries. With a median follow-up of 18 months (range 1–79 months), 1 patient (0.6%) developed primary peritoneal cancer 17 months after PO. The median total direct medical cost for L-PO was $8488 (range $2620 –$29,207). Conclusion. PO utilizing video-laparoscopy is a safe and effective outpatient method for primary prevention of ovarian cancer in women at risk for HOC. Occult ovarian or tubal cancer occurred in 1.7% of patients. Longer follow-up is required to determine the incidence of peritoneal cancer, overall survival, and cost-effectiveness of PO as a risk reducing strategy for women at high risk for HOC. 12. Pathologic Findings in Prophylactic Oophorectomy Specimens in HighRisk Women. Katherine Leeper, Rochelle Garcia, Elizabeth Swisher, Barbara Goff, Benjamin Greer, and Pamela Paley. University of Washington Medical Center, Seattle, Washington. Objective. The aim of this study was to ascertain the frequency of significant pathologic alterations in prophylactic oophorectomy (PO) specimens in high-risk women referred to a tertiary care center. Methods. Surgical cases for PO referred to a gynecologic oncology clinic from November 1996 –January 2001 were reviewed. Serial sections of entirely submitted tubes and ovaries were procured and reviewed by a pathologist with expertise in gynecologic malignancies. All patients had undergone genetic counseling and either underwent mutational analysis of BRCA1 and BRCA2 genes or had family history suggestive for ovarian and breast cancer susceptibility. Results. Thirty women underwent PO during the study period. Seventy-three percent had undergone genetic testing. Of those, 63.5% harbored a BRCA1 mutation, 13.5% were BRCA2 carriers, and the remaining 23% tested negative. Five of the 30 women (17%) were found to have a clinically occult malignancy. Four of the 5 malignancies were diagnosed only on histologic review. A single patient had grossly apparent primary peritoneal carcinoma at the time of laparoscopy. Three patients were found to have primary fallopian tube malignancy, 2 with in situ papillary serous carcinoma and 1 with early invasive disease. Each of the fallopian tube neoplasms measured less than 1 cm. The final patient was diagnosed with an ovarian adenofibroma with a focus of low-malignantpotential neoplasm and clear cell features. Three of the 5 women were known BRCA1 mutation carriers, 1 had a documented BRCA2 mutation, and 1 has not yet been tested. Conclusions. The high rate of occult malignancy detected in this series suggests that this finding in women at heightened risk for ovarian cancer is relatively common. Further, clinically occult tumors were not limited to ovarian origin, and the majority of cases harbored malignant foci less than 1 cm in greatest dimension that was not recognized at the time of surgery. These findings support the recommendations that in the high-risk population (i) the fallopian tubes and ovaries should be submitted entirely and be evaluated by a pathologist with expertise in gynecologic malignances in serial sections; (ii) laparoscopy or laparotomy are the surgical modalities of choice to allow inspection of the peritoneal surfaces at time of prophylactic oophorectomy; and (iii) despite the rarity of fallopian tube carcinoma in the general population, BRCA1 and BRCA2 mutation carriers may be at increased risk for tubal cancers. 13. Predictors of Peritoneal Failures in Endometrial Cancer. Andrea Mariani, Maurice J. Webb, Gary L. Keeney, Giacomo Aletti, and Karl C. Podratz. Mayo Clinic, Rochester, Minnesota; and University of Milano, Milan, Italy. Objective. The aim of this study was to assess determinants of peritoneal failures in endometrial cancer patients (pts) following definitive primary treatment. Methods. A total of 131 relapses were observed in 599 endometrial cancer pts who had primary surgery at our institution during the decade prior to 1994. We defined peritoneal failures as relapses when such occurred in the upper abdomen or involved the pelvic peritoneum (or both). Median follow-up was 72 months. ␹ 2, Kaplan–Meier, log-rank, and Cox models were used for statistical analysis. Results. Peritoneal failures were detected in 37 of 599 (6%) pts and represented 28% of identified failures. Stage IV tumor, cervical stromal

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS invasion (CSI), adnexal involvement, myometrial invasion ⬎50%, primary tumor diameter ⬎2 cm, positive peritoneal cytology, positive lymph nodes (pelvic and/or paraaortic), grade 3 tumor, nonendometrioid histology (nEH), absence of associated hyperplasia, and lymph–vascular invasion significantly (P ⬍ 0.05) correlated with peritoneal failure. However, based on Cox regression, only stage IV tumor (P ⬍ 0.001; RR ⫽ 7.53), nEH (P ⫽ 0.02; RR ⫽ 3.01), and CSI (P ⫽ 0.04; RR ⫽ 2.83) were independent predictors of peritoneal failure. Specifically, 3% of patients with stage I–III tumor had peritoneal failures compared to 41% with stage IV disease; 3% with endometrioid histology had peritoneal failures versus 28% with nEH; and 5% without CSI had peritoneal failures compared to 26% with CSI (P ⬍ 0.001). Considering those patients presenting with at least one of the above three variables, 24% had peritoneal failures compared to only 1% of those with endometrioid stage I–III disease without CSI (P ⬍ 0.001). Conclusion. Stage IV disease, nonendometrioid histology, and cervical stromal invasion were independent predictors of peritoneal failures. In the absence of the above three factors, pts had a very low (1%) risk of developing peritoneal failures. However, peritoneal failure was observed in 24% of pts harboring one or more of the above three characteristics and hence would be candidates for new therapeutic trials that would incorporate treatment of the entire abdominal cavity. 14. Population Characteristics in Cervical Cancer Trials. Search for External Validity. Annie A. Yessaian, Robert Burger, and Wendy Brewster. University of California, Irvine Medical Center, Orange, California. Objective. Since cooperative group trials in cervical cancer have influenced the standard practice of medicine, it is imperative to evaluate whether subjects enrolled are reflective of the general diseased population. This may have implications on the generalization of protocol results. Our objective was to compare the characteristics of cervical cancer patients enrolled in cooperative group trials (study population) with those of cervical cancer population in the United States (target population). Methods. We analyzed peer-reviewed Phase III treatment trials in primary cervical cancer conducted by large cooperative groups in the United States between 1981 and 1997. These trials were grouped into four categories based on disease stage and primary treatment modality: (i) stage IB with negative pelvic nodes treated with radical hysterectomy (RH) (n ⫽ 277), (ii) stage IB–IIA with positive pelvic nodes treated with RH (n ⫽ 239), (iii) stage IB 2 with negative pelvic and paraaortic nodes treated with radiation (n ⫽ 369), and (iv) stage IIB–IVA with negative paraaortic nodes treated with radiation (n ⫽ 1190). For each category, the Surveillance, Epidemiology, and End Results (SEER) database was used to identify comparable patients in the general population diagnosed over the same interval. Statistical comparisons between the age and ethnic distributions of each study population and that of SEER were performed using SAS. Results. The age distribution between the populations under comparison was equivalent, except for those with IB 2 disease treated with radiation where cooperative group subjects were more likely to be younger than 50 years, OR 0.17, 95% CI (0.11– 0.26). Evaluation of ethnicity revealed a higher proportion of black and Hispanic women enrolled in cooperative group studies in comparison to those registered by SEER. This was statistically significant in all four study categories. Conclusions. Black and Hispanic women are recruited into cooperative group trials in proportions slightly higher than the disease distribution in the general cervical cancer population. This is likely offset by the higher disease burden in these two groups. The age group distribution of the cooperative group trial population is comparable to that of the general population. This suggests that cooperative group trial results may be generalized to the “target population” without being significantly confounded by age or ethnicity. 15. Stage IC Adenocarcinoma of the Endometrium. Survival Comparisons of Surgically Staged Patients with and without Adjuvant Radiation Therapy. J. Michael Straughn Jr., Warner K. Huh, James W. Orr Jr., F. Joseph Kelly, Phillip Y. Roland, Michael A. Gold, Matthew A. Powell, David G. Mutch, Rebecca J. Howard, Yuting Zhang, Edward E. Partridge, Larry C.

483

Kilgore, J. Max Austin Jr., and Ronald D. Alvarez. Florida Gynecologic Oncology, Fort Myers, Florida; University of Alabama at Birmingham, Birmingham, Alabama; University of Oklahoma Health Science Center, Oklahoma City, Oklahoma; and Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to determine the outcomes of stage IC endometrial carcinoma patients who are managed with and without adjuvant radiation therapy after comprehensive surgical staging. Methods. Patients with FIGO stage IC adenocarcinoma of the endometrium diagnosed from 1988 to 1999 were identified from tumor registry databases at four institutions. A retrospective chart review identified 220 women who underwent comprehensive surgical staging including a total hysterectomy, bilateral salpingo-oophorectomy, pelvic/para-aortic lymphadenectomy, and peritoneal cytology. Data were collected on pathologic features, adjuvant therapy, recurrence, salvage therapy, and survival. High-risk histologic subtypes were excluded. Survival analysis and comparisons were performed using the Kaplan–Meier method and the log-rank test. Results. Of the 220 stage IC patients, 62 (28%) were G1, 111 (51%) were G2, and 47 (21%) were G3. A total of 56 (25%) patients received adjuvant brachytherapy (BT), 19 (9%) received whole pelvic radiation (WPRT), and 24 (11%) received both WPRT and BT. A total of 121 patients (55%) did not receive adjuvant radiation. There were a total of 20 recurrences— 6 (5%) in the radiated group and 14 (12%) in the nonradiated group. All 6 recurrences in the radiated group were distant and none of these were salvagedSeven of 14 recurrences in the nonradiated group were local and all were salvaged with radiation therapy. Two of 7 distant recurrences in this group were also salvaged with surgery and chemotherapy. The overall salvage rate for nonradiated patients was 64%. There was a statistical difference in 5-year disease-free survival between the radiated and nonradiated groups (93% vs 75%; P ⫽ 0.013). However, the 5-year overall survival was similar between the two groups (92% vs 90%; P ⫽ 0.717). Conclusions. Surgically staged patients with stage IC endometrial carcinoma who receive adjuvant radiation have fewer recurrences than conservatively managed patients. However, overall survival is not improved since the majority of local recurrences in conservatively managed patients can be salvaged with radiation therapy.

FOCUSED PLENARY SESSION ON OVARIAN CANCER—TUESDAY, MARCH 19, 2002 Moderator: Abstracts 16 –20, Nelson Teng 16. Chemoprediction in Ovarian Cancer—Genomic Approaches. Lynn C. Hartmann, Fergus J. Couch, Scott H. Kaufmann, William A. Cliby, Stephen J. Iturria, Kimberly R. Kalli, Karen Lu, Bob Bast, Jim Lillie, Jim Stec, Viji Shridhar, David I. Smith, and Ed Clark. Mayo Clinic, Rochester, Minnesota; M. D. Anderson Cancer Center, Houston, Texas; and Millennium Predictive Medicine, Cambridge, Massachusetts. Objective. At present, all women with advanced epithelial ovarian cancer are treated with a standard platinum–paclitaxel regimen. While most initially respond to therapy, the majority ultimately succumb to drug-resistant disease. We used expression array analysis to profile ovarian cancers from women with chemosensitive versus chemoresistant disease. We sought to identify mRNA markers that correlated with outcome. Methods. Fifty-one fresh-frozen epithelial ovarian cancer specimens obtained prior to exposure to chemotherapy were studied. All were advanced stage and high grade. All women had surgical debulking followed by standard platinum–paclitaxel therapy. Each sample was profiled for mRNA expression levels of 30,000 human genes using MLNM nylon cDNA arrays provided by Millennium Predictive Medicine. We applied a series of filters and algorithms to the total marker set to reduce it to 500 genes whose expression correlated most closely with response to chemotherapy. Then a supervised learning method (support vector machines, SVM) was applied to the 500-marker set to identify that set of markers which optimally classified the specimens. Results. The median time to recurrence for the 51

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SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS

patients was 21 months. Specimens obtained from women who were disease free for ⱖ21 months after diagnosis were considered sensitive; those from women who had recurred after less than 21 months were considered resistant. Clustering the samples by their overall genomic profile did not distinguish chemosensitive from chemoresistant disease. The SVM algorithm identified a top marker set of 10 candidate genes. When applied to a validation set of 28 samples, this particular marker set was associated with an error rate of 21%. By employing a combination of algorithms, we reduced the error rate to 14%. Conclusion. Expression array techniques may be able to identify chemoprediction markers in ovarian cancer. These may enable a more targeted approach to therapy for this disease and may serve to identify mediators of key pathways in chemosensitivity and resistance. 17. Prognostic Implications of Serum Soluble TNF Receptors Coupled with CA-125 in Patients with Epithelial Ovarian Cancer. A Gynecologic Oncology Group Study. Robert A. Burger, Kathleen M. Darcy, Philip J. Disaia, Bradley J. Monk, Elizabeth A. Grosen, Tetsuya Gatanaga, Gale A. Granger, Chungiao Tian, Parviz Hanjani, and David Cohn. Abington Memorial Hospital, Abington, Pennsylvania; Columbus Cancer Council, Columbus, Ohio; Gynecologic Oncology Group, Buffalo, New York; and University of California, Irvine, Orange, California. Objective. The aim of this study was to evaluate the association of simultaneously measured pretreatment levels of soluble tumor necrosis factor receptors (Sp55 and Sp75) and CA-125 with clinical characteristics and outcome of women with epithelial ovarian carcinoma. Methods. Subjects entered onto Gynecologic Oncology Group phase III platinum- and/or paclitaxel-based treatment trials from 1994 to 1999 were eligible. Serum samples obtained after primary surgery, prior to front-line chemotherapy, were analyzed for Sp55 and Sp75 by ELISA and CA-125 by RIA, with values evaluated using a natural log (ln) scale to approximate a normal distribution. The association between marker levels and clinical variables was evaluated using linear regression with the t test and an analysis of variance. Effects of markers on progression-free survival (PFS) were examined using the Kaplan–Meier method with the log-rank test and the Cox hazard regression model using the Wald test. Multivariate regression models were employed to adjust for the influence of confounding factors. Results. The median age of 139 women studied was 59 years, 87% were Caucasian, 78% had FIGO stages III/IV disease, and 58% had serous carcinomas. After adjusting for covariates, none of the three markers were associated with initial performance status, tumor grade, or cell type. Levels of Sp75 were directly associated with advanced age (P ⬍ 0.05). Sp55 and CA-125 levels were both directly associated (P ⬍0.05) with extent of disease, categorized as early stage (I/II), advanced– optimal (III with ⬍1 cm gross residual disease), and advanced–suboptimal (III/IV with ⬎1 cm residual disease). After adjusting for covariates, all three biomarkers were independently predictive of PFS (not overall survival) when the combination of the three biomarkers was included in the model. The hazard ratios for PFS after adjusting for age, extent of disease, cell type, and treatment were 1.28 (95% CI: 1.02–1.62) for CA-125, 0.41 (95% CI: 0.19 – 0.87) for Sp55, and 3.36 (95% CI: 1.28 – 8.78) for Sp75. Conclusions. Serum Sp75 may be directly associated with advanced age, while Sp55 and CA-125 both appear to be directly associated with extent of disease. Data from the combination of all three biomarkers in an adjusted multivariate Cox hazard regression model suggest that high serum levels of Sp75 and CA-125 are associated with shorter PFS, while high Sp55 levels predict longer PFS. 18. Vascular Endothelial Growth Factor Promotes Resistance to Platinum in Ovarian Carcinoma. Lin Zhang, Nuo Yang, Jose R. Garcia, Jonh Yao, Alisha Mohamed-Hadley, Stephen C. Rubin, and George Coukos. University of Pennsylvania, Philadelphia, Pennsylvania. Objectives. The aim of this study was to assess the effects of proangiogenetic factor vascular-endothelial growth factor (VEGF) on sensitivity to platinum in epithelial ovarian cancer (EOC). Methods. Thirty-one EOC specimens with disease-free interval (DFI) ⬍6 months (n ⫽ 15) or ⬎30 months (n ⫽ 16)

were evaluated for the expression of VEGF mRNA by quantitative real-time PCR. Expression of VEGF mRNA by established human EOC line A2780 and its platinum-resistant A2780/30CP was assessed by Northern blot. A murine EOC cell line overexpressing the murine VEGF-A 164 isoform was generated using the murine MIGR1 retrovirus encoding humanized green fluorescent protein (GFP), MIGR1/GFP, in which the murine VEGF-164 isoform cDNA was inserted upstream of the GFP. MIGR1/GFP or MIGR1/GFP encoding VEGF-164 was used to permanently transfect ID8 cells, a C57BL/6 murine ovarian carcinoma line generously provided by Dr. P. Terranova (Univ. of Kansas). A 99% GFP-positive population was selected by cell sorting. ID8 cells were incubated with recombinant murine VEGF (R & D Systems, U.S.A.) at 100 mcg/ml for 24 h and/or cisplatin (50 ␮M) for 24 h in vitro. Cell survival in vitro was assessed by MTT assays. Apoptosis in vitro was assessed by annexin V staining by flow cytometry. Statistical analysis was performed using Student’s t test. Results. EOC with disease-free interval ⬍6 months displayed threefold higher levels of VEGF mRNA compared to tumors with DFI ⬎30 months. The A2780/30CP line was found to express significantly higher constitutive levels of VEGF compared to A2780. ID8 cells were readily killed by cisplatin in a dose-dependent manner (IC 50 ⫽ 30 ␮M), while the VEGFoverexpressing ID8 line was found to be relatively resistant to cisplatininduced cell killing (IC 50 ⫽ 50 ␮M). VEGF-overexpressing ID8 cells displayed a threefold lower number of apoptotic cells compared to control ID8 cells following exposure to 50 ␮M cisplatin for 24 h (P ⬍ 0.01). Exposure of ID8 cells to recombinant murine VEGF in 100 ␮g/ml in vitro reduced the sensitivity of ID8 cells to cisplatin to levels comparable to the VEGF-overexpressing cell line. Conclusion. VEGF inhibits cisplatin-induced apoptosis in EOC cells in vitro and may contribute to the generation of chemotherapy resistance in vivo, suggesting an additional mechanism by which VEGF may adversely affect the outcome of EOC.

19. Determination of a Candidate Gene in Predicting in Vivo Ovarian Cancer Response to Combination Therapy with Carboplatin and Paclitaxel. Ramin Mirhashemi, J. Fernando Arena, Tony Frudakis, Nicholas Lambrou, Jane Arboleda, Marsha Hunt, Hervy E. Averette, and Manuel A. Penalver. DNAPrint Genomics, Sarasota, Florida; and University of Miami, School of Medicine, Miami, Florida. Objective. Patient response rates to primary treatment of ovarian cancer with a combination of paclitaxel and the carboplatin agents is subject to a high degree of uncertainty and interindividual variability. In an attempt to define the genetic determinants for this variability, we are conducting a pharmacogenomics study to predict response based on patient genomics. Methods. Our approach is a systematic haplotype-based candidate gene approach, where we genotype each patient at each single nucleotide polymorphic (SNP) site for each gene known to be relevant for xenobiotic disposition, and then computationally infer haplotypes and geometrically model the data in order to identify associations between haplotypes and response. We have chosen this novel approach to objectively define an optimal pharmacogenomics solution. Results. We have constructed SNP maps for 50 genes known to be involved in xenobiotic metabolism and/or the disposition of paclitaxel and carboplatin and have discovered an average of 30 candidate SNPs per gene, which, upon polymorphism screening, validated at a rate of about 18 SNPs per gene. Having obtained genotypes for 57 patients at each of the SNPs in several genes, preliminary results have revealed a statistically significant association (Fisher’s exact P ⫽ 0.00332 ⫾ 0.00043) between haplotypes at the CYP3A4 gene and a lack of response to paclitaxel/carboplatin as measured by the CA-125 tumor marker. In particular, the GAC and GAT CYP3A4 haplotypes were only present in the nonresponder group (n ⫽ 22), when an absolute decrease in CA-125 was used to define responders (n ⫽ 40). When a 20% decrease in CA-125 was used, a similar result was obtained (Fisher’s exact P ⫽ 0.016 ⫾ 0.001); GAC was found in the nonresponder group 71% of the time, and the GAT haplotype was found in the nonresponder group 100% of the time. Conclusion. SNPs in candidate genes being identified could potentially be used pretreatment to individualize chemotherapy for patients with ovarian

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS

TABLE 1—ABSTRACT 20 Study group (n ⫽ 26) Mean serum albumin (g/dl) cycle 1 3.4 (SD ⫽ 0.7) Albumin value after last cycle 3.9 (SD ⫽ 0.3) Performance status cycle 1 0 (SD ⫽ 1.2) Performance status after last cycle 1 (SD ⫽ 0.8) Mean CA 125 (U/ml) cycle 1 1830 (SD ⫽ 1128) Mean CA 125 value after last cycle 87.7 (SD ⫽ 98)

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Jeffrey M. Fowler, and David E. Cohn. James Cancer Hospital and Solove Research Institute; Ohio State University, Columbus, Ohio; and Washington University School of Medicine, St. Louis, Missouri.

Control group (n ⫽ 38)

P value

3.7 (SD ⫽ 0.7)

0.0785

4.0 (SD ⫽ 0.2)

0.2923

1 (SD ⫽ 1.1)

0.0066

1 (SD ⫽ 0.7)

0.7300

1326 (SD ⫽ 1131)

0.4400

15.9 (SD ⫽ 12.5)

0.1000

cancer. This in vivo assay could help classify ovarian cancer patients as potential responders or nonresponders to our conventional chemotherapeutic agents. 20. Comparison of Tolerance of Combination Carboplatin and Paclitaxel Chemotherapy by Age in Women with Ovarian Cancer. Jeannine A. Villella, Taimur L. Chaudhry, Michael L. Pearl, Fidel A. Valea, Paul A. Disilvestro, Simcha Pollack, and Eva Chalas. Columbia University College of Physicians & Surgeons, New York, New York; St. John’s University, Jamaica, New York; University at Stony Brook, Stony Brook, New York; and Winthrop-University Hospital, Mineola, New York. Objective. The aim of this study was to compare the tolerance of combination chemotherapy in women with ovarian cancer ⱖ70 years of age to those ⱕ55 years old. Methods. Charts of 26 women ⱖ70 years old (Study Group), and 38 women ⱕ55 years old (Control Group), receiving primary therapy for epithelial ovarian cancer between 1996 and 2001, were reviewed. Demographics included age, stage, histologic grade, cell type, volume of residual disease following surgery, perioperative complications, medical comorbidities, nutritional and performance parameters, and toxicities related to chemotherapy administration. The data were analyzed using ␹ 2 and Student’s t tests. Results. All patients underwent aggressive initial cytoreduction followed by chemotherapy with carboplatinum and paclitaxel. The groups were similar in stage, grade, and residual disease, number of cycles completed, the average dose of paclitaxel and carboplatinum, and the number of grade III/IV toxicities. A statistically significant difference was found in performance status at cycle 1 (Table 1). Conclusion. Women in the study group tolerated aggressive cytoreductive surgery and therapeutic doses of chemotherapy, despite a greater number of medical comorbidities. Although older women are more likely to have chemotherapy dose reduction, it still remains within the recommended standard dosage for treatment. This is likely based on age-related prejudice rather than adverse effects of therapy.

FOCUSED PLENARY SESSION ON ENDOMETRIAL/CERVICAL CANCER—TUESDAY, MARCH 19, 2002 Moderator: Abstracts 21–26, Bradley Monk 21. Lymphovascular Space Invasion Can Be Used to Assign Patients to Radiation or Lymphadenectomy as Adjuvant Therapy for Unstaged Endometrial Cancer. Neil S. Horowitz, David G. Mutch, Randall K. Gibb, Thomas J. Herzog, Janet S. Rader, Seok-Mo Kim, Tom P. Manolitsas,

Objective. The aim of this study was to determine the influence of lymphovascular space invasion (LVSI) on the risk of lymph node metastases from endometrial cancer. Methods. Patients who underwent surgical staging (including lymphadenectomy) for endometrial cancer from 1998 to 2000 were identified. Surgicopathologic data were abstracted. The influence of LVSI on the risk for nodal metastases was determined and comparisons were made with the ␹ 2 or Fisher exact test. Results. We identified 366 patients who fit study criteria. Pathologically, 92 tumors (25%) had LVSI, and 46 patients (13%) had nodal metastases. Cancers with LVSI were significantly more likely to have positive nodes (35/92 vs 11/274, P ⬍ 0.001). When controlled for tumor grade (G), the presence of LVSI continued to be a predictor of nodal disease (G1, 5/8 vs 13/151, P ⬍ 0.001; G2, 11/15 vs 12/91, P ⬍ 0.001; G3, 19/23 vs 32/77, P ⬍ 0.001). When controlled for depth of invasion, LVSI increased the risk of nodal disease (inner 1/3 invasion, 1/1 vs 2/90, P ⬍ 0.05; middle 1/3, 5/9 vs 23/148, P ⬍ 0.01; outer 1/3, 29/36 vs 31/81, P ⬍ 0.001). When tumor grade and depth of invasion were evaluated together, LVSI led to a significantly increased risk of pelvic node metastases, but only in deeply invasive tumors (Table 1). Conclusion. LVSI leads to an increased risk of lymph node metastases in deeply invasive endometrial cancers when tumor grade and depth of invasion are evaluated together. Consideration of lymphadenectomy or empiric pelvic radiation, not vaginal cuff brachytherapy alone, should be recommended for patients with an unstaged, deeply invasive endometrial cancer with LVSI. 22. Ten-Year Outcome for Poor-Histology or High-Risk Endometrial Cancer Patients Treated by Whole Abdominopelvic Irradiation. Alvaro A. Martinez, Sheldon Weiner, Donald A. Brabbins, Christine Mitchell, Kimberly D. Stewart, John Jennings, Peter Y. Chen, Jannifer Stromberg, and Alfred Sherman. William Beaumont Hospital, Royal Oak, Michigan. Objective. The aim of this study was to evaluate the long-term results of adjuvant whole abdominopelvic irradiation with a vaginal boost (WAPI) in patients with stage I–III endometrial carcinoma at high risk for intraabdominopelvic recurrence including clear cell and serous-papillary histologies. Methods. In a prospective nonrandomized trial, 119 patients were treated with adjuvant WAPI between November 1981 and April 2000. Mean age at diagnosis was 66 years (39 – 88). Thirty-eight patients (32%) were 1998 FIGO stage I–II, and 81 (68%) were stage III. Pathological features included 64 patients (54%) with deep myometrial invasion, 48 (40%) with positive peritoneal cytology, 69 (58%) with high-grade lesions, 21 (18%) with positive pelvic/para-aortic lymph nodes, and 44 (37%) with serous papillary or clear cell histology. Results. Mean follow-up was 5.8 years (0.2–14.7). The 5- and 10-year cause-specific survival (CSS) was 75 and 69%, whereas disease-free survival (DFS) was 58 and 48%. When stratified by histology the 5- and 10-year CSS for adenocarcinoma was 76 and 71% while for serous papillary/ clear cell it was 74 and 63% (P ⫽ 0.917). The 5- and 10-year DFS for adenocarcinoma was 60 and 50%, whereas for serous papillary/clear cell it was 54 and 37% (P ⫽ 0.498). For surgical stages I–II the 5-year CSS was 82% for adenocarcinoma and 87% for –papillary (P ⫽ 0.48). For stage III, it was 75 and 66% (P ⫽ 0.129), respectively. When stratified by histology, 32% of patients with adenocarcinoma and 30% with serous-papillary developed recurrent disease. The majority of failures for both groups were in the abdominopelvic region. Multivariate regression analysis (age, surgical stage, grade, myometrial invasion, histologic type, lymph node status, and peritoneal cytology) demonstrated age (P ⫽ 0.01) and surgical stage (P ⫽ 0.03) to be significant for CSS while age (P ⫽ 0.03) was the only significant prognostic factor for DFS. Chronic grade 3 GI toxicity was 12% and grade 3 renal toxicity was 2%. Conclusion. Adjuvant WAPI is a very effective treatment with excellent 10-year results for stage I–III endometrial carcinoma with risk factors for intraabdominopelvic recurrence, including serous–papillary or clear cell histology, deep myometrial invasion, high grade, nodal involvement, and positive

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peritoneal cytology. The low long-term complication rate with high CSS makes WAPI the treatment of choice for these patients. 23. CYP2E1, GSTM1, and mEH Genetic Polymorphisms and Susceptibility to Cervical Cancer. Carlos H. Sierra, Sonia C. Robazetti, Concepcion D. Arrastia, Stephen K. Tyring, and William W. Au. University del Cauca, Popayan, Colombia; and University of Texas Medical Branch, Galveston, Texas. Objective. Infection with high-risk human papillomavirus (HPV) plays a major role in the etiology of cervical cancer (CC). However, most infected women do not develop cancer. Therefore, exposure to other carcinogenic agents such as those present in cigarette smoke may be a contributing risk factor toward the development of CC. The aim of this study was to investigate the hypothesis that inheritance of genetic polymorphisms in the cytochrome P4502E1 (CYP2E1), glutathione S-transferase mu (GSTM1), and microsomal epoxide hydrolase (mEH) genes, involved in the chemical metabolism of cigarette smoke, significantly increases the risk for CC. Methods. This molecular epidemiology study was conducted in the United States and Venezuela. A total of 300 subjects were recruited for this study, of which 114 women with biopsy-confirmed high-grade cervical intraepithelial neoplasia or CC were selected as cases and 158 healthy women were selected as controls. We collected an exfoliated cervical cell sample for high-risk HPV DNA detection using hybrid capture II and a blood sample to extract genomic DNA for genetic polymorphism characterization using a PCR-RFLP method. In addition, women were interviewed to collect information on personal, smoking, and health history using a questionnaire. Controls were matched for age, ethnicity, and place of recruitment. Results. Cases were 44 times more likely to be infected with HPV than controls (P ⬍ 0.001). Women who smoked ⬎15 pack-years have a 2.9-fold increased risk for CC (95% CI ⫽ 1.2–7.0, P ⬍ 0.05). The CYP2E1 variant and GSTM1 null genotypes had a nonsignificant 1.5-fold increased risk for CC compared to women with the CYP2E1 wild-type and GSTM1 present genotypes, respectively. The mEH variant genotype induced a significant 2.6-fold increase in risk for CC (95% CI ⫽ 1.4 – 4.9, P ⬍ 0.01) compared to women with the wild-type genotype. Furthermore, smokers inheriting the mEH variant genotype have a significant 3.6-fold increase in risk for CC compared to nonsmokers with this trait (2.8-fold). Cases with both GSTM1 null and mEH variant genotype have a 3.2-fold increased risk for CC (95% CI ⫽ 1.2– 8.5, P ⬍ 0.05). Conclusion. Our data suggest that the mEH variant genotype confers susceptibility to CC, especially among smokers. In addition, our study provided a better understanding of the differential contribution of risk factors for CC in the United States and Venezuela. 24. Human Papillomavirus DNA Triage in the Management of Women with ASCUS Cytology—Results from the ALTS Trial. Edward E. Partridge for the Alts Group. National Cancer Institute, Bethesda, Maryland; and, University of Alabama at Birmingham, Birmingham, Alabama. Objective. The most effective way to manage the approximately two million women in the United States who receive a cervical cytologic diagnosis of ASCUS each year is unclear. One of the objectives of the ALTS trial was to determine the most effective way to manage women with this diagnosis.

Methods. The ALTS trial enrolled 3488 women with an ASCUS Pap smear at four clinical centers. Women were randomized to one of three strategies: immediate colposcopy (IC arm); triage to colposcopy if the Hybrid Capture II for cancer-associated HPV types was positive or missing or if the ThinPrep was HSIL (HPV arm); or conservative management with triage to colposcopy if the ThinPrep was HSIL (CM arm). All women were followed at 6-month intervals for 24 months: an HSIL ThinPrep triggered referral to colposcopy. All women received a colposcopic exam at exit from the study. Results. At enrollment, 100% of women in the IC arm were referred to colposcopy compared to 56% in the HPV arm and 9% in the CM arm. The cumulative number of cases of CIN3⫹ detected over 2 years was 97 (8.3%) in the IC arm, 100 (8.6%) in the HPV arm, and 107 (9.2%) in the CM arm. Fifty-eight percent of the cumulative CIN3⫹ was detected at enrollment in the IC arm compared to 70% in the HPV arm and only 37% in the CM arm. Thirty-six percent of the CIN3⫹ was detected at the exit colposcopy in the CM arm compared to 18% in the HPV arm and 25% in the IC arm. Fifteen percent of women with an ASCUS Pap test had CIN 2 or 3 detected within 2 years. Overall, for all cumulative cases of CIN3⫹ detected over 2 years in all arms, the single enrollment HPV test had a triage sensitivity of 93% and would have referred 55% of women for colposcopy. By comparison, in the CM arm, two repeat cytologies at an HSIL threshold had only 48% sensitivity and referred 10% to colposcopy. Two repeat cytologies at an ASCUS threshold provided 93% sensitivity and referred 65% for colposcopy. Conclusion. Following an ASCUS cytology, HPV DNA triage is effective compared with immediate colposcopy in the timely detection of histologically confirmed CIN3⫹. Repeat cytology surveillance is a safe option at a threshold of ASCUS, provided that women are compliant; however, the tradeoff of sensitivity with specificity is not as favorable. 25. Costs and Effectiveness of Alternative Strategies for Cervical Cancer Screening in Military Beneficiaries. G. Larry Maxwell, Jay W. Carlson, Mark Ochoa, Thomas C. Krivak, and Evan Myers. Duke University Medical Center, Durham, North Carolina; and Walter Reed Army Medical Center, Washington, DC. Objective. The aim of this study was to determine the potential effects, on costs and outcomes, of changes in sensitivity and specificity associated with new screening methods for cervical cancer in the military. Methods. A Markov model of the natural history of cervical cancer was created to simulate a cohort of 100,000 military beneficiaries aged 15– 85. Probability estimates for various outcomes and the accuracy of screening tests were obtained from the literature. Cost estimates were obtained from military sources when available; otherwise, civilian costs were used. Costs were valued in 2000 U.S. dollars, and costs and life expectancy were discounted at a 3% annual rate. The outcomes and costs of conventional cytology, liquid-based cytology (LBC), and LBC with human papillomavirus (HPV) testing were compared at 1-, 2-, and 3-year screening frequencies. Results. Marginal reductions in the incidence of cervical cancer from increasing screening sensitivity are greater than reductions in cancer mortality at every screening interval. Incremental improvements in both cancer incidence and mortality are higher at less frequent screening intervals. Increases in the ratio of low-grade to high-grade lesions result from increasing the sensitivity of the screening test or shortening the

TABLE 1—ABSTRACT 21 Pelvic Lymph Node Metastases Stratified by Tumor Grade, Depth of Invasion, and LVSI (ⴙ or ⴚ)

Grade 1 Grade 2 Grade 3

Inner 1/3 invasion

Middle 1/3 invasion

Outer 1/3 invasion

0/0 (⫹) vs 0/65 (⫺) 1/1 (⫹) vs 0/12 (⫺) 0/2 (⫹) vs 0/11 (⫺)

1/8 (⫹) vs 2/59 (⫺) 1/6 (⫹) vs 5/50 (⫺) 3/14 (⫹) vs 2/20 (⫺)

4/10 (⫹) vs 1/17 (⫺), P ⬍ 0.05 9/15 (⫹) vs 5/23 (⫺), P ⬍ 0.05 15/35 (⫹) vs 2/18 (⫺), P ⬍ 0.05

Note. (⫹), LVSI positive; (⫺), LVSI negative; comparisons not significantly different except when specified.

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS screening interval. Both LBC and LBC/HPV testing are cost effective (⬍$50,000 life-year saved) when performed at 3-year screening intervals. However, no strategy (including conventional cytology) is cost effective when performed more frequently than every 3 years. Conclusion. Use of a more sensitive cervix cancer screening test increases costs; however, a more sensitive test done less frequently may be more effective and less expensive than the conventional cytology done annually. In the military setting, this has significant implications for both expense reduction and readiness enhancement. 26. Confirming the Mechanisms of Fragile Histidine Triad Inactivation for Clinical Biomarker Development in Cervical Cancer. Jayanthi S. Lea, David G. Burbee, Sabeeha Muneer, Raheela Ashfaq, David S. Miller, John D. Minna, and Carolyn Y. Muller. University of Texas Southwestern Medical Center, Dallas, Texas. Objective. Loss of the fragile histidine triad (FHIT) protein has been documented in cervical cancers and dysplasia. Genomic deletions and aberrant promoter methylation, two potential clinical biomarkers, have been implicated in FHIT inactivation. The goal of this study is to confirm the utility of homozygous deletions, aberrant methylation, and immunohistochemical (IHC) evaluations of FHIT, which are proposed biomarkers of FHIT status, as functionally relevant determinants of FHIT expression in cervical carcinogenesis. Methods. Matched DNA, RNA, and protein from early passaged cervical cancer cell lines (SiHa, Caski, HeLa, C4II, C4I, MS 751, ME 180, HT3, C33A) were studied. Fourteen DNA markers spanning FHIT were used to examine the extent of homozygous deletions for each DNA. We investigated 5⬘ CpG island methylation of FHIT by methylation-specific PCR assays designed to detect either methylated or unmethylated FHIT sequences. FHIT transcripts were characterized by RT-PCR. Western blot analysis and IHC were performed using polyclonal antibody against the FHIT protein. Results. Homozygous deletions removing part of both alleles were found in six of nine cell lines but only one (C33A) had a homozygous deletion involving an exon (exon 5). Complete loss of wild type (wt) FHIT transcripts was found in four of nine (SiHa, C4II, MS751, C33A) cell lines. As reported previously, aberrant FHIT transcripts were found in normal cervical cells and nine of nine lines. By the gold standard, Western blot, FHIT protein expression was lost in four of nine cell lines (SiHa, C4II, MS751, C33A); a perfect correlation with loss of wt FHIT transcript. By contrast, all of the nine lines stained positively for FHIT by IHC. All nine lines had methylated alleles, while six also exhibited unmethylated alleles (SiHa, HeLa, C4II, C4I, ME180, C33A). Thus, there were two lines (Caski, HT3) that expressed FHIT transcripts and protein while exhibiting only methylated alleles. Conclusion. Our analysis indicates that there is excellent concordance between loss of wt FHIT transcripts and loss of FHIT protein expression by Western blotting. By contrast, aberrant methylation and immunohistochemical staining for FHIT are not concordant with these features and caution should be taken in their use as biomarkers for cervical cancer. Further studies correlating biomarkers to mechanisms are of critical importance.

PLENARY SESSION III—TUESDAY, MARCH 19, 2002 Moderator: Abstracts 27–29, Terri Cornelison 27. Standard Timed Doxorubicin plus Cisplatin versus Circadian-Timed Doxorubicin plus Cisplatin in Patients with FIGO Stage III/IV or Recurrent Endometrial Carcinoma. A Gynecologic Oncology Group Study. Holly H. Gallion, Virginia L. Brunetto, Samuel S. Lentz, Gary Reid, John T. Soper, Robert A. Burger, and Willie Anderson. Duke University Medical Center, Durham, North Carolina; Magee-Women’s Hospital, University of Pittsburgh, Pittsburgh, Pennsylvania; Riverside Methodist Hospital, Columbus, Ohio; Roswell Park Cancer Institute, Buffalo, New York; University of California Irvine Medical Center, Orange, California; Uni-

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versity of Virginia Medical School, Charlottesville, Virginia; and Wake Forest University School of Medicine, Winston-Salem, North Carolina. Objective. The aim of this study was to determine whether circadian-timed (CT) chemotherapy results in improved response, progression-free survival (PFS), overall survival (OS), and toxicity, compared to standard-timed (ST) chemotherapy. Methods. Patients (pts) with stage III or IV or recurrent endometrial cancer and poor potential for cure by radiation therapy or surgery entered this randomized Phase III Gynecologic Oncology Group study. All pts had measurable disease and no prior chemotherapy. Therapy was randomly allocated between ST doxorubicin (60 mg/m 2) plus cisplatin (60 mg/m 2) and CT doxorubicin (60 mg/m 2) at 6 AM plus cisplatin (60 mg/m 2) at 6 PM. Courses were repeated every 3 weeks for a maximum of eight cycles. Results. The ST arm was allocated to 169 pts and the CT arm to 173 pts. More than 90% of cycles were given within 30 min of schedule on the CT arm. Response rates were 46% in the ST group compared to 49% in the CT group (P ⫽ 0.26, one-tailed). Median PFS and OS were 6.5 and 11.2 months., respectively, in the ST group and 5.9 and 13.2 months in the CT group (PFS: P ⫽ 0.31, OS: P ⫽ 0.21: one-tailed). Median total doses were 216 mg/m 2 doxorubicin and 349 mg/m 2 cisplatin in the ST group versus 251 mg/m 2 doxorubicin and 356 mg/m 2 cisplatin in the CT group. Grade 3 or 4 leukopenia occurred in 73% patients on the ST arm and 63% of pts on the CT arm. Treatment-related deaths were as follows: renal failure 3 pts, cardiogenic shock 1 pt, sepsis 3 pts, AML 1 pt. Conclusion. Circadian-timed doxorubicin plus cisplatin chemotherapy offers no significant benefit in terms of response rate or progression-free or overall survival in pts with advanced or recurrent endometrial cancer. 28. Gemcitabine Reverses Cisplatin Resistance. Demonstration of Activity in Platinum and Multidrug-Resistant Ovarian and Peritoneal Carcinoma. Peter G. Rose, Kimberly Mossbruger, Nancy Fusco, Mary Smrekar, Susan Eaton, and Michael Rodriguez. University Hospitals of Cleveland, MacDonald Women’s Hospital, Cleveland, Ohio. Objective. Preclinical models in an ovarian cancer cell line (A2780) demonstrate synergistic activity with the combination of gemcitabine and cisplatin compared to either single agent alone. Furthermore, the combination results in increased platinum-adduct formation compared to cisplatin alone. Platinum sensitivity has been shown to be related to the expression of excision repair proteins, one of which (ERCC-1) has been identified as playing a critical role in the synergy of gemcitabine and cisplatin. We evaluated the cisplatin and gemcitabine regimen in patients with platinum-refractory and multidrug-refractory ovarian and peritoneal carcinoma. Methods. Gemcitabine at a dose of 750 mg/m 2 was administered intravenously over 30 min followed by cisplatin at a dose of 30 mg/m 2 on days 1 and 8 every 21 days. Day-8 therapy was held for an absolute neutrophil count ⬍1000/mm 3 or platelet count ⬍75,000/mm 3. Dose reductions of gemcitabine to 600 mg/m 2 were prescribed in the event of canceled therapy, neutropenic sepsis, or grade 4 thrombocytopenia. Results. Twenty-nine platinum-resistant patients were studied. The patients were heavily pretreated with a median of 3 nonplatinum/paclitaxel prior regimens (range 0 – 6). Twenty-six patients are currently evaluable of which 4 had progressed on gemcitabine as a single agent. Ten (38%) responded (8 ⫽ PR, 2 ⫽ CR), with 3 of the 4 patients who had failed gemcitabine as a single agent responding. None of the responding patients have progressed with a median response duration of 3⫹ months (range 2⫹– 8⫹ months). For all patients the progression-free interval was 3 months (range 1– 6⫹ months). Survival is immature, with only 3 patient deaths. Conclusion. The combination of gemcitabine and cisplatin is active in patients who are platinum resistant. Additionally, activity is demonstrated even in patients who have previously been resistant to gemcitabine. 29. Reduced Frequency of HLA-A2 Class I Found in Subjects with Low- and High-Grade Squamous Intraepithelial Lesions. Peggy A. CrowleyNowick, Frederick P. Bowman, Jennifer M. Geores, Edmund S. Cibas, and Ellen E. Sheets. Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts.

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Objective. Human leukocyte antigen-A2 (HLA-A2) is a common class I HLA allele and is therefore often targeted by therapeutic vaccines to bind peptides for antigen presentation and subsequent stimulation of cytotoxic T lymphocytes. During several HPV vaccine trials few subjects with HSIL were shown to express HLA-A2, suggesting that HSIL subjects do not demonstrate a normal distribution of HLA alleles. The objective of this study was to determine the frequency of HLA-A2 positivity in women with normal cytology and low- and high-grade SIL and to evaluate possible associations of HLA-A2 with HPV 16 infection. Methods. ThinPrep cytology material or peripheral blood was obtained from women with HSIL (n ⫽ 90), LSIL (n ⫽ 82), and normal cytology (n ⫽ 111). DNA was isolated using standard techniques and subjected to low-resolution PCR amplification with sequence-specific primers (PCR-SSP; Dynal Limited, Wirral, UK) for analysis of the HLA-A haplotype. DNA isolated from ThinPrep material of 55 HSIL patients was examined by PCR for analysis of HPV 16 positivity. Results. The HLA-A2 haplotype was found in 46.8% of women with normal cytology compared to 23.2 and 23.3% for LSIL and HSIL, respectively (␹ 2 P ⫽ 0.0002). Both LSIL and HSIL subject groups demonstrated lower HLA-A2 frequency compared to subjects with normal cytology (P ⫽ 0.002 and 0.0015, respectively). No difference in the A2 frequency was found between HSIL and LSIL subjects. A subgroup of 10 positive and 45 negative HLA-A2 HSIL subjects was analyzed for HPV 16 infection. Among the 10 HLA-A2-positive patients, 4 were HPV16 DNA positive (40.0%), while 15 of the 45 (33.3%) HLA-A2-negative patients were HPV 16 positive. In this limited subgroup, no significant association between HPV 16 infection and HLA-A2 was found. HPV typing of all subjects is ongoing. Conclusion. The frequency of the HLA-A2 haplotype is significantly lower in subjects with abnormal cervical cytology regardless of the grade of disease. However, HLA status was not associated with HPV 16 infection. While the development of SIL may be a complicated process, these data suggest that individuals who express the HLA-A2 haplotype may be protected from development of SIL. (Supported by CYTYC Corporation and CA81541.)

FOCUSED PLENARY SESSION ON MOLECULAR ANALYSIS OF GYNECOLOGIC CANCERS—WEDNESDAY, MARCH 20, 2002 Moderator: Abstracts 30 –34, Richard Buller 30. MSI, MLH1 Promoter Methylation, and Loss of Mismatch Repair in Endometrial Cancer and Concomitant Atypical Hyperplasia. Neil S. Horowitz, Karen Pinto, David G. Mutch, Thomas J. Herzog, Janet S. Rader, Randall K. Gibb, Tina Bocker Edmonston, and Paul J. Goodfellow. Thomas Jefferson University School of Medicine, Philadelphia, Pennsylvania; and Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to determine the relative timing of hMLH1 promoter methylation (Meth) and the loss of DNA mismatch repair in endometrial tumorigenesis. Method. We investigated microsatellite instability (MSI) and Meth in a large series of endometrial carcinoma (CA) and concomitant atypical endometrial hyperplasia (AEH). All cases for which the research tumor specimen DNA was shown to be MSI-high (H) and Meth-positive were evaluated for concomitant AEH. If AEH was present, laser capture microdissection (LCM) was used to resample areas of CA and isolate foci of AEH from archival tissue. LCM CA and AEH DNAs were assessed for MSI using PCR. Meth was evaluated by amplifying sodium bisulfite converted DNA with two rounds of PCR, subjecting the resultant amplicon to restriction digest with BstUI, resolving the restriction fragments on 6 –10% polyacrylamide gels, and visualizing them by autoradiography. Immunohistochemistry (IHC) was performed to assess expression of MLH1. Results. Among 87 MSI-H research tumor specimens, 62 were previously shown to be Meth-positive and, of these, 27 had identifiable concomitant AEH. We isolated 27 foci of CA and 51 foci of AEH by LCM. Like the original research tumor, the majority of LCM-

derived DNA was MSI-H, with 26 of 27 CAs (96%) and 46 of 51 AEHs (90%) being MSI-H. The majority of CAs, 23 of 27 (85%), and AEHs, 41 of 51 (80%), were also Meth-positive. Of the 72 MSI-H LCM-prepared DNAs, 13 (18%) were MLH1 unmethylated, while 5 of 6 (83%) MSI-stable or MSI-low DNAs were Meth positive. In addition to these 18 DNAs with discordant MSI or Meth status, 3 cases failed to have a focus of AEH that matched the MSI or methylation profile of the LCM CA or research tumor specimen. All other cases had at least one focus of AEH that was MSI and Meth identical to the LCM CA or research tumor. IHC revealed that the MLH1 protein was absent in both Meth-positive and -negative areas of CA and AEH. Regions of simple hyperplasia without atypia also did not stain with the MHL1 antibody. Conclusions. MLH1 promoter methylation is an early event in endometrial tumorigenesis and may precede the development of MSI in a subset of tumors. Although Meth is correlated with loss of mismatch repair, it may not be necessary for gene silencing. The observed patterns of MSI and Meth are consistent with a model in which CA and AEH are polyclonal with multiple genetically distinct populations arising within the same uterus. 31. The Role of DAP Kinase Hypermethylation in Ovarian Carcinomas. Yvonne C. Collins and Shashikant B. Lele. Roswell Park Cancer Institute, Buffalo, New York. Objective. Death-associated protein (DAP) kinase is a serine/threonine kinase that plays an integral role in programmed cell death. Additionally, it has been shown to have a role in metastasis in multiple cancers. Epigenetic silencing of this gene occurs due to hypermethylation of the promoter region. The purpose of our study was to determine whether the hypermethylation status of DAP kinase plays a role in the aggressiveness of ovarian carcinomas. Methods. We studied a total of 45 samples including human genomic DNA, a transformed normal surface epithelial ovarian cell line, ovarian cancer cell lines (A2780 and OvCAR 3), ovarian carcinoma tumor samples, and peripheral blood. There were 7 unpaired (tumor only) ovarian samples: 2 were stage II, 4 were stage III, and 1 was stage IV, all with varied histology. There were 17 paired (blood/tumor) samples. Methylation-specific polymerase chain reaction was performed using special primers (methylated and unmethylated) to determine the DAP kinase methylation status. Results. The human genomic DNA sample, as well as the normal surface epithelial ovarian cell line, was unmethylated as expected. The 2 ovarian cancer cell lines were found to be methylated. Six of 7 (86%)in the unpaired class were methylated. All of the patients in this group were dead at the time of the study. In the paired group, 3 of 34 (8.8%) of the samples were unmethylated. At the time of the study, there were 8 surviving patients: 5 with papillary serous histology, 1 consistent with papillary adenocarcinoma, 1 clear cell, and 1 cystadenoma. With the exception of 1 patient, all of these patients were noted to have hypermethylation of the DAP kinase gene. Conclusion. Hypermethylation of the DAP kinase promoter region is common in ovarian carcinomas despite histology or stage. Although more research must be done, this mechanism may play a role in the development of future diagnostic modalities. Hypermethylation may be a source of the aggressiveness of ovarian carcinomas. 32. The CA125 Gene. An Extracellular Superstructure Dominated by Repeat Sequences. Timothy J. O’Brien, John B. Beard, Lowell J. Underwood, Alessandro D. Santin, Richard A. Dennis, and Lyndal York. University of Arkansas for Medical Sciences, Little Rock, Arkansas. Objective. The aim of this study was to define the genomic structure and the gene sequence of CA125. Methods. Cloning of the CA15 gene was accomplished by purification of cognitive glycopeptides using cyanogen bromide digestion and amino acid sequencing. Gene sequencing was accomplished by PCR amplification using redundant primers followed by 3⬘ and 5⬘ race extension. Results. The CA125 protein core is composed of a short cytoplasmic tail, a transmembrane domain, and an extraordinary large glycosylated extracellular structure. This structure is dominated by a repeat domain of 156 amino acid repeat units which encompass the epitope binding domains. The molecule also includes an amino terminal domain of serine/threonine rich sequences which

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS would account for most of the O-glycosylation known to be present in CA125. CA125 is an unusually large transmembrane glycoprotein. Its release from the surface of the cell is most probably dependent on cytoplasmic phosphorylation followed by proteolytic cleavage. The extracellular domain is characterized by a large number of repeat units (probably 40 – 60) which encompass an interactive C-loop and are the site of OC125 and M11 binding. Sequencing the gene provides us with the ability to initiate the quest to understand the biological function of CA125. Conclusion. Sequencing of the CA125 gene provides us with the ability to begin to understand its biological function and to design better diagnostic and therapeutic tools for patient care. 33. High Expression of Tumor Necrosis Factor-Related Apoptosis-Inducing Ligand (TRAIL) Is Associated with Favorable Survival in Ovarian Cancer. Johnathan M. Lancaster, Laura J. Havrilesky, David W. Schomberg, Robyn Sayer, Jeffrey Marks, and Andrew Berchuck. Duke University Medical Center, Durham, North Carolina. Objective. The molecular basis for differences in responsiveness to therapy between ovarian cancers remains poorly understood. Recently, the tumor necrosis factor-related apoptosis-inducing ligand (TRAIL), which is expressed by various cell types, has been shown to act synergistically with cytotoxic agents to induce apoptosis in ovarian cancer cell lines. In this study, we sought to determine whether high expression of TRAIL by ovarian cancers is predictive of favorable survival. Methods. Quantitative real-time polymerase chain reaction was used to measure relative expression of the TRAIL gene in tissue samples from 133 epithelial ovarian cancers (16 stage I/II, 117 stage III/IV) and 8 human ovarian surface epithelial samples. Patients with ovarian cancer underwent surgical resection of their primary tumor and debulking of metastases followed by platinum-based chemotherapy. Results. Ovarian cancers demonstrated a 10-fold higher mean TRAIL expression compared to ovarian epithelial samples (P ⬍ 0.001). Among the 133 ovarian cancers, after controlling for stage, high TRAIL expression was associated with favorable survival (Spearman correlation coefficient, 0.26, P ⫽ 0.03), and TRAIL expression was 2.3-fold higher in cancers from patients who lived more than 5 years compared to those who died within 1 year (P ⫽ 0.03). TRAIL expression was quantitated relative to an internal control and, using a cutoff value of 0.5, the median survival for 76 patients with low TRAIL (⬍0.5) expression was 37.5 months compared to 46 months for 57 patients with high TRAIL (⬎0.5) expression (P ⫽ 0.07). Grade II/III cancers expressed 3.1-fold more TRAIL than grade I tumors, and mean TRAIL expression was 75% greater in advanced stage (III/IV) cancers relative to early stage (I/II) cancers (P ⫽ 0.14). No difference was identified in TRAIL expression between cancers subject to optimal versus suboptimal primary cytoreduction. Conclusion. Expression of TRAIL is significantly higher in ovarian cancers relative to normal ovarian epithelium. High TRAIL expression in ovarian cancers is associated with favorable survival and this may be attributable to increased chemosensitivity of cancers that express the most TRAIL. The use of TRAIL to enhance chemosensitivity of ovarian cancers represents an appealing molecular therapeutic strategy. 34. Antitumor Immune Response Significantly Affects the Outcome and Provides Important Prognostic Biomarkers in Epithelial Ovarian Cancer. George Coukos, Lin Zhang, Jose R. Conejo-Garcia, Eugene Kang, Dionyssios Katsaros, Micheal Liebman, Phyllis Gimotty, and Stephen C. Rubin. University of Pennsylvania, Philadelphia, Pennsylvania; and University of Turin, Turin, Italy. Objectives. The aim of this study was to assess whether antitumor immune response affects the outcome of epithelial ovarian cancer (EOC). Methods. A total of 165 consecutive snap-frozen stage III EOC specimens from a single institution collected between 1989 and 1999 were evaluated. Kaplan–Meier curves for disease-free interval (DFI) were compared using a log-rank test. Multivariate analysis was performed with an accelerated failure time model. Tumor-infiltrating T lymphocytes (TILs), memory TILs, and activated antigenpresenting cells were detected by immunohistochemistry using monoclonal antibodies against CD3, CD45RO, and CD86 (Pharmingen BD), respectively.

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Quantitative real-time PCR (q-PCR) was performed using a SYBR green I PCR kit. Clustering analysis was performed using the Cluster and TreeView programs. Transcriptional profiling was performed using Clontech ATLAS hematology/immunology filter arrays. Results. TILs were detected within tumor islets (intratumoral TILs) in approximately 50% of tumors, while they were restricted to the stroma surrounding tumor islets (peritumoral T cells) in the remainder. Among 81 consecutive tumors identified with complete clinical response following first-line platinum-based chemotherapy, tumors with intratumoral TILs displayed 6.2-fold longer median DFI compared to tumors lacking intratumoral TILs (P ⫽ 0.001). Only surgical debulking (P ⬍ 0.001) and TILs (P ⬍ 0.01) were independent prognosticators of DFI length, while patient age, tumor histology or grade, and paclitaxel were not. Tumors with intratumoral TILs displayed significantly higher numbers of activated or memory TILs and mature antigen-presenting cells (APCs) as well as significantly higher mRNA levels of inflammatory cytokines, chemokines, and vascular cell adhesion molecules (VCAMs) involved in the chemoattraction, extravasation, and migration of activated or memory T cells and APCs. Clustering analysis of q-PCR data revealed sets of genes which could predict DFI in tumors with intratumoral TILs or independent of TILs. Molecular profiling of tumors revealed that the same chemokines, VCAMs, and markers of lymphocyte activation provide important biomarkers for the prognosis of ovarian carcinoma. Conclusion. Antitumor immune response significantly affects the outcome of ovarian carcinoma and provides important biomarkers for this disease.

FOCUSED PLENARY SESSION ON SURGICAL TECHNIQUES–WEDNESDAY, MARCH 20, 2002 Moderator: Abstracts 35– 40, Manuel Penalver 35. Abdominal Radical Trachelectomy Follow-Up on the First 20 Cases. Laslo Ungar, Giuseppe Del Priore, Deborah C. Boyle, and J. Richard Smith. Bellevue Hospital, New York University School of Medicine, New York, New York; Charing Cross Hospital, Imperial College of Medicine, London, United Kingdom; and St Stephens Hospital, Budapest, Hungary. Objectives. For fertility preservation in early cervical cancer, we developed a new technique in 1997 called the abdominal radical trachelectomy (ART). We now present our updated experience with the first 20 patients. Methods. Since 1997, all patients with IB1/2 cervical cancer and a desire to retain fertility were candidates for ART. Standard abdominal radical hysterectomy is preformed as previously described. Briefly, the ovarian vessels are preserved while the lower uterine segment is transected to retain the fundus. The cervix is then removed en bloc with the parametria and upper vagina. A section of the retained fundus is sent for frozen section to ensure a tumor-free margin. A mushroom catheter is inserted into the endometrial cavity of the retained uterus to prevent occlusion of the newly formed “cervical” canal. The vault of the vagina is sutured to the lower uterine segment. Results. Mean age at surgery was 30.6 years, height was167.2 cm, weight was64.3 kg, and operative time was 3.75 h and 32.2 pelvic nodes were removed. No paraaortic nodes were removed. The average EBL was 1000 cc, 66.6% of patients received perioperative transfusions, and 44.4% required antibiotics. There were no bowel or bladder injuries except 1 case of unilateral ureteral injury. There were no positive margins or parametria. Median follow-up has been 21months (range 3– 48) with no recurrences. All patients resumed normal menses within 3 months. Five patients have tried to conceive. Two did so at 20 and 22 months after surgery. One pregnancy ended in miscarriage at 5weeks EGA. The other patient is still pregnant (EDC 2/1/02). Another patient was 4 weeks EGA at the time of ART but the pregnancy ended in miscarriage 4 weeks later. One patient elected to undergo an abdominal hysterectomy because of an abnormal Pap smear 5 months after ART surgery. No tumor was seen in the hysterectomy specimen. Conclusions. ART appears to provide the same pelvic lymph node dissection and parametrial clearance as traditional radical abdominal hysterectomy with no detectable increase in cancer recurrences. Selection criteria for ART can be equivalent to those of the traditional abdominal Wertheim hys-

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terectomy. There is no need for special competency in vaginal or laparoscopic surgery. All trained gynecologic oncologists should be capable of performing this procedure. Additional studies are needed to define the place for ART in gynecologic oncology for cervical cancer patients wishing to preserve fertility. 36. Total Mesometrial Resection—Nerve-Sparing Extended Radical Hysterectomy. Surgical Techniques and Results of a 3-Year Prospective Study. Michael Hoeckel, Gert Naumann, Bettina Hentschel, Lars-Christian Horn, and Susanne Hoeckel. University of Leipzig, Leipzig, Germany. Objective. In the surgical treatment of rectal cancer both the incidence of locoregional recurrences and late sequelae from intraoperative pelvic autonomic nerve damage have been significantly reduced by total mesorectal excision. We claim to achieve similar improvements with a corresponding concept and technique for the surgical treatment of cervical cancer. Methods. Based on new findings on the topographic anatomy of the female pelvis and insights in the pathoanatomy of recurrent cervical cancer after the Wertheim– Meigs operation, we developed the total mesometrial resection (TMMR) which removes the uterus and proximal vagina together with their integrated mesentery by consequent preparation along embryologically derived tissue planes with minimal traumatization. Lymph node dissection is extended to additional pelvic sites. The pelvic autonomic nerve system is exposed, partially mobilized, and sufficiently spared to preserve rectal, vulvovaginal, and bladder function. After a feasibility trial we initiated a prospective study including in-depth urogynecologic investigations preoperatively and 3 resp. 12 months postoperatively. Results. From 7/1998 until 5/2001 a total of 65 patients with cervical cancer stages pT1b1 (n ⫽ 37), pT1b2 (n ⫽ 12), pT2a (n ⫽ 3), and pT2b (n ⫽ 13) were treated by TMMR. Median pathological tumor size was 30 mm (7–100 mm). The mean number of removed pelvic lymph nodes was 45 (25–104), and the mean periaortic lymph node count was 11 (5–31). A total of 31% of the patients had stage pN1, and 9% had stage pM1(LYM). By 9/2001, at a median observation period of 20 months, 1 locoregional relapse occurred which could be successfully treated with LEER. Two-year recurrence-free survival probability was 91% for the whole group, 100% for patients with cancers confined to the cervix, and 80% for those with extracervical tumor spread. No severe (grades 2 and 3) long-term impairment of bladder, vulvovaginal, and rectal functions was observed. Conclusion. Based on these preliminary results TMMR achieves a superior therapeutic index in the surgical treatment of cervical cancer with respect to locoregional tumor control and posttreatment sequelae due to pelvic autonomic nerve damage. Indications and the role of multimodality treatment for TMMR must be defined by further study. 37. Surgical Staging of Cervical Cancer via a Laparoscopic Extraperitoneal Approach. Yukio Sonoda, Eric Leblanc, Theocharis C. Papageorgiou, Eric Lambaudie, Fabrice Narducci, and Denis Querleu. Center Oscar Lambret, Lille, France. Objective. Patients with locally advanced cervical cancer are at risk for metastasis to the para-aortic lymph nodes. Surgical sampling of these nodes remains the gold standard for identifying those patients who may benefit from extended field radiotherapy. The purpose of this study was to report on a large series of patients who underwent surgical staging by a novel technique for aortic and common iliac lymph node dissection. Methods. Between 1/97 and 8/01, 98 patients who underwent an infrarenal aortic and common iliac lymph node dissection via a laparoscopic extraperitoneal approach for bulky, locally advanced, or recurrent cervical cancer were identified. The medical records were reviewed for patient age, body mass index (BMI), tumor stage, histology, surgical procedure, postoperative complications, operative time, postoperative stay, lymph node count, and node status. Results. All patients underwent laparoscopic extraperitoneal aortic and common iliac lymph node dissection without intraoperative complication. The mean patient age was 46 ⫾ 9 years. The mean BMI was 24 ⫾ 5 kg/m 2. FIGO stages of the population were 25 IB2, 3 IIA, 25 IIB, 5 IIIA, 37 IIIB, and 1 IVA, and there were 2 patients with recurrent disease. Ninety-one (93%) patients had epidermoid tumors. The

mean node count was 18 ⫾ 11. Twenty-three (24%) patients had lymph node metastasis. The mean operative time was 158 ⫾ 48 min, and the mean postoperative stay was 2 days. There were 13 (13%) postoperative complications associated with this procedure. Ten patients had symptomatic lymphoceles: 7 were drained under radiological guidance, 2 required drainage catheter placement under general anesthesia, and 1 required drainage by laparoscopy. There were 2 retroperitoneal hematomas, of which 1 required ureteral stent placement. One patient required reoperation for a bowel obstruction resulting from a trocar site hernia. Thus, 5 patients (5%) required a second procedure under anesthesia, but only 2 (2%) required reoperation. Conclusions. Laparoscopic extraperitoneal aortic and common iliac lymph node dissection is a feasible technique that combines the benefits of laparoscopy with those of a retroperitoneal approach. It can be employed in the management of cervical cancer to identify patients who may benefit from extended field radiotherapy while possibly minimizing associated toxicities secondary to adhesions. 38. Adequate Staging for Uterine Cancer Can Be Performed through Pfannenstiel Incisions. Neil S. Horowitz, Matthew A. Powell, Charles W. Drescher, Michael R. Smith, Mary Atwood, Timothy A. Mate, and William A. Peters III. Swedish Medical Center, Seattle, Washington; and Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to determine whether the type of skin incision influences the adequacy of surgical staging in patients with uterine cancer. Methods. All patients with uterine cancers referred to the Tumor Institute of the Swedish Medical Center between June 1,1989, and June 1, 1999, who underwent comprehensive surgical staging and for whom complete records could be obtained were eligible. Data on type of incision, weight, medical comorbidities, histology, total number and distribution of lymph nodes (LN), estimated blood loss (EBL), and surgical complications were abstracted retrospectively. The t, ␹ 2, and Fisher’s exact tests and Kaplan–Meier survival analyses were performed. Results. A total of 503 women with uterine cancers were referred to the Tumor Institute with 331 meeting inclusion criteria. A vertical midline incision (VMI) was used in 237 (72%) while 94 (28%) received a Pfannenstiel incision (PI). No panniculectomies were performed. There were no statistically significant differences in age, weight, stage, histology, comorbidities, intraoperative or postoperative complications, or EBL between the VMI and PI groups. When compared to a VMI, a greater number of total LNs were procured through a PI [19.5 ⫾ 11.7 vs 16.0 ⫾ 8.3 (P ⫽ 0.007)]. Although more patients with a VMI had para-aortic lymph nodes (PALN) dissected (48% vs 21%), there was no statistically significant difference in the mean number of PALNs removed when they were obtained through a PI (2.85 vs 3.27, P ⫽ 0.48). Even in the heaviest quartile of patients (⬎180 pounds), a PI continued to provide access to a statistically greater number of total LNs (22.3 vs 16.2, P ⫽ 0.007) but statistically fewer PALNs (0.3 vs 1.4, P ⫽ 0.01). In this group as well there were no statistically significant differences in the EBL or complication rates for the two incision types. There was no difference in the projected 5-year disease-free (83% vs 85%) or diseasespecific survival (87% vs 85%) for patients undergoing a VMI or PI. Conclusion. Comprehensive surgical staging for uterine cancers can be adequately performed through a PI without greater morbidity or mortality. PALN yield may be limited in morbidly obese patients via PI. By using this surgical approach patients with uterine cancers can benefit from the increased wound strength, decreased pain, limited pulmonary complications, and improved cosmesis as previously documented for PI. 39. Laparoscopically Assisted Vaginal Hysterectomy and Bilateral SalpingoOophorectomy for the Treatment of Clinical Stage I Uterine Carcinoma. Alan J. Ferrier. Royal North Shore Hospital, University of Sydney, St. Leonards, Australia, North Sydney, Australia. Objectives. The aim of this study was to assess the feasibility, lengths of stay, perioperative morbidity, survival, and pattern of failure in patients with clinical stage I uterine cancer. Methods. Women with a new histological diagnosis of uterine cancer were offered a laparoscopically assisted vaginal

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS hysterectomy and bilateral salpingo-oophorectomy (LAVH/BSO) as an experimental procedure or a standard open surgical procedure as primary treatment. Inclusion criteria were age ⬍85 years, ASA score 1–2, no current or other advanced malignancy, uterine size ⬍12 weeks, and adequate access. Women with a grade I tumor on curettage were offered a LAVH/BSO. If upon opening the specimen there was gross involvement of the cervix or ⬎50% myometrial invasion, a laparoscopic pelvic node dissection (LAVH/BSO/nodes) was performed. Where the initial curettage specimen demonstrated a grade 2 or 3 endometrial lesion, a LAVH/BSO/nodes procedure was performed. A curettage specimen demonstrating serous carcinoma, or clear cell or sarcomatous features was offered an omentectomy in addition to LAVH/BSO/nodes. Informed consent was obtained from all patients. Results. The first 107 patients were analyzed. Forty underwent LAVH/BSO, 50 LAVH/BSO/nodes, and 10 LAVH/BSO/nodes/omentectomy. Median age was 63 years (56 –72 IQR). Median BMI was 26 (16 – 48 IQR). Seven were converted to open procedures. Median follow-up was 25 months. Ninety six patients were FIGO stage I/II and 9 stage III. Two were unstaged. Complications included 1 bladder injury and 1 vascular injury. Three patients received blood transfusions. The average length of hospitalization was 3.6 days (3.3–3.9, 95%CI).Ten patients recurred, 8 at extrapelvic sites and 2 in the pelvis. There were no port site failures. A comparison of the laparoscopic procedure with a historical cohort of patients treated with open surgery showed no significant survival difference (P ⫽ 0.08). Conclusion. The laparoscopic approach for apparent early stage uterine cancer is safe, demonstrates comparable survival with open surgery, and warrants further evaluation in clinical trials.

40. Outcome of Reproductive-Age Women with Stage IA or IC Invasive Epithelial Ovarian Cancer Treated with Fertility-Sparing Surgery. Jeanne M. Schilder, Amy M. Thompson, Paul D. Depriest, Frederick R. Ueland, Michael L. Cibull, Richard J. Kryscio, Susan C. Modesitt, John P. Geisler, Robert V. Higgins, Paul M. Magtibay, David E. Cohn, Matthew A. Powell, Frederick B. Stehman, and John R. Van Nagell Jr. Carolinas Medical Center, Charlotte, North Carolina; Indiana University School of Medicine, Indianapolis, Indiana; Mayo Clinic, Rochester, Minnesota; Ohio State University, Columbus, Ohio; University of Kentucky, Lexington, Kentucky; University of Texas M. D. Anderson Cancer Center, Houston, Texas; University of Iowa Hospitals and Clinics, Iowa City, Iowa; and Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to determine the recurrence rate, survival, and pregnancy outcome in patients with stage IA and stage IC invasive epithelial ovarian cancer treated with unilateral adnexectomy. Methods. A multiinstitutional retrospective investigation was undertaken to identify patients with stage IA and IC epithelial ovarian cancer who were treated with fertility-sparing surgery. All patients with ovarian tumors of borderline malignancy were excluded. Long-term follow-up was obtained through tumor registries and telephone interviews. The time and sites of tumor recurrence, survival, and pregnancy outcomes were recorded for every patient. Results. Forty-four patients with stage I epithelial ovarian cancer were identified. Thirty-five patients had stage IA disease and 9 had stage IC cancers. Histologic differentiation was as follows: 31 grade 1; 10 grade 2; and 3 grade 3. Seventeen patients received adjuvant chemotherapy (3–12 courses, mean ⫽ 6.06 courses.) Patients received the following chemotherapy agents: cisplatin or carboplatin and paclitaxel 7; melphalan 5; cisplatin and cyclophosphamide 3; cisplatin and etoposide 1; and single-agent cisplatin 1. Eight had second assessment laparotomies (all negative.) Duration of follow-up ranged from 3 to 423 months (median ⫽ 67.5 months). Four patients developed tumor recurrence 8 –78 months after initial surgery. Sites of recurrence were as follows: contralateral ovary 2; contralateral ovary and fallopian tube 1; and lung 1. Eight patients underwent subsequent contralateral oophorectomy and hysterectomy. At present, 43 patients are alive without evidence of disease and 1 patient has died of disease 97 months after initial treatment. The estimated survival rate was 100% at 5 years and 93.7% at 10 years. The estimated disease-free survival

491

rate was 95.2% at 5 years and 86.3% at 10 years. Twelve patients (27%) have achieved 19 pregnancies with 16 term deliveries (no congenital anomalies noted) and 3 spontaneous abortions. Conclusion. The long-term survival of patients with stage IA and IC epithelial ovarian cancer treated with unilateral adnexectomy is excellent. Fertility-sparing surgery should be considered a treatment option in women with stage I epithelial ovarian cancer who desire further childbearing.

PLENARY SESSION IV—WEDNESDAY, MARCH 20, 2002 Moderator: Abstracts 41– 46, Wendy Brewster 41. Long-Term Follow-Up of Patients Diagnosed with Granulosa Cell Tumors of the Ovary. A Surveillance, Epidemiology, and End Results Database Review. Thomas C. Krivak, Wendy R. Brewster, Jay E. Allard, James H. Segars, William E. Winter, Jay W. Carlson, John C. Elkas, G. Larry Maxwell, and G. Scott Rose. Uniformed Services University of the Health Sciences, Bethesda, Maryland; University of California, Irvine, Orange, California; and Walter Reed Army Medical Center, Washington, DC. Objective. The fact that granulosa cell tumors are rare ovarian neoplasms makes it difficult to study a large series of patients and report patient follow-up and survival. The objective of this study is to review the Surveillance, Epidemiology, and End Results (SEER) database for patients diagnosed with granulosa cell tumors of the ovary to identify disease characteristics and survival. Methods. The SEER public-use database was searched for patients diagnosed with ovarian granulosa cell tumors from 1973 to 1998. The stage of disease, patient age, and survival were abstracted. The registries classified the disease stage as local, regional with direct extension, regional with lymph node metastases, and unstaged. Kaplan–Meier survival curves were plotted with respect to stage. Statistical analysis was performed using SAS. Results. A total of 621 granulosa cell tumors were identified in the database and utilized for this analysis between 1973 and 1998. With respect to disease stage, 301 (48.5%) were classified as localized, 76 (12.2%) as regional with direct extension, 191 (30.8%) as regional extension with lymph node involvement, and 53 (8.5%) as unstaged. Evaluation of the mean age of women with granulosa cell tumors demonstrated a later age at diagnosis with more advanced stage (P ⫽ 0.01). Kaplan–Meier analysis indicated a difference in survival based upon stage. The percentage survival at 10 years for women with known stage of disease was localized disease in 67%; regional with direct extension in 64%; and regional extension with lymph node involvement in 31%. Age at diagnosis and stage remained statistically significant independent risk factors in multivariable analysis. Conclusion. Granulosa cell tumors are generally regarded as low-malignant-potential tumors. It is therefore likely that the number of tumors reported in this database is an underrepresentation of the true magnitude of this disease. Even with this limitation, this is a large population-based study of patients diagnosed with granulosa cell tumors. An excellent 10-year survival is observed for all stages; however, the prognosis is significantly poorer for women with nodal involvement. As this study demonstrates a higher percentage of nodal involvement than previously reported, this would suggest the need for further evaluation of the treatment recommendations for this group of patients. 42. Immune Activation Is Associated with Poor Prognosis in Ovarian Cancer Patients. A Study of the Austrian Association for Gynecologic Oncology. Christian Marth, Gudrun H. Windbichler, Lothar Fuith, Hans Concin, Anton Graf, Wolfgang Stummvoll, and Dietmar Fuchs. Department of Obstetrics and Gynecology, Bregenz, Austria; Department of Obstetrics and Gynecology, Linz, Austria; Department of Obsterics and Gynecology, Salzburg, Austria; Department of Obsterics and Gynecology, Eisenstadt, Austria; University Hospital Innsbruck, Innsbruck, Austria; and University Innsbruck, Innsbruck, Austria.

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Objective. Neopterin is produced by activated macrophages upon stimulation with interferon-gamma (IFN-␥) and is elevated in viral and bacterial infections, including AIDS, in autoimmune disease, and in malignancies. The aim of the study was elevation of the importance of the cellular immune response in patients with ovarian neoplasms. Methods. In a study of the Austrian Gynecologic Oncology Group in patients with benign and borderline ovarian tumors (n ⫽ 504) as well as invasive ovarian cancer patients (n ⫽ 223), urinary neopterin was determined prior to therapy by means of HPLC. Results. Elevated levels (cutoff 250 ␮mol/mol creatinine) were found in about one-fourth (16 to 29%) of women with benign ovarian cystadenomas, borderline tumors, and FIGO stage I and II invasive tumors, while in stages III and IV tumors elevated levels were found in 65 and 91%, respectively. Only 57% of ovarian cancer patients with elevated neopterin levels responded to therapy (complete and partial responses), in contrast to 86% of women with normal neopterin levels (P ⬍ 0.001). Along with residual tumor, FIGO stage, age, histological type, pretreatment hemoglobin, and platelet levels, neopterin was significantly associated with overall and progression-free survival (OS and PFS). Median OS was 81 versus 24 months for patients with elevated and normal neopterin, and median PFS was 52 and 12 months, respectively, P ⬍ 0.001. In a multivariate Cox regression analysis, which included all these factors, only residual tumor, neopterin, and age were independently associated with OS, while residual tumor alone was predictive for PFS. Thirty patients with surgically staged early stage invasive ovarian cancer (FIGO I and II) were analyzed separately. Three had elevated neopterin levels. Two of 3 died of disease progression in contrast to 2/27 deaths in women with normal neopterin. Conclusion. In ovarian cancer the negative impact of pretreatment urinary neopterin on survival points to a detrimental role of immune activation for the course of the disease. 43. Cost-Effectiveness Analysis of the Treatment for Intermediate-Risk Endometrial Cancer. Postoperative Brachytherapy vs Observation. James Fanning, Michael L. Hoffman, Stephen J. Andrews, Allen W. Harrah, and John J. Feldmeier. Medical College of Ohio, Toledo, Ohio. Objective. The aim of this study was to compare the survival, morbidity, and cost of treating women with intermediate-risk endometrial cancer with postoperative vaginal cuff brachytherapy vs observation followed by treatment for vaginal recurrence. Methods. A cost-effectiveness analysis was performed comparing two treatment protocols for intermediate-risk endometrial cancer (stage IC, IG3, II). All patients undergo hysterectomy, oophorectomy, and lymphadenectomy: protocol 1—postoperative vaginal cuff brachytherapy, protocol 2— observation. Protocol 2 patients who develop vaginal recurrence undergo examination under anesthesia, cystoscopy, proctoscopy, and abdominal–pelvic CT scan, followed by teletherapy and brachytherapy. Assumptions used in the cost-effectiveness analysis based on previous trials include a 33% incidence of intermediate-risk endometrial cancer, an 8% vaginal recurrence rate for patients on protocol 2, a 60% survival for patients on protocol 2 who develop a vaginal recurrence, a 0% vaginal cuff recurrence rate for those treated with postoperative vaginal cuff brachytherapy (protocol 1), and a 38% complication rate from teletherapy and 4% from brachytherapy. All six principles of cost-effectiveness analysis were employed. Importantly, actual payer costs were evaluated, not charges. Results. Although the treatment for vaginal cuff recurrence is expensive, since only 8% of patients develop a vaginal recurrence and require this treatment, there was a 31% decreased cost by not treating patients with postoperative low-dose-rate brachytherapy (protocol 2). Also, although the complication rate for teletherapy is greater than that for brachytherapy, since only 8% of patients develop a vaginal recurrence and require teletherapy, projected complication rates for the two protocols are similar. Survival would be decreased 3% by withholding postoperative brachytherapy (protocol 2). Conclusion. Using a cost-effectiveness analysis we have shown that withholding postoperative brachytherapy for patients with intermediate-risk endometrial cancer results in a 31% decrease in cost, has a similar radiation complication rate, and results in a 3% decrease in survival. The cost per life saved with postoperative high-dose-rate brachytherapy (protocol 1) would be $38,764 for intermediate-risk patients.

44. The Utility of Positron Emission Tomography in Ovarian Cancer. Kim A. Crute, Robert W. Naumann, Robert V. Higgins, and James B. Hall. Carolinas Medical Center, Charlotte, North Carolina. Objective. The aim of this study was to evaluate the sensitivity and specificity of positron emission tomography (PET) in women with ovarian cancer compared to computed tomography (CT). Methods. All PET scans performed at Carolinas Medical Center on women with ovarian, peritoneal, or fallopian tube cancer from 1994 to 2000 were reviewed. PET scan reports were correlated with clinical findings and recurrence data. Scans were determined to be true positive or true negative by correlating the scan with the site of disease recurrence over a 12-month period. PET scan results were compared to CT scans obtained within 6 months and the sensitivity and specificity were determined for the CT and PET scans. Results. One hundred seven PET scans were performed on 60 women during the study period. Seventy-one PET scans could be correlated with a CT scan. The PET scan was obtained a median of 17 days after the CT scan. Ten percent of the PET scans were read as equivocal compared to 32% of the CT scans. The sensitivity of the PET scan was 95% compared to 45% for CT scan (P ⬍ 0.00001). If all equivocal CT scans were considered positive the sensitivity for CT scan was only 65%. Two PET scans and 1 CT scan were read as positive without disease recurrence in more than 12 months of follow-up. The CA-125 level, tumor type, and history of radiation treatment did not seem to correlate with the sensitivity of the PET scan or the CT scan. Of interest, the PET was noted to influence medical decision making in 90% of cases. In 14% of cases surgical intervention was dependent on the PET scan results. In addition, it was noted that 50% of recurrences were first detected by PET scans. Conclusion. PET scans appear to have a significant impact on patient care and are useful in the management of ovarian cancer. Although CT scans appear to have a low false-positive rate they are often equivocal and have a significant false-negative rate. A PET scan may be useful if a CT is negative when recurrent ovarian cancer is suspected or surgical intervention is considered. 45. Evaluation of Whole-Body 18F-Fluorodeoxyglucose Positron Emission Tomography Imaging for the Detection of Metastatic Tumors in Patients with Suspected Recurrence of Malignant Ovarian Tumors. Masaru Murakami, Tadashi Arai, Masako Shida, Tsuyoshi Mitamoto, Takao Shinozuka, Tsunehisa Makino, Seiei Yasuda, Yutaka Suzuki, Hiroshi Fujii, Mitsuru Ide, and Akira Shotsu. Himedic Imaging Center, Lake Yamanaka/ Yamanashi, Japan; and Tokai University School of Medicine, Isehara/ Kanagawa, Japan. Objective. Accurate diagnosis of metastatic sites in gynecological malignancies is important in determining treatment strategy. Lymph-nodal or hepatic metastases especially affect both clinical staging and prognosis after treatment. Unfortunately, current diagnostic techniques, including CT, MRI, and ultrasonography (US), are not efficient for detecting recurrence. This study assessed the diagnostic accuracy of whole-body positron emission tomography (PET) imaging with 18F-fluorodeoxyglucose (FDG) for the detection of tumor foci in patients with suspected recurrent or metastatic lesions of malignant ovarian tumors in comparison to CT, MRI and US, including specific tumor makers (TM). We also evaluated whether the availability of FDG-PET depended on the sites of recurrence (intraperitoneal tumors or retroperitoneal tumors). Methods. Forty-four patients with histologically proven ovarian malignancies had FDG-PET, CT, MRI, and US, including the specific tumor makers. Postvoid static images were obtained in all patients to minimize bladder FDG activity. The final diagnoses of metastases were established by surgery (n ⫽ 15) or clinical follow-up for at least 6 months following the PET scan (n ⫽ 29). Thirty-seven patients had each specific tumor marker on primary treatment. Results. Twenty-two patients were confirmed for metastasis or recurrence (14 patients with intraperitoneal tumors, 11 patients with retroperitoneal tumors, and 3 patients with hepatic tumors). Of 21 recurrent patients with previously elevated TM, 14 patients with confirmed metastasis showed elevated tumor markers. The sensitivities (%) of PET/CT/MRI/US/TM for the detection of intraperitoneal metastases were 93/71/83/71/92, respectively. The specificities

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SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS

TABLE 1—ABSTRACT 46 HS (0.0 ⫽ worst, 1.0 ⫽ best)

T1

T2

NED

1.0

1.0

Chemo w/mild side effects Alopecia

0.97

0.96

0.66

0.72

Pancytopenia

0.45

0.56

HS (0.0 ⫽ worst, 1.0 ⫽ best) Neuropathy (T1 3 T2, P ⫽ 0.007) Mucositis Urinary dysfunction Ototoxicity (T1 3 T2, P ⫽ 0.058)

were 93/93/88/100/56, respectively. The sensitivities (%) of PET/CT/MRI/ US/TM for retroperitoneal tumors were 91/55/40/45/70, respectively. The specificities were 94/97/94/94/56, respectively. Conclusion. FDG-PET imaging had high sensitivity for detecting both intraperitoneal and/or retroperitoneal metastases. PET imaging was especially useful for detecting solitary small (1.5–2 cm) intraperitoneal or retroperitoneal tumors in patients with elevated specific tumor markers, which were very difficult to detect using CT or US. 46. Patient Preferences for Side Effects of Chemotherapy for Ovarian Cancer. Do Preferences Change over Time? Charlotte C. Sun, Candice L. Borden, Michele L. Donato, Sheryl Cooke, Karen Basen-Engquist, Mary A. Fitzgerald, John J. Kavanagh, David M. Gershenson, and Diane C. Bodurka. University of Texas M. D. Anderson Cancer Center, Houston, Texas. Purpose. Little is known about patient preferences (PP) for side effects of standard and high-dose chemotherapy (HDCT) for ovarian cancer (OVCA) and whether PP change over time. We assessed PP of patients (pts) with stage III/IV OVCA participating in ongoing phase II trials of HDCT with stem cell transplant treated at our institution from 1999 to the present. Methods. We used a validated instrument, the visual analog scale (VAS), to assess PP of 23 pts at two points in time. PP were assessed for the following health states (HS): NED, chemotherapy with mild/severe side effects, mucositis, alopecia, pancytopenia, neuropathy, nausea/vomiting (NAVM), hepatotoxicity, ototoxicity, fatigue, and urinary dysfunction. HS descriptions were presented to pts in a written format. Time 1 interviews were conducted during inpatient mobilization chemotherapy (ifosfamide/etoposide) and stem cell harvesting; Time 2 interviews were conducted 4 –5 weeks later during hospitalization for HDCT (topotecan/cyclophosphamide/melphalan) and stem cell transplant. Each assessment involved a 45-min interview conducted at the pt’s bedside. The VAS asks pts to rank each HS relative to the others on a scale from 0 to 100 (0 ⫽ least favorable; 100 ⫽ most favorable). VAS scores were then converted to a 0.0 to 1.0 scale (0.0 ⫽ worst; 1.0 ⫽ best). Data were analyzed using paired and independent t tests. Results. Outcomes of interest were mean PP scores (see Table 1). Median time from diagnosis to HDCT was 10 months (range 6 –126). Median patient age was 51 years (range 33– 64). All women were Caucasian. The median number of previous regimens was 2 (range 1– 4). Conclusions. Across the board, PP of women undergoing HDCT increase over time. NAVM and hepatotoxicity are the HS consistently least preferred by these pts. Our data suggest that pts may view side effects less negatively even though the intensity of the treatment increases.

POSTER SESSION I—SUNDAY, MARCH 17, 1:00 PM–5:30 PM AND MONDAY, MARCH 18, 7:00 AM–1:00 PM Abstracts 47–120 47. Frequency of BRCA Founder Mutations among Ashkenazi Jewish Patients with Primary Peritoneal and Fallopian Tube Adenocarcinoma. Douglas

T1

T2

HS (0.0 ⫽ worst, 1.0 ⫽ best)

T1

T2

0.46

0.62

Fatigue

0.44

0.45

0.34

0.38

NAVM

0.24

0.30

0.33

0.38

0.15

0.26

0.33

0.50

Hepatotoxicity (T1 3 T2, P ⫽ 0.06) Chemo w/severe side effects

0.09

0.13

A. Levine, Cindy Yee, David S. Marshall, Narciso Olvera, Faina Bogomolniy, Richard R. Barakat, Robert A. Soslow, and Jeff Boyd. Memorial Sloan-Kettering Cancer Center, New York, New York. Objective. Inherited mutations in the BRCA1 or BRCA2 genes are present in approximately 40% of Ashkenazi Jewish (AJ) patients with epithelial ovarian cancer (EOC). The incidence of BRCA mutations among all patients with fallopian tube adenocarcinoma (FTC) is reported to be 16%. The purpose of this study was to test the hypothesis that the incidence of founder mutations among AJ patients with primary peritoneal adenocarcinoma (PPC) and FTC is similar to the incidence among AJ patients with ovarian cancer. Methods. A retrospective review conducted over a 13-year period identified 39 AJ patients at this institution with PPC or FTC. All patients were genotyped according to standard laboratory methods for the three BRCA founder mutations (185delAG and 5382insC in BRCA1 and 6174delT in BRCA2) that exist in this population. Demographics, family history, tumor characteristics, and survival data were obtained from hospital records. Thirty (77%) cases were available for pathology review. Results. The mean age of the study population was 67 ⫾ 9 years, range 44 – 87 years. The stages at diagnosis were stage I, three (8%); stage II, three (8%); stage III, 32 (82%); and stage IV, one (3%). All tumors had serous histology. Nine (23%) patients had at least one firstdegree relative with breast or ovarian cancer. There were 9 (41%) BRCA founder mutations among 22 patients with PPC and 3 (18%) mutations among 17 patients with FTC. There were 7 mutations in BRCA1 (5 at 185delAG and 2 at 5382insC) and 7 mutations in BRCA2. One patient with PPC and 1 with FTC had mutations at both 185delAG and 6174delT. Patients with founder mutations had a lower mean age (61 vs 70 years, P ⬍ 0.01) and had a nonsignificant increase of first-degree relatives with breast or ovarian cancer (46% vs 20%, P ⫽ 0.22). With a median follow-up of 23 months, the overall median survival was 57 months, 40 months for patients without mutations, and not reached for mutation carriers (P ⫽ 0.22). Conclusions. The data suggest that for AJ patients with PPC the incidence of BRCA founder mutations is similar to the incidence of mutations in AJ patients with EOC. The incidence of mutations in AJ patients with FTC is lower than that found in AJ patients with EOC, yet similar to the reported incidence among all patients with FTC. Patients with founder mutations in the BRCA genes are almost 10 years younger at the time of diagnosis than those patients without such mutations. 48. CYP1A1 Gene Polymorphism in Epithelial Ovarian Neoplasms. Dilek Aktas, Inci Guney, Mehmet Alikasifoglu, Kunter Yuce, Ergul Tuncbilek, and Ali Ayhan. Department of Genetics and Department of Obstetrics & Gynecology, Hacettepe University School of Medicine, , Ankara, Turkey. Objective. An association between risk and the CYP1A1*3 polymorphism has been noticed for several cancers. The CYP1A1 gene polymorphism may play a role in the development of epithelial ovarian neoplasms (EON). Therefore, we assessed the association of the CYP1A1 gene polymorphism in patients with EON in Turkish populations through a case– control study. Methods. Using an allele-specific PCR-based method; the CYP1A1*3 poly-

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morphism was analyzed in 117 EON patients and 155 control subjects. Results. The CYP1A1 Ile/Val genotype significantly increased the risk for patients with EON (OR:5.2) and there were statistical differences in the distribution of the CYP1A1 Val/Val genotype among all patients (OR: 6.66). In other words, the presence of Ile/Val and Val/Val genotypes significantly increased the risk of EON. Among benign ovarian tumors, the frequency of Ile/Val and Val/Val genotypes was found to be statistically different with ORs of 5.51 and 5.0, suggesting that the presence of Ile/Val and Val/Val genotypes significantly increased the risk of benign tumor. In benign serous tumors, patients with Ile/Val and Val/Val revealed a 6.6- and 12-fold higher risk of having this type of tumor, respectively. In benign mucinous tumors, the frequency of Ile/Val was found to be statistically different with an OR of 4.7. However, no patient with the Val/Val genotype was observed in this group. Among borderline tumors, the CYP1A1 Ile/Val genotype significantly increased the risk for patients. However, the frequency of the Val/Val genotype was not found to be statistically different, with an OR of 2.85. Among ovarian carcinoma patients, there were statistically significant differences in the distribution of the CYP1A1 Ile/Val and Val/Val genotypes (OR:5.25 and OR:8.4), suggesting that patients carrying these genotypes were at increased risk for ovarian carcinoma. In serous carcinoma, patients with CYP1A1 Ile/Val and Val/Val revealed a 6.5- and 10-fold higher risk of having ovarian cancer. In mucinous carcinoma, patients with CYP1A1 Ile/Val and Val/Val also revealed a 4.9- and 10-fold higher risk of having ovarian cancer. However, there were no statistically significant differences in the distribution of the Ile/Val and Val/Val genotypes among endometrioid ovarian cancer patients. Conclusions. Our data suggest that the CYP1A1 gene polymorphism may play an important role in the development of epithelial ovarian neoplasm. Furthermore, the CYP1A1 genotype may influence the onset of this disease. 49. Inhibition of Angiogenesis and Progressive Growth of Human Ovarian Carcinoma Cells by Optimal Biologic Dose of Pegylated IFN-␣. Sean Tedjarati, Cheryl Baker, Sachin Apte, and I. J. Fidler. M. D. Anderson Cancer Center, Houston, Texas. Objective. IFN-␣ has been previously shown to downregulate the expression of the proangiogenic molecules MMP9, bFGF, and IL-8. Studies of experimental therapy for ovarian carcinoma have demonstrated that the efficacy of IFN-␣ therapy is dependent on daily administrations of an optimal biologic dose. Pegylated IFN-␣ (PEG-IFN-␣) is a novel, sustained release formulation of IFN-␣-2a. In the present study we determined whether systemic administrations of the optimal dose of PEG-IFN-␣ can inhibit angiogenesis and progressive growth of human ovarian carcinomas implanted orthotopically in nude mice. Methods. Female nude mice were injected intraperitoneally with human SKOV3ip1 carcinoma cells. Seven days later, groups of mice (n ⫽ 10) were injected sc with different doses of PEG-IFN-␣ (3500, 7000, 35,000, and 350,000 units). The injections were repeated once per week for 4 weeks. The mice were killed 7 days after the last injection. Tumor incidence and weight were recorded. The tumor tissues were processed for immunohistochemistry. Results. PEG-IFN-␣ at 7000 units/week produced the most significant decrease in tumor incidence and size. PEG-IFN-␣ at doses exceeding 7000 units was less efficacious. Therapy with PEG-IFN-␣ correlated with a significant inhibition in expression of bFGF, MMP9, and IL-8, decreased tumor cell division (PCNA⫹), decreased vessel density (CD31⫹), and increased apoptosis of endothelial cells (TUNEL⫹). Conclusion. Administration of PEGIFN-␣ at the optimal biologic dose (7000 units/week) decreased angiogenesis and progressive growth of human ovarian carcinoma cells in the peritoneal cavity of nude mice. 50. Survivin Is Expressed and Its Promoter Activated in Ovarian Cancer. Rudi Bao, Denise Connolly, Maureen Murphy, Jeffrey Green, Jillian Weinstein, Debra Pisarcik, and Thomas Hamilton. Fox Chase Cancer Center, Philadelphia, Pennsylvania; and NCI, Bethesda, Maryland. Objectives. The possibility of using the survivin promoter to control cancerspecific gene expression in the context of gene therapy and murine oncogenic

transgenesis was evaluated. Methods. Survivin protein level was detected by Western blot analysis in a panel of human and murine cancer cell lines derived from different organs including the ovary. We also determined survivin protein level in normal tissues of the adult female C57BL/6 mouse. A reporter construct using 1092 bp of the 5⬘ region of the survivin gene driving human secreted alkaline phosphatase (SEAP) was created (pSRVN-SEAP). This construct was transiently transfected into cancer cell lines by lipofection. The promoter activation was determined by measuring SEAP activity in the culture medium of the cell lines. Stable transfectants were created by transfecting pSRVN-SEAP-NEO into the A2780 human ovarian cancer cell line using electroporation and selection with G418. Two stable transfectant cell lines were injected into the intrabursal space of immunodeficient mouse ovaries. Plasma SEAP levels were measured to determine the promoter activity in vivo. Results. Survivin protein expression was demonstrated in all of the cancer cell lines examined. Survivin protein was not detected in the majority of normal adult mouse tissues. Strong activity of the survivin promoter was demonstrated in all of the cancer cell lines and in all cases was greater than the constitutive SV40 promoter driving SEAP. After 0.8 ⫻ 10 6 A2780 stable transfectant cells were introduced into the intrabursal cavity, plasma SEAP activity was detected within 24 h and the plasma level increased with time/tumor growth. Conclusion. Survivin expression is a common feature of cancer cell lines regardless of the organ site or species from which the tumor arose. The transfection of pSRVN-SEAP into cancer cell lines indicates that the mechanism of activation of survivin expression in oncogenesis is at least in part by transcriptional activation. These data suggest that the survivin promoter will have utility for gene therapy and to elicit SEAP expression upon tumor formation in animals transgenic for SRVN-SEAP and an appropriate combination of oncogenes. 51. A Modified Oncolytic Adenovirus for Treatment of Ovarian Cancer. Gerd J. Bauerschmitz, John T. Lam, Anna Kanerva, Kaori Suzuki, Dirk M. Nettelbeck, Mack N. Barnes, Ronald D. Alvarez, Peter Dall, David T. Curiel, and Akseli Hemminki. Duesseldorf University Medical Center, Duesseldorf, Germany; and University of Alabama at Birmingham, Birmingham, Alabama. Objective. Ovarian adenocarcinoma is the leading cause of gynecological cancer mortality in the United States. Most cases of ovarian cancer are detected in an advanced stage, resulting in a 5-year overall survival rate of less than 30%. The understanding of the molecular mechanisms in neoplastic transformation and progression means that cancer can be regarded as a genetic disease. Due to the poor prognosis with existing treatments any benefit by novel therapeutic approaches could be significant. Therefore, gene therapy represents a rational approach to the treatment of ovarian cancer and has recently displayed some clinical utility. Method. We developed an oncolytic adenovi¨ 24RGD, which replicates selectively in cells defective in the rus, Ad5-A p16-Rb pathway, a feature of virtually all human cancers, including ovarian ¨ 24RGD was modified with an integrin-binding carcinoma. The fiber of Ad5-A motif (RGD-4C), which allows Coxsackie-adenovirus receptor (CAR) independent infection of cancer cells. As the expression of CAR is frequently low in primary tumor specimens, this modification allows enhanced infectivity of cancer cells. Results. In ovarian cancer cell lines, the virus had comparable oncolytic potential to a wild-type adenovirus control. Replication in primary tumor material was shown utilizing a novel three-dimensional spheroid model based on purified and unpassaged ovarian cancer cells obtained from malignant ascites. Finally, significantly prolonged survival (P ⬍ 0.0001) was observed for mice treated with this agent in a highly aggressive orthotopic murine model of ovarian cancer, with complete eradication of intraperitoneal disease. Con¨ 24RGD could be useful for the clusion. These results suggest that Ad5-A treatment of ovarian cancer in humans and merits clinical evaluation. 52. An International Randomized Trial on Systematic Aortic and Pelvic Lymphadenectomy vs Resection of Any Bulky Nodes in Advanced Ovarian Cancer. Preliminary Results of Feasibility and Complications. Pierluigi Benedetti Panici, Fabio Landoni, Claudio Scarabelli, Reimund Winter,

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS Angelo Maggioni, Stephan Ackermann, Giuseppe Favalli, John M. Monaghan, Roberto Grassi, Stefano Greggi, Mariangela Amoroso, Diana Giannarelli, Valter Torri, Costantino Mangioni, and Neville Hacker. Campus BioMedico, Rome, Rome, Italy; CRO, Aviano, Italy; European Institute of Oncology, Milan, Italy; Gateshead Hospital NHS, Gateshead, United Kingdom; Mario Negri Institute, Milan, Italy; National Cancer Institute of Naples, Naples, Italy; Regina Elena Institute, Rome, Italy; Royal Hospital for Women, Sydney, Australia; S Gerardo Hospital, Monza, Italy; Treviglio Hospital, Treviglio, Italy; University of Brescia, Brescia, Italy, University of Erlangen, Erlangen, Germany; and University of Graz, Graz, Austria. Objective. The role of therapeutic systemic aortic and pelvic lymphadenectomy (SAPL) has never been evaluated in a controlled randomized trial. Such a study is being performed by a collaborative international group. Results of feasibility and complications are reported. Methods. After the completion of cytoreductive surgery, all patients (pts) considered eligible for SAPL were randomized into two arms: SAPL (arm A) vs bulky nodes (BN) (arm B). Eligibility criteria were age ⬍75 years; histologically proven epithelial OC; FIGO stage IIIB–C IV (pleural effusion only); and intraperitoneal residual tumor ⬍1 cm. Cytoreductive surgery included total abdominal hysterectomy, bilateral salpingo-oophorectomy, radical omentectomy, appendectomy, resection of macroscopic abdominal tumor, and resection of bulky nodes. Systematic pelvic lymphadenectomy included the removal of at least 25 nodes, with the dissection of external iliac, interiliac, obturator, and common iliac nodes. Systematic aortic lymphadenectomy included the removal of at least 15 nodes up to the level of the renal vessels. Complications were classified using NCI-CTG Common Toxicity criteria. Results. From January 1995 to September 2001, 12 institutions randomized 306 pts with advanced ovarian cancer (AOC). A total of 285 (93%) pts (146 arm A, 139 arm B) were considered eligible for SAPL. Age, grade, FIGO stage, and residual tumor were similarly distributed in both arms. In arm A 85% of pts underwent SAPL; the median total number of removed nodes was 59 (range 38 –118): 35pelvic (range 25–76) and 27 aortic (range 15– 63). In arm B BN were resected in 67% of cases. A significant increase in operative time, blood loss, and units transfused was observed in arm A (P ⫽ 0.02). There was no death due to surgery. Postoperative complications occurred in 37 and 18% of arm A and B pts, respectively (P ⫽ 0.02). In particular, severe (G3–G4) morbidity, mainly represented by deep vein thrombosis with or without thromboembolism, was observed in 20 and 10% of the cases, respectively (P ⫽ 0.06). Conclusions. These preliminary data show that SAPL in pts with AOC is a feasible procedure, with a significant increase in postoperative morbidity. More mature and detailed data will be presented and discussed. 53. Results of a Phase II Trial of Cisplatin and Gemcitabine in Relapsed Ovarian Cancer. Robert A. Nagourney, Cheryl A. Brewer, Barbara Sommers, Steven S. Evans, David Minor, and Philip Disaia. Long Beach Memorial Medical Center and Rational Therapeutics, Long Beach, California; Pacific Medical Center, San Francisco, California; Rational Therapeutics, Long Beach, California; University of California Irvine, Irvine, California; and University of Illinois College of Medicine at Peoria, Peoria, Illinois. Objective. Our objective was to assess the efficacy and safety of cisplatin and gemcitabine in relapsed ovarian cancer. We have previously reported synergy between cisplatin and gemcitabine in a variety of human tumors (Nagourney R, Oncology 2001) and reported a response rate of 50% in relapsed breast cancer patients (Nagourney R, et al., J Clin Oncol 2000). Methods. Between 2/97 and 12/00, 161 cycles of 30 mg/m 2 of cisplatin and 600 –750 mg/m 2 of gemcitabine doublet therapy, days 1 and 8, every 21 days, were given to 27 relapsed ovarian cancer patients. These patients had received a median of 3 prior chemotherapy regimens (range 1 to 5). Results. There were 7 (26%) complete responses (CR) and 12 (44%) partial responses (PR) observed with a median time-to-progression of 20.3 weeks (range 4 – 43 weeks). Two of 2 post bone marrow transplant relapses achieved CR. Grade III/IV

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toxicities included anemia (11%); diminished absolute neutrophil count (22%); thrombocytopenia (26%); nausea and vomiting (5%); alopecia (2%); fatigue (2%), and peripheral neuropathy (1%). Seventeen of the 27 patients underwent ex vivo analyses (EVA) and blinded results were correlated with response and time to progression. Dividing the patients at the median gemcitabine and cisplatin IC 50, there were 9/10 CR/PR (90%) in the “assay-sensitive” group and 2/8 CR/PR (25%) in the “assay-resistant” group (P ⫽ 0.035, Fisher’s exact test). By univariate analysis, time to progression significantly favored the assay-sensitive group (P ⫽0.043). This was strengthened when adjusted for the effect of number of prior therapies (P ⫽ 0.013) but lost significance when adjusted for clinical platinum resistance (P ⫽ 0.128) by Kaplan–Meier analysis. Conclusions. (i) The combination of gemcitabine and cisplatin is effective for the treatment of relapsed ovarian cancer. (ii) With appropriate dose adjustments, gemcitabine and cisplatin can be safely yet effectively administered even in heavily pretreated patients. (iii) Laboratory results using cell death measures as surrogates for drug-induced apoptosis (EVA) correlate with response and time to progression. (iv) Further studies are underway to assess the efficacy of gemcitabine and cisplatin specifically in platinum-resistant disease (GOG 126-L). 54. Three-Consecutive-Day Topotecan Is an Active Regimen for Recurrent Epithelial Ovarian Cancer. John V. Brown III, William A. Peters III, Mark A. Rettenmaier, Charles W. Drescher, Michael R. Smith, Robert A. Dillman, and / John P. Micha. Gynecologic Oncology Associates, Newport Beach, California; Hoag Memorial Hospital Cancer Center, Newport Beach, California; and Pacific Gynecology Specialists, Seattle, Washington. Objective. The aim of this study was to determine the response rate and toxicity of topotecan administered days 1–3 Q 21 days for recurrent epithelial cancers of the ovary, peritoneum, or fallopian tube. A 3-day regimen will be more convenient and less expensive than a 5-day schedule. Methods. Patients with recurrent epithelial cancer of the ovary, peritoneum, or fallopian tube who had adequate hepatic, renal, and hematologic function were eligible for participation. Topotecan (2.0 mg/m 2) was administered for 3 consecutive days Q 21 days. Response was measured clinically and serologically. Granulocyte colony stimulating factors (GCSF) were not utilized prophylactically, but could be added under specific circumstances. Results. Thirty-three patients with recurrent ovarian cancer whose median age was 65 (range 32– 84) received 177 cycles of topotecan (median ⫽ 6) and are evaluable for toxicity. The median number of prior regimens was 1. Topotecan was administered on schedule in 96.6% of cycles. Grade 3/4 neutropenia was seen in 28.8 and 24.9% of courses, respectively, but only 3.4% of cycles required GCSF support (6 cycles for 2 patients). Grade 4 thrombocytopenia was rare (1.0% of cycles). Nonhematologic toxicity was mild. The response rate for 28 evaluable patients was 25.9% (7.4% CR and 18.5% PR); stable disease was seen in 25% of patients. The median progression-free interval (PFI) for all patients was 15.5 weeks (range 5– 40). Seventeen platinum-sensitive patients demonstrated a 35.3% response rate (11.8% CR and 23.5% PR); stable disease was documented in 29.4%. The median PFI for platinum-sensitive patients was 18 weeks (range 5– 40). Conclusion. Topotecan is an effective regimen with acceptable toxicity for recurrent ovarian cancer when administered for 3 consecutive days (2.0 mg/m 2) Q 21 days. It can be delivered on schedule without GCSF support in the vast majority of patients. 55. Second-Look Surgery as a Prognostic Tool for Optimally Cytoreduced Ovarian Carcinoma Patients. Ilana Cass, Christine H. Holschneider, Alison C. Madden, Michael R. Manuel, Khai Tieu, Joanthan S. Berek, Ron S. Leuchter, Leo D. Lagasse, and Beth Y. Karlan. Cedars-Sinai Medical Center, Los Angeles, California; and University of California at Los Angeles, Los Angeles, California. Objective. The aim of this study was to determine the incidence of carcinoma identified at second-look surgery (SL) following optimal surgical cytoreduction and standard paclitaxel/platinum chemotherapy in stage IIC–IV

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ovarian carcinoma patients. The ability of SL to predict time to recurrence and overall survival was evaluated. Methods. Patients were identified through institutional ovarian cancer registries. Patients were eligible if they had optimal cytoreduction to ⬍1 cm residual disease, received paclitaxel/platinum chemotherapy, and had no evidence of disease (normal CA 125, physical exam, imaging studies) at the completion of primary therapy. SL was performed ⱕ12 weeks following completion of chemotherapy. Data were extracted on patient demographics, surgical findings, and clinical outcome. Primary outcomes were (i) incidence of disease at SL, (ii) relapse rate following negative SL, and (iii) median time to relapse and overall survival. Results were stratified by stage, residual disease at primary surgery, and time to normalization of CA 125. Results. A total of 103 patients were eligible (stage IIC 10%, IIIA 10%, IIIB 5%, IIIC 65%, IV 10%). Following initial cytoreduction, 42 patients (41%) had microscopic disease; the remainder had ⬍1cm residual disease. Sixty-one percent of SL were performed by laparoscopy. Detection of disease at SL did not differ between laparotomy (30%) and laparoscopy (27%). Twenty-nine patients (28%) had evidence of disease at SL (52% grossly visible vs 48% microscopically detected). Seventy-four (72%) patients had a negative SL. Following a negative SL, 43% of patients developed recurrent disease at a median of 14.3 months. Microscopic residual disease at primary surgery (P ⫽ 0.01) and normalization of CA 125 within three cycles of chemotherapy (P ⫽ 0.03) correlated with negative SL. Stage did not predict presence of disease at SL (P ⫽ 0.2). Four-year survival was 88% for patients with negative SL vs 20% for those with positive SL (P ⬍ 0.01). Rapid (⬍3 cycles of chemo) vs protracted (⬎3 cycles) normalization of CA 125 did not predict a significant difference in overall survival (P ⬎ 0.1). Conclusions. SL evaluation of disease status is a more effective prognostic tool than time to normalization of CA 125 for patients with optimally cytoreduced ovarian cancer and complete clinical response to chemotherapy. Patients with disease at second look or with a slow decline in CA 125 may benefit from additional therapy to improve clinical outcome.

56. Feasibility of Tumor-Associated Macrophages from Ovarian Cancer Patients as a Source for the ex Vivo Generation of Functional Dendritic Cells for Use in Immunotherapy. Christina S. Chu, Edward Y. Woo, George Coukos, Stephen C. Rubin, Katia Schlienger, and Carl H. June. Abramson Family Cancer Center Research Institute, Philadelphia, Pennsylvania; and University of Pennsylvania Medical Center, Philadelphia, Pennsylvania. Objective. The aim of this study was to investigate the potential for in vitro generation of dendritic cells (DCs) from peripheral blood mononuclear cells (PBMCs) and tumor-associated macrophages (TAMs) of ovarian cancer patients and to assess their functional utility for immunotherapy. Methods. After informed consent, we collected blood, tumor, and/or ascites from eight patients with advanced ovarian carcinoma. Solid tumor was enzymatically digested to produce a single cell suspension. Next, blood, ascites, and tumor suspension were processed by density gradient separation to yield the desired cell fractions. PBMCs and TAMs were subjected to 2-h and 30-min plastic adherence, respectively. Adherent cells were cultured for 7 days with IL-4 and GMCSF to produce immature DCs. The DCs were cultured with and without TNF␣ for 4 days. Cells were evaluated by fluorescent antibody cell surface marker staining and FACS analysis for CD14, HLADR, CD32, CD40, CD80, CD83, and CD86 at days 7 and 11 of culture. The functional capacity of cells was tested by allogeneic MLR at day 11. Results. After culture with IL-4 and GM-CSF, ascites fluid produced an average of 2.6 ⫻ 10 4 DCs/ml of ascites versus 12.8 ⫻ 10 4 cells/ml of peripheral blood. However, because several liters of ascites could often be obtained from individual patients, DCs derived from these TAMs represent a quantitatively satisfactory source of DCs. At day 7, greater persistence of CD14⫹/HLADR⫹ cells was noted in TAM cultures than in PBMC cultures. For every cell surface marker tested after a 4 – day exposure to TNF␣, TAM DCs demonstrated the ability to undergo maturation, but to a lesser degree than PBMC DCs. Despite this evidence of impaired maturation, TAM DCs demonstrated equivalent or better functional capacity in seven of eight patients when compared to PBMC DCs, as measured by their ability to

stimulate proliferation of T cells in allogeneic mixed lymphocyte reactions. Conclusion. TAMs are a viable source for ex vivo production of significant numbers of DCs in ovarian cancer patients. Despite inferior expression of cell surface maturation markers, TAM DCs display equivalent, and occasionally superior, functional capacity as assessed on a per-cell basis for their ability to stimulate T cell proliferation when compared to PBMC DCs. TAM DCs show potential for utilization in either ex vivo or in vivo DC-based immunotherapies. 57. In Vitro Chemoresistance and Biomarker Profiles Are Unique for Histologic Subtypes of Epithelial Ovarian Cancer. Noelle G. Cloven, Ainura Kyshtoobayeva, Robert A. Burger, and John P. Fruehauf. Oncotech, Inc., Irvine, California; and University of California at Irvine, Orange, California. Objective. The molecular characteristics, biologic behavior, and response to treatment of epithelial ovarian cancer vary widely. The aim of this study was to determine whether histologic subtype is related to chemoresponsiveness and molecular marker expression. Methods. Epithelial ovarian cancer specimens referred to Oncotech, Inc., between 1995 and 1998 for performance of extreme drug resistance assay (EDR) and marker profiles were included in the study. We analyzed differences in in vitro drug resistance and expression of biomarkers known to be prognostic for ovarian cancer among six histologic subtypes. Results. Of the 5195 cases reviewed, histologic diagnosis was available for 4170 cases. Overall, extreme drug resistance to cisplatin, carboplatin, cyclophosphamide, doxorubicin, gemcitabine, paclitaxel, and topotecan was noted in 10, 16, 16, 40, 21, 22, and 13%, respectively. When other histologic types were compared to papillary serous tumors, there were significant differences in drug resistance. Endometrioid tumors were less resistant to cisplatin and doxorubicin (P ⫽ 0.02, P ⬍ 0.0001, respectively). Mucinous tumors were more resistant to cisplatin but less resistant to topotecan and doxorubicin (P ⫽ 0.002, P ⫽ 0.05, P ⬍ 0.001, respectively). Although generally thought to be more aggressive, clear cell carcinomas were less resistant to paclitaxel, doxorubicin, and cyclophosphamide (P ⫽ 0.03, P ⬍ 0.0001, P ⫽ 0.01). Borderline tumors showed high rates of EDR to paclitaxel and cyclophosphamide (P ⬍ 0.0001) and low resistance to topotecan and doxorubicin (P ⫽ 0.04 and P ⬍ 0.0001, respectively). With respect to markers, mP53 was detected in 46%, Her-2 neu in 16%, and EGFR in 30% of the cases evaluated. Compared to all other subtypes, clear cell carcinomas had significantly higher Her-2 neu expression (19%, P ⫽ 0.002). Relative to papillary serous carcinomas, borderline tumors exhibited significantly lower mP53 expression (60% vs 17%, P ⫽ 0.04). Conclusions. We conclude that there are significant differences in the frequency of extreme drug resistance to chemotherapeutic agents and expression of molecular markers among histologic subtypes of epithelial ovarian cancer. The data collected in this investigation may provide useful information for clinical trials that stratify patients based on histology and expression of molecular markers to determine optimal treatment. 58. Molecular Profiling of Serous Ovarian Carcinomas by cDNA Microarray Reveals Clinically Distinct Groups That Correlate with Altered Expression of Multiple Genes. Yvonne C. Collins, Tanja Pejovic, Gil Mor, Shashikant B. Lele, Thomas Rutherford, Devin McQuaid, Norma Nowak, and Kunle Odunsi. Roswell Park Cancer Institute, Buffalo, New York; and Yale University School of Medicine, New Haven, Connecticut. Objective. As a step toward understanding the molecular events involved in ovarian carcinogenesis, we utilized cDNA microarray to determine the molecular properties of serous epithelial ovarian carcinomas. We also sought to identify genes and gene clusters that correlate with disease-free and overall survival. Methods. Using an autogen plasmid isolation system, 2382 clones with cancer related properties were PCR amplified and used for the fabrication of microarrays on Corning CMT-GAPS slides using an Affymetrix 417 arrayer. Total RNA from normal ovarian and 20 tumor tissues was labeled with Cy5-dUTP and Cy3-dUTP, respectively, hybridized, and scanned to measure fluorescent intensity. Distance measures and hierarchical clustering computations were performed such that genes and tumors with similar expression

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS patterns were adjacent to each other. Survival distributions were calculated by the Kaplan–Meier method and statistical significance was determined with the log-rank test. Results. We identified 150 genes that were upregulated in 70% of tumor samples. Genes showing upregulation in all tumors included v-myc avian myelocytomatosis viral oncogene homolog 1; osteoblast-specific factor 2 fasciclin I-like; and tissue plasminogen activator. The genes exhibiting greater than 20-fold increased expression included transmembrane 9 superfamily member 2 and POU domain, transcription factor 1. We also identified 27 genes that were downregulated in 60% of tumors. Genes showing greater than 40% underexpression included TGF␤ receptor; TNF ligand superfamily, member 11; and cytochrome P450, subfamily XIX. The median duration of follow-up of the patients was 16.8 months (range 1.4 – 61.8 months) with 50 and 24% disease-free survival at 1 and 2 years, respectively. Hierarchical clustering of the expression data revealed clinically distinct groups that correlated with the risk of recurrent disease and survival. Conclusions. This study demonstrates that multiple regulatory pathways are involved in ovarian carcinogenesis. Genome-wide expression profiling may permit a molecular classification of these tumors. Our data should make it possible to define the nature of individual tumors, provide clues for identifying new therapeutic targets, and ultimately optimize the treatment of each patient.

59. Intraperitoneal Immune-Gene Therapy with Adenovirus-Encoded Interferon-␤. Alisha Mohamed-Hadley, Jose R. Conejo-Garcia, David Allman, Stephen C. Rubin, Steven M. Albelda, and George Coukos. University of Pennsylvania, Philadelphia, Pennsylvania. Objective. The aim of this study was to assess the efficacy and immune effects of intraperitoneal (ip) immune-gene therapy with adenovirus carrying interferon-␤ (IFN-␤) in ovarian cancer escaping T cell recognition. Methods. The mouse ovarian teratocarcinoma (MOT) line lacks expression of major histocompatibility complex-I molecules. Immunocompetent syngeneic C3H mice or severe combined immunodeficiency (SCID) mice, which lack only lymphocytes, were injected ip with 10 5 MOT cells. Ad.IFN-␤; Ad.tk; and Ad.PECAM-1 are E1/E3-deleted replication-incompetent adenoviral vectors encoding murine IFN-␤-1a; herpes simplex virus thymidine kinase (tk); and human platelet– endothelial cell adhesion molecule-1 (PECAM-1) cDNA, respectively, under a cytomegalovirus promoter. Mice were injected ip once with 1 ⫻ 10 9 particle-forming units (pfu) Ad.IFN-b, control Ad.tk, or saline 72 h following tumor inoculation. Survival analysis was computed using log-rank statistics. To test the effects of Ad.IFN-␤ immune-gene therapy on the peritoneal immune milieu, healthy animals were injected with 1 ⫻ 10 9 pfu Ad.IFN-␤, control Ad.tk, or saline. Cells harvested from the peritoneal cavity at 24 h were analyzed with four-color flow cytometry utilizing dye-labeled monoclonal antibodies recognizing specific immune populations (BD PharMingen, San Diego, CA). Results. MOT proved susceptible to adenoviral infection, as assessed by PECAM-1 expression following incubation with Ad.PECAM-1 (30 MOI resulted in a 94.5% infection rate). A single ip injection of Ad.IFN-␤ resulted in a 10% cure and significantly prolonged median survival (4.8 weeks) compared to Ad.tk (3.5 weeks) or saline (3.1 weeks) in C3H mice. In SCID mice, Ad.IFN-␤ induced a similar survival advantage, confirming that such a response was T cell independent. Following ip inoculation of Ad.IFN-␤ but not Ad.tk, we observed a dramatic increase in the number of peritoneal NK cells and granulocytes and significant activation of macrophages. Conclusion. Intraperitoneal immune-gene therapy with Ad.IFN-␤ exerts antitumor effects against ovarian carcinoma, even in the face of escape from adaptive antitumor immune responses, possibly through the recruitment and activation of innate immune system effector cells. Ad.IFN-␤ may be a promising therapeutic strategy in EOC.

60. Development of a Syngeneic Ovarian Carcinoma Model Overexpressing Vascular Endothelial Growth Factor-164 in the C57BL/6 Mouse. Lin Zhang, Nuo Yang, Alisha Mohamed-Hadley, Jose R. Conejo-Garcia, and George Coukos. University of Pennsylvania, Philadelphia, Pennsylvania.

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Objectives. The aim of this study was to develop a syngeneic mouse model of ovarian carcinoma. Methods. The backbone of murine stem cell virus MIGR1 retrovirus encoding humanized green fluorescent protein (GFP), MIGR1/GFP, was used to insert the murine VEGF-164 isoform cDNA (generously provided by Dr. P. D’Amore, Harvard Univ.) upstream of GFP. MIGR1/GFP encoding VEGF-164 or control MIGR1/GFP constructs was used to permanently transfect ID8 cells, a cell line derived from spontaneous malignant transformation in vitro of C57BL/6 murine ovarian surface epithelium (generously provided by Dr. P. Terranova, Univ. of Kansas). GFPpositive cells were procured through flow cytometry cell sorting. H5V, a BL6 murine endothelial tumor cell line, was used to test the effects of ID8-derived VEGF in vitro. To test the effects of VEGF-164 in vivo, 5 ⫻10 6 ID8 cells were injected subcutaneously (sc) to C57BL/6 mice in 250 mcl of growth-factorenriched Matrigel. To test the ability of VEGF-164 to promote intraperitoneal (ip) tumor growth, 10 ⫻ 10 6 ID8 cells were injected ip to C57BL/6 mice. Results. ID8 cells were successfully transfected with MIGR1/GFP or MIGR1/ GFP encoding VEGF-164 and a 99%-pure cell population expressing GFP was isolated by cell sorting. VEGF-positive clones displayed 20-fold higher expression of VEGF-164 mRNA, 8-fold higher expression of total VEGF mRNA, and higher total VEGF protein product compared to control cells transfected with MIGR1/GFP alone. Supernatants of ID8 cells overexpressing VEGF exerted a significantly higher stimulatory effect on murine endothelial cell migration in vitro compared to control ID8 cells. ID8 cells overexpressing VEGF-164 yielded significantly (10- to 20-fold) larger flank tumors following sc inoculation compared to control ID8 cells. ID8 cells overexpressing VEGF164 injected ip led to the development of significantly larger tumors (1- to 5-mm widespread tumor nodules within 6 weeks vs ⬍1-mm nodules within 12 weeks) and a significantly larger amount of ascites compared to control ID8 cells. Conclusions. We have established a convenient syngeneic model of ovarian carcinoma overexpressing murine VEGF-164 in the C57BL6 mouse, which is suitable for the study of events related to malignant progression, angiogenesis, and tumor immune recognition. 61. Ovarian Cancer. in Vivo Assessment of TGF-␤ Signaling via Collagen Biomarkers in Malignant Ascites. Bernadette M. Cracchiolo, Timothy A. McCaffrey, Setsuko K. Chambers, Peter E. Schwartz, Qiuhu Shi, Joseph T. Chambers, and Hartmut M. Hanauske-Abel. College of Physicians and Surgeons, Columbia University, New York, New York; George Washington University Medical Center, Washington, DC; New Jersey Medical School, Newark, New Jersey; North Shore University, Manhasset, New York; Weill Medical College, Cornell University, New York, New York; and Yale University School of Medicine, New Haven, Connecticut. Objective. Oncogenesis in general and ovarian cancer in particular involve the TGF-␤s and their receptors (TGF-␤Rs) [e.g., Lynch et al., Cancer Res 1998;58:4227–32]. The TGF-␤/TGF␤R system also is one of the major elements controlling collagen synthesis [e.g., Roberts et al., Ann NY Acad Sci 1990;580:225–32]. We therefore hypothesized that in malignant ascites, TGF-␤s and collagen biomarkers display a dose– effect relation, as a reflection of functionally intact TGF-␤ signaling. Methods. With IRB approval, ascites was sampled at staging laparotomy in 35 patients (24 at FIGO stage III, 8 at stage IV); 19 patients. had died at study conclusion (ave. follow-up, 21 months). Active (act.) and total (tot.) TGF-␤ were bioassayed by inhibition of [ 3H]-thymidine incorporation in CCL64 mink lung fibroblasts, sensitive to TGF-␤1, -␤2, and -␤3. The fibrillar collagens type I and type III were radioimmunoassayed via their synthesis markers PICP and PIIIIP, respectively. The four measurements obtained per sample were normalized to each sample’s protein concentration (pn) and used for correlation and regression analysis. Results. The overall study cohort displayed only moderate correlations between act. or tot. pnTGF-␤ and pnPICP or pnPIIINP (Pearson correlation [PC], about 0.4), achieving significance just for act. pnTGF-␤ (P ⱕ 0.008). The levels of the four parameters did not differ with statistical significance between those alive and those deceased. However, in those alive at study conclusion (n ⫽ 16), PC between either collagen marker and act. or tot.

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pnTGF-␤ ranged at 0.9 (P ⱕ 0.0001), corroborated by Spearman analysis. The samples of this subgroup also displayed a linear dose– effect relation of act. or tot. pnTGF-␤ with either collagen marker (R 2 ⫽ 0.7; P ⱕ 0.0001). By contrast, in the subgroup of those deceased at study conclusion, a discernible TGF-␤/ collagen correlation did not emerge, and no dose– effect relation was apparent. Conclusion. Assessed via biomarkers for collagen synthesis in malignant ascites, signaling via the TGF-␤/TGF␤R system does not occur in a uniform manner in ovarian cancer. In a subgroup of patients, defective TGF-␤ signaling is apparently associated with early mortality, consistent with similar observations in other cancers [e.g., Tokunaga et al., Clin Cancer Res 1999;5:2520 –5]. [Supported by the UMDNJ Foundation (19 –99) and the NIH (MO1RR06020/ R29CA60665/KO8HD01013).] 62. Rho-Kinase in LPA-Mediated Ovarian Cancer Migration and Invasion. Thuy-Vy Do, Jay Symowicz, Jason Navari, and David A. Fishman. Northwestern University, Chicago, Illinois. Objective. Lysophosphatidic acid (LPA)is a phosphoplipid which signals through G protein-coupled receptors to induce diverse cellular responses. LPA levels are elevated in serum and ascites in ovarian cancer patients and may mediate intraperitoneal dissemination. LPA activates the small GTPase, Rho, which plays a pivotal part in cancer migration and invasion. To determine whether LPA activation of Rho-regulated pathways is required for ovarian cancer migration and invasion, we investigated the effects of inhibiting Rhokinase (ROCK) on LPA-mediated changes in actin cytoskeleton morphology, proteinase activation, haptotactic migration, and cellular invasion. LPA treatment of DOV13 cells results in a reduction in stress fibers but an increase in peripheral actin bundles, suggesting that cells are contracting. This is consistent with our observation that cells appear to round up and lose adhesion upon LPA treatment. Since Rho GTPases are believed to regulate stress fiber formation, we reasoned that inhibiting ROCK would further enhance LPAinduced stress fiber disassembly and, consequently, adhesion. These events should, consequently, have an impact on cell migration and invasion. Methods. Phalloidin staining of actin filaments in cells treated with both LPA and Y-27632, a specific inhibitor of ROCK, revealed that compromising ROCK function augments the loss of stress fibers observed with LPA treatment. Interestingly, the inhibition of ROCK with Y-27632 enhances LPA-mediated activation of the metalloproteinase, MMP-2, but has no significant effect on uPA activity. Since previous studies have shown that LPA increases haptotactic migration and invasion through a synthetic matrix, we wanted to determine the effects of Y-27632 treatment on cell migration and invasion. Results. Y-27632 treatment alone does not significantly affect haptotactic migration on colloidal gold-coated coverslips, but in the presence of both Y-27632 and LPA, migration is reduced close to basal levels. Furthermore, inhibition of ROCK abrogates LPA-mediated invasion through a complex matrix, indicating that ROCK activity is required for LPA-stimulated invasion, perhaps via its role in mediating cell migration. Conclusions. Taken together, these results suggest that inhibition of ROCK blocks LPA-mediated migration and invasion, but enhances LPA-stimulated proteinase activation. This enhanced MMP-2 activation, however, does not promote cell invasion above basal levels. 63. Comparison of Survival and Disease-Free-Interval in Patients with Dual Primaries of Breast and Epithelial Ovarian Cancer (EOC) versus Patients with Single Primary EOC. James Dunlop, Jeanne M. Schilder, Daynelle Dearnley, Jean A. Hurteau, David H. Moore, and Katherine Y. Look. Indiana University School of Medicine, Indianapolis, Indiana; and IN, University of Kentucky, Lexington, Kentucky. Objective. The aim of this study was to determine whether there is a difference in median disease-free or overall survival between patients (pts) with BRCA-linked dual breast and EOC primaries versus pts with EOC alone. Previous estimates (Domchek 2001) suggest that 88% of pts with dual primaries have BRCA1 mutations. Methods. A retrospective case– control study of pts treated at Indiana University and the University of Kentucky was performed. Twenty-eight pts with stage III or IV EOC and a history of breast

cancer were identified. Three controls were identified for each case, except in three instances where only two controls were obtained. Controls were matched for age of diagnosis, stage, year of treatment, residual disease, and chemotherapy regimen. All patients had surgical debulking staffed by gyn– oncologists at one of the two institutions. Kaplan–Meier survival curve analysis and log-rank comparison of curves were done. Results. Survival curves were carried out to 84 months. The median disease-free-interval was 11 months for the controls with EOC alone versus 20 months for BRCA-linked pts [P ⫽ 0.15]. Median survival times were 28 months for pts with EOC alone and 31 months for pts with dual primaries [P ⫽ 0.44]. Conclusion. While not statistically significant, the results for the disease-free interval reflect the trend noted by others (Boyd 2000). There does not appear to be a distinct survival advantage for either group. 64. Does the Extent and Location of Intraabdominal Metastatic Disease Influence Survival for Patients with Advanced Ovarian Cancer? Scott Eisenkop, Nick Spirtos, Albert Pisani, and Sergio Perticucci. Woman’s Cancer Center, Bakersfield, California; Woman’s Cancer Center, Encino– Tarzana, California; Woman’s Cancer Center, Palo Alto, California; and Woman’s Cancer Center, San Diego, California. Objective. The aim of this study was to determine whether the extent of metastatic epithelial ovarian cancer in five anatomic locations influences survival and correlates with biologic aggressiveness for patients with stage IIIC disease undergoing maximal effort cytoreductive surgery. Methods. Between 1990 and 2001, 281 patients with stage IIIC epithelial ovarian cancer underwent cytoreduction to a visibly disease-free outcome before treatment with systemic platinum-based combination chemotherapy. A numeric (0 –3) rating system was developed to reflect the extent of metastatic disease involving the pelvis, omentum, diaphragm, and retroperitoneum, as well as the intestinal serosa and peritoneal surfaces. Univariate survival analysis was performed on the basis of the numeric rating of the extent of disease present in each of these locations (log rank), the sum of numeric ratings of all intraabdominal disease locations (Cox’s proportional hazards), and other variables reported to independently influence survival. Multivariate survival analysis (stepwise Cox proportional hazards) confirmed independently significant influences of clinical variables on survival. Results. The median and estimated 5-year survival for the cohort was 73.0 months and 52%, respectively. Survival was not influenced by the extent of metastatic disease associated with the pelvis, diaphragm, omentum, retroperitoneum, or isolated segments of intestine. Survival was independently influenced only by the extent of peritoneal metastatic implants that were present [none (rating ⫽ 0) versus ⱕ50 (rating ⫽ 1) versus ⬎50 (rating ⫽ 2) versus ⬎50 with confluent bowel involvement (rating ⫽ 3), P ⫽ 0.03], histology [clear cell and mucinous versus all other histology, P ⫽ 0.03], and patient age (P ⫽ 0.02). Conclusions. Extensive carcinomatosis of the mesentery and intestinal serosa marginally correlates with diminished survival, but not significantly enough to preclude long-term survival or justify abbreviation of the operative effort. Among patients who undergo complete cytoreduction, the extent of intraabdominal metastatic disease correlates poorly with both the prognosis for survival and the innate biological aggressiveness and should not be used to determine operability. 65. Determinants of Survival for Patients with Stage IIIC and IV Ovarian Cancer Who Are Clinically Disease-Free after Primary Surgery and Chemotherapy. Scott Eisenkop. Woman’s Cancer Center, Encino–Tarzana, California. Objective. The aim of this study was to determine clinical and pathologic variables that influence subsequent survival for patients with ovarian cancer who are clinically disease-free after completion of primary treatment. Methods. Between 1990 and 2001 a total of 298 patients with stage IIIC and IV epithelial ovarian cancer underwent primary cytoreductive surgery and completed a planned program of multiagent platinum-based chemotherapy. A second-look laparotomy was considered for patients who were serologically and clinically disease-free upon completion of treatment. The goal at second

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS look was to obtain a minimum of 100 tissue samples for patients without macroscopic persistent disease. Secondary cytoreduction was attempted for patients with macroscopic visible disease. Salvage treatment of patients with positive second looks was individualized. A univariate analysis (log rank) determined which clinical and pathological variables influenced the probability of subsequent survival for patients who were serologically and clinically disease-free upon completion of treatment. Multivariate analysis (Cox model) confirmed which variables independently influenced the probability of survival for patients who were serologically and clinically disease-free after completion of primary treatment. Results. 271 (90.1%) patients were serologically and clinically disease-free after completion of primary treatment. Two hundred three (74.4%) underwent a second-look laparotomy. Of those who underwent the procedure, 112 (55.2%) were negative, 56 (27.6%) were microscopically positive, and 35 (17.2%) were grossly positive. Of the total cohort that were clinically disease-free after completion of primary therapy, the subsequent median and estimated 5-year survivals were 69.8 months and 54%. After completion of primary treatment, survival was independently influenced by the largest metastatic disease present at primary cytoreduction (ⱕ 10 cm; median not reached versus ⬎10 cm; median 46.8 months, P ⫽ 0.02), the primary cytoreductive outcome (no residual disease; median 72.8 months versus any residual disease; median 33.3 months, P ⫽ 0.02), and the performance of a second-look procedure (performed; median 81.1 months versus not performed; median 38.5 months, P ⫽ 0.004). Conclusions. The performance of secondlook laparotomy potentially conveys an improved prognosis for survival by identifying patients who might benefit from additional chemotherapy. A large multicenter, randomized trial should be considered to confirm these findings.

66. Factors Affecting Complete Cytoreducibility in Advanced-Stage Ovarian Cancer. Gamal H. Eltabbakh, Sharon L. Mount, Barbara Beatty, Linda Simmons-Arnold, Kumarasen Cooper, Cheung Wong, and Ann Morgan. University of Vermont, Burlington, Vermont; and University of Vermont/ Fletcher Allen Health Care, Burlington, Vermont. Objective. Cytoreducibility among women with ovarian cancer has been variously attributed to the surgical effort, tumor volume, and biological aggressiveness of the tumor. The aim of the current study was to determine whether tumor volume or biological markers of tumor aggression can predict complete cytoreducibility among women with ovarian cancer. Methods. We conducted a prospective study among women with FIGO stage III and IV primary epithelial ovarian cancer. All patients underwent similar aggressive attempts at cytoreduction (80% of the surgeries were performed by the same surgeon). Patients’ demographics, CA-125, tumor volume, and ascites were recorded. The same pathologist reviewed all pathologic material and recorded tumor histology and grade. Tumor samples were assessed for p53, p21, bclx, and bax expression using immunohistochemistry. Complete cytoreduction was defined as the ability to remove all gross tumor. Factors affecting cytoreducibility (stage, CA-125, ascites, histology, grade, p53, p21, bclx, and bax) were assessed using the odds ratio and associated 95% CI. Significant univariate odds ratios were assessed jointly in a multivariate logistic regression model. Receiver operating characteristic curve analysis was performed to determine the CA-125 level with the maximal cytoreduction prognostic power. Results. Sixty-seven consecutive women (mean age 58.1 ⫾ 12.5) were studied. Twenty-five (37.3%) had complete cytoreduction, 30 (44.8%) had ⬍1 cm residual, 10 (14.9%) had 1–2 cm residual, and 2 (2.9%) patients had ⬎2 cm residual tumor. Factors with significant (P ⬍ 0.05) univariate associations included stage, CA-125, ascites, and histology, and those with marginally significant (0.10 ⬍ P ⬍ 0.05) associations included grade and p53. The only factor which remained significant in the multivariate logistic regression model was stage (OR 9.4, 95% CI 1.3, 65.9). A preoperative CA-125 level of ⬎500 U/ml had the highest sensitivity and specificity (73 and 76%, respectively) in predicting complete cytoreduction. Conclusions. Standardizing for surgical effort, the ability to achieve complete cytoreduction among women with advanced stage ovarian carcinoma is mainly influenced by the volume of disease as reflected by the surgical stage and not the biological markers of

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tumor aggression. A preoperative CA-125 ⬎500 U/ml has high sensitivity and specificity in predicting complete cytoreduction. 67. Alterations in Cyclin E and p27 in Early Epithelial Ovarian Cancer. A Gynecologic Oncology Group Study. John H. Farley, Leia Smith, Kathleen M. Darcy, Chungiao Tian, Eugene Sobel, and Michael J. Birrer. Colorado State University, Fort Collins, Coloradp; GOG Statistical & Data Center, Roswell Park Cancer Institute, Buffalo, New York; National Cancer Institute, Rockville, Maryland; and Tripler Army Medical Center, TAMC, Hawaii. Objective. Cyclin E is a G1 cyclin that is one of the key regulators of the G1/S transition, and p27 is a cyclin-dependent kinase inhibitor that mediates cell growth by regulating G1/S transition. We recently showed that abnormalities in the protein expression levels of p27 and cyclin E are related to survival in advanced stage epithelial ovarian adenocarcinomas. The purpose of this study was to evaluate the relationship of p27 and/or cyclin E protein expression in early stage epithelial ovarian cancers. Methods. Immunohistochemical expression of p27 and cyclin E was evaluated in 145 early FIGO stage I and II ovarian cancer specimens from women treated on Gynecologic Oncology Group Protocol 157. We used the following cutoff points previously identified in our analysis of advanced ovarian cancer patients: ⬎40% cyclin E and ⬎40% p27, considered high staining. Results. Analysis of p27 expression in the early stage ovarian adenocarcinomas revealed high p27 protein expression (⬎40% positive tumor cells) in 126 (87%) of patients. High cyclin E protein expression (⬎40% positive tumor cells) was seen in 50 (34%) early stage ovarian cancer patients. We previously evaluated 139 advanced ovarian cancer patients by immunohistochemistry for cyclin E and p27. A significantly greater percentage of early stage epithelial ovarian cancer patients demonstrate high p27 expression, 87% versus 35%, than advanced stage ovarian cancer patients, P ⬍ 0.0001. In contrast, cyclin E overexpression was only slightly lower, 34% versus 45%, in early compared to late stage ovarian cancer patients, P ⬍ 0.007. Finally, only 15% of early stage patients had a cyclin E to p27 ratio ⬎1.00, compared to 45% of advanced ovarian cancer patients, P ⬍ 0.001. Conclusions. Down regulation of p27 correlates with the stage of ovarian cancer. Lower expression is found in advanced stage disease. Up regulation of cyclin E occurs in early stage disease and may be an early event in the development of ovarian cancer. Additional statistical analyses will examine the clinical associations of cyclin E and/or p27 in women with early stage ovarian cancer. 68. Distinct Allelotype Profiles in Mucinous Ovarian and Mucinous Appendiceal Carcinomas. Colleen M. Feltmate, Kenneth R. Lee, Jae Hoon Kim, Debra A. Bell, William R. Welch, Ross S. Berkowitz, and Samuel C. Mok. Brigham and Women’s Hospital and Dana Farber Cancer Center, Harvard Medical School, Boston, Massachusetts,. Objective. The pathogenetic mechanism of mucinous ovarian cancer is poorly understood. In more widespread disease, the nature of mucinous tumors in the ovary remains difficult to determine. Our objective was to generate an allelic profile for mucinous ovarian epithelial carcinoma. Additionally, mucinous appendiceal carcinomas were studied to compare loss regions and to develop an allelotype “fingerprint” by which to differentiate the two types of tumors. Methods. Twenty-seven invasive mucinous ovarian epithelial and 6 appendiceal carcinomas were examined for allelic losses across the genome. Pure epithelial and corresponding normal cell populations were procured selectively by laser capture microdissection. Extracted DNA was amplified using an improved primer-extension-preamplification PCR method. Highthroughput allelotyping was performed on the amplified DNA using fluorescent dye-labeled primer pairs at 20-cM intervals spanning the chromosomes. The percentage loss of heterozygosity (LOH) for each marker and the fractional allelic loss for each sample were calculated for the different tumor types and grades. Statistical analysis using the t test, ␹ 2 test, and ANOVA was performed using SPSS v9.0. Results. Mucinous ovarian carcinomas had a significantly higher mean LOH rate (29.5% vs 10.7%, P ⬍ 0.0001) and fractional allelic loss (30% vs 11%, P ⫽ 0.01) than appendiceal tumors.

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Ovarian carcinomas had the highest deletions (⬎40%) noted in regions of chromosomes 1p, 5q, 6q, 8p, 17p, 18p, and 18qter. In appendiceal tumors high regions of loss were found in 6q, 18pter, and 18qter. Significantly higher LOH rates at D1S2868 (P ⫽ 0.04) and D5S436 (P ⫽ 0.05) were noted in ovarian versus appendiceal tumors. A significant increase in LOH rate was associated with increasing grade in markers D1S2667, D2S117, D5S436, and D8S270 in mucinous ovarian cancer. Conclusion. Different allelic loss patterns in mucinous ovarian carcinoma and mucinous appendiceal carcinoma suggest that these two tumor types have different pathogenetic pathways. Use of specific markers may help determine the origin of mucinous carcinomas when questions arise regarding primary ovarian or metastatic disease. 69. The Association of BRCA1 and BRCA 2 Germline Mutations in Patients with Papillary Serous Carcinoma of the Peritoneum. Abbie L. Fields, Gary L. Goldberg, and Carolyn D. Runowicz. Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York. Objectives. The aim of this study was to determine the incidence of BRCA1 and BRCA2 germline mutations in patients with papillary serous carcinoma of the peritoneum (PSCP) and to correlate the presence of these mutations with personal and family histories of malignancies. Method. Patients diagnosed with PSCP were contacted to participate in this IRB-approved study. Complete medical and family histories were obtained. Consent for genetic testing was obtained following appropriate counseling. Full sequence analysis of both BRCA1 and BRCA2 was performed in collaboration with Myriad Genetic Laboratories. Results. Twenty-four patients have been analyzed, 3 of whom are Ashkenazi Jews. The median age at diagnosis was 64 years (range 47– 83). Twelve of 24 (50%) were found to have mutations in BRCA1 (3/12 ⫽ 25%) or BRCA2 (9/12 ⫽ 75%). None of the mutations was identified among the 3 Ashkenazi Jewish patients. The three mutations known to be deleterious in BRCA1 were IVS9-2A⬎C, 5083 del 19, and IVS6-2 del A; the three in BRCA2 were E 1308X, 6174 del T, and 2792 del CA. The remaining six mutations, all in BRCA2, were M23221, H2116R, 12490T, S9761, P655R, and 12490T and further investigation is required to assess the significance of these mutations as deleterious. Two patients with known deleterious mutations and 1 with no mutation had a personal history of breast cancer. Twelve of 24 (50%) patients had family histories significant for breast, ovarian, pancreatic, prostate, or colon cancers, 8 of whom were in the group with mutations. Conclusion. PSCP is associated with a high frequency of mutation in BRCA1 or BRCA2. BRCA2 mutations were more common than BRCA1 mutations. As with other known BRCA-associated malignancies, family history is significant. The age at onset of diagnosis is not remarkably earlier. Given these data, continued mutational analysis in a larger population of patients with PSCP is warranted with plans for the expanded project already underway. (Supported by the Ovarian Cancer Research Fund.) 70. Ultrasound for Detection of Early Stage Epithelial Ovarian Carcinoma. David A. Fishman, Leeber Cohen, Kenny Bozorgi, Diljeet Singh, Anna O’Donnell, Mary Ann Donnely, Jennifer O’Rourke, Pedro Escobar, and John Lurain III. Northwestern University, Chicago, Illinois. Objective. The National Ovarian Cancer Early Detection Program, as part of the National Cancer Institute’s Early Detection Research Network, is committed to developing effective means for the detection of early stage epithelial ovarian cancer. Clinically relevant bioassays based on the scientific basis of carcinogenesis, invasion, and metastasis are combined with new diagnostic imaging technologies to achieve our goal. We report the utility of ultrasound as an independent modality. Method. Asymptomatic women with normal gynecologic exams deemed at increased risk are eligible to participate in our IRB-approved program. Increased risk includes women with at least one affected first-degree relative with ovarian cancer; a personal history of breast, ovarian, or colon cancer; one or more affected first- and second-degree relatives with breast and or ovarian cancer; inheritance of a BRCA mutation from an affected family member; or membership within a recognized cancer syndrome. Participants undergo pelvic and ultrasound exams every 6 months in

conjunction with investigational biomarker analyses. Doppler and 3-D studies are performed only if an adnexal mass is identified and an overall impression of malignancy risk is assigned based on morphologic appearance and the presence or absence of central vascularity. A total of 1159 women were evaluable (702 premenopausal and 457 postmenopausal). A total of 5480 scans were performed. Results. A total of 76 women had persistent adnexal masses. Fourteen simple cysts greater than 5 cm were treated with percutaneous drainage with benign cytology. Fifteen women received operative intervention with benign ovarian pathologies. Thirty-six menopausal women with stable simple cysts, hydrosalpinges, or fluid-filled adhesive disease have been followed expectantly. Three asymptomatic gynecologic malignancies (⬍2 cm) were identified with aberrant central flow. Final pathology revealed 2 fallopian tube carcinomas (stage IIIB⫺ omentum⫹, and stage IIIC⫺ lymph nodes⫹) and 1 primary peritoneal cancer (stage IIIA). Interestingly, all 3 women had normal physical and ultrasound examinations within our program 12 and 6 months prior to the diagnosis of cancer. Conclusions. This ongoing study demonstrates that diagnostic ultrasound has proven efficacy in detecting asymptomatic adnexal malignancies. As yet, we have not confirmed the utility of diagnostic ultrasound as an independent modality for the detection of early stage ovarian cancer in asymptomatic high-risk women.

71. Age Contrasts in Clinical Characteristics and Pattern of Care in Patients with Epithelial Ovarian Cancer. Ami Fishman, Ilan Bruchim, and Marco Altaras. Meir Hospital–Sapir Medical Center, Kfar-Saba, Israel. Objective. The aim of this study was to document and highlight aspects of ovarian cancer (OvCa) treatment that pertain, especially, to elderly women. Methods. We retrospectively collected data from all epithelial OvCa patients who were diagnosed in the Gyn–Oncology Unit at our institution from January 1994 to December 1998. Results. The study group comprised 143 patients (⬍69 years, n ⫽ 97, ⬎70 years, n ⫽ 46). The median age for the younger and older patients was 57 and 75 years, respectively. The older group presented with the same distribution of stages as their younger counterparts. The most commonly recorded medical problem was cardiovascular disease, which occurred in 71.7% of the elderly patients compared to 22.7% of the younger patients (P ⬍ 0.001). As a group, the elderly patients had fewer primary debulking surgical interventions (73.9%) than the younger patients (91.8%) (P ⫽ 0.004). Although the elderly women were less likely to undergo surgical intervention, age was not a limiting factor in achieving optimal debulking (older 53%, younger 54%) in those patients who did undergo surgery. Almost 92% of the younger patients entered a first-line chemotherapy regimen compared to 65.2% of the older patients (P ⫽ 0.001). The elderly patients were more likely to receive neoadjuvant chemotherapy (43.3.3% vs 13.4%, P ⬍ 0.01). Hematological toxicity was significantly more common in the elderly group (75% vs 36.3%; P ⫽ 0.001) although no significant difference was noted between the groups in Grade 3– 4 patients (⬎69 years 62.5% vs ⬍70 years 45.5%; P ⫽ 0.2). The elderly patients were more likely to have dose reductions and treatment delays compared to the younger patients (60% vs 22.4%; P ⬍ 0.001, and 46.6% vs 19.1%; P ⫽ 0.004, respectively). The elderly patients had similar overall response rates (RR) and complete responses compared to the younger patients (80% vs 87.6% and 60% vs 71.9%, respectively). Conclusions. Surgically, older women who present with the same distribution of stages as their younger counterparts are likely to be treated more conservatively than younger OvCa patients. When surgery was performed, the optimal tumor debulking rates of older women were similar to those of the younger group. Although high morbidity, most often hematological toxicity, occurs in this group of patients following chemotherapy, the overall RR was comparable to that of the younger patients.

72. Impact of Clinical Comorbidity in the Decision to Treat Ovarian Cancer Patients with Adjuvant Chemotherapy. Randall K. Gibb, David G. Mutch, Janet S. Rader, Thomas J. Herzog, and Jay F. Piccirillo. Washington University School of Medicine, St, Louis, Missouri.

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS Objective. The aim of this study was to determine the impact of comorbidity in the decision process to treat ovarian cancer patients with adjuvant chemotherapy and its independent effect on overall survival. Methods. The overall severity of comorbidity was determined prospectively for all stage 3 and 4 ovarian cancer patients treated at Washington University Medical Center between 1995 and 2001. A total of 244 patients were identified of which 31 (13%) received adjuvant chemotherapy, comprising the study population, compared to 204 (87%) who received surgery followed by standard chemotherapy. Standard demographics, levels of comorbid health, FIGO stage, and survival were compared. Bivariate analysis was conducted to identify pretreatment variables related to survival and multivariate analysis was performed to confirm the independent prognostic significance of these variables. Overall survival was the primary endpoint. Results. Adjuvant treatment was significantly more likely to have been used in stage 4 disease, 45% versus 12%, in the group receiving surgery (P ⬍ 0.001). At all levels studied, the severity of comorbidity was independently related to the use of adjuvant chemotherapy in this population (P ⫽ 0.88). Negative independent prognostic factors for survival defined by risk ratios (RR) were the use of adjuvant therapy (RR 2.3), stage of disease (RR 1.8), age (RR 1.02), and African-American race (RR 2.4). Patients who did not receive surgery following adjuvant chemotherapy had a increased risk of dying (RR 9.6), compared to those that did have surgery. Adjuvant patients receiving surgery after chemotherapy were independent of the level of comorbidity (P ⫽ 0.3). Controlling for the level of comorbidity, those adjuvant patients who receive surgery after chemotherapy are independent of stage as well (P ⫽ 0.055). Conclusions. The decision to use adjuvant chemotherapy in this population is based on the extent and stage of disease and not on preexisting levels of comorbidity. Furthermore, the decision to proceed with surgery following adjuvant chemotherapy is unrelated to the patients’ level of comorbidity and stage. The decision to proceed with interval surgery is likely related to the response of the tumor to treatment and not the patient’s overall health. 73. The Relationship of Molecular Markers of p53 Function and Angiogenesis to Prognosis of Stage I Epithelial Ovarian Cancer. Michael J. Goodheart, Stephen Rose, Justine M. Ritchie, John P. Fruehauf, Barry R. Deyoung, and Richard E. Buller. Oncotech, Inc., Irvine, California; and University of Iowa Hospitals and Clinics, Iowa City, Iowa. Objectives. Multiple angiogenic factors are thought to influence tumor progression and metastasis. Several of these factors are modified by the p53 tumor suppressor gene. We sought to identify molecular markers for high-risk stage I epithelial ovarian cancers by analyzing their expression along with conventional histopathological data in relation to tumor p53 dysfunction. Methods. Stage I epithelial ovarian cancers (n ⫽ 77) were evaluated for p53, CD31 (microvessel density), thrombospondin-1, vascular endothelial growth factor (VEGF), and p21 (a direct p53 response gene) immunohistochemical staining (IHC), as well as sequenced p53 gene mutations. After maximizing individual study variable hazard ratios (HR), interrelationships among p53 dysfunction, mutation, and IHC were explored by ␹ 2 analysis. The influence of these factors upon survival was then evaluated with a bivariate model (log-rank test). Results. Thirteen deaths have occurred. Ten of the 13 patients who died received chemotherapy. FIGO stage (IA, IB, IC) (HR ⫽ 5.70, P ⫽ 0.003), VEGF staining (HR ⫽ 4.50, P ⫽ 0.01), and p21 staining (HR ⫽ 5.01, P ⫽ 0.05) were significant in the bivariate models. Neither p53 mutation nor dysfunction (sequenced mutation or IHC-positive tumor) was correlated with the expression of the angiogenic markers. The median survival for stage IC/VEGF score ⱕ 240 group (n ⫽ 18) is 49.6 months (P ⫽ 0.001). Similarly, patients with stage IC disease/positive p21 staining (n ⫽ 20) were also more likely to have poorer outcomes with a median survival of 63 months (P ⫽ 0.006). The other six subgroups [IC/VEGF ⬎240, IA/IB/VEGF (⬎240 or ⱕ240), IC/p21 negative, IA/IB/p21 (positive or negative)] have not yet reached a median survival after a mean follow-up of 66 months. Conclusions. Both tumor VEGF and p21 expression add prognostic value for stage I epithelial ovarian cancer. Contrary to the expected results, lower VEGF scores and positive p21 staining are markers for adverse outcome.

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74. Clinical and Immunologic Outcomes of Patients with Recurrent Epithelial Ovarian Cancer Treated with OvaRex MAb and Chemotherapy. Alan N. Gordon, Allen Stringer, Robert P. Edwards, Theresa L. Whiteside, Howard J. Fingert, and Birgit C. Schultes. AltaRex Corporation, Waltham, Massachusetts; Magee–Womens Hospital, Pittsburgh, Pennsylvania; University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania; and US Oncology, Texas Oncology, Pennsylvania, Dallas, Texas. Objective. The aim of this study was to evaluate humoral and cell-mediated immune responses and clinical outcomes from combined OvaRex MAb (Ov) and chemotherapy (Ct) treatment of patients (pts) with recurrent epithelial ovarian cancer (EOC). Methods. Pts with recurrence after platinum were enrolled if they were candidates for secondary surgery and continued Ct. Ov was administered by 20-min infusion in weeks 1, 3, 5, and 9 prior to initiation of Ct, with the option to continue every 8 weeks ⫻ two doses concurrent with Ct. Humoral immune responses, including HAMA, Ab2, and anti-CA125 antibody, were assessed at baseline and serially. Using interferon-␥ ELISPOT assay, T cell responses were evaluated for activation by Ov, CA125, or autologous tumor. Results. Twenty pts were enrolled; the median follow-up is 6 months, with a range of up to 2 years. Ov was well tolerated and did not produce drug-related serious adverse reactions. In 14 of 19 (71%) evaluable pts, robust treatment-emergent humoral responses were observed to the constant (HAMA) and variable regions of the antibody (Ab2). To date, five of eight (62.5%) pts tested demonstrated functionally active T cells, stimulated by CA125 or by autologous tumor. T cell responses to Ov were demonstrated in four pts. T cell responses were MHC class I and II restricted, indicating the activation of CTL and T helper cells. Immune responses were commonly induced by week 12 after four doses, and were generally maintained in pts continuing combined treatment with Ov and Ct. Seventy-five percent are still alive and median survival has not been reached. Conclusions. OvaRex MAb is well tolerated and induces multiple antigen-specific immune responses, even when combined with chemotherapy. In advanced EOC, these data are among the first to demonstrate induction of tumor-specific T cells. Coupled with outcomes from ongoing randomized studies, continued follow-up will determine the efficacy and safety of combination therapy and will confirm the relationship of immune responses to clinical outcomes and survival. 75. Does Tamoxifen Use Increase the Risk for Ovarian Cancer in BRCA Carriers? Ran Goshen, Ping Sun, and Steven A. Narod. Center for Research on Women’s Health, University of Tel-Aviv, Tel-Aviv, Israel; and Center for Research on Women’s Health, University of Toronto, Toronto, Ontario, Canada. Objectives. The BRCA1 and BRCA2 genes are responsible in the majority of families with hereditary breast– ovarian cancer syndrome. Approximately 10% of unselected women with invasive ovarian cancers and 40% of Ashkenazi Jewish women with ovarian cancer are carriers of a deleterious mutation in one of these genes. Tamoxifen has been found to be protective against contralateral breast cancer in carriers of BRCA1 mutations and the drug is now offered to gene carriers in some centers as chemoprevention. There have been some concerns expressed that tamoxifen (by stimulating the release of gonadotrophins) may increase the risk of ovarian cancer in premenopausal women and thereby limit its usefulness. Methods. To evaluate the effect of tamoxifen on ovarian cancer risk, we conducted a matched case– control study. We matched 144 women with ovarian cancer following a diagnosis of breast cancer (cases) to 144 women with breast cancer who did not get ovarian cancer (controls). Cases and controls were matched for age (within 2 years); for age of breast cancer diagnosis (within 3 years), and for mutation (BRCA1 versus BRCA2). Results. The mean age at breast cancer diagnosis was 44.0 years and that of ovarian cancer diagnosis was 57.2 years. Tamoxifen use was reported by 24% of the cases and by 22% of the controls (P ⫽ 0.58). Based on a comparison of 40 discordant pairs, the relative risk of ovarian cancer, given tamoxifen exposure, was estimated to be 1.1 (95% CI: 0.6 to 2.0). Conclusions. We conclude that tamoxifen use does not appear to significantly increase the risk of ovarian cancer in BRCA carriers.

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76. Predictors of Short-Term Survival after Surgical Exploration for Ovarian Cancer. Natalie S. Gould, Teresa L. Rutledge, Scott A. Kamelle, Michael A. Gold, and D. Scott McMeekin. University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma. Objective. The aim of this study was to determine predictors of short-term survival after surgical exploration for ovarian carcinoma. Methods. A retrospective review was performed of patients who underwent surgery for ovarian cancer from 1991 to 2001 and survived less than 1 year after diagnosis. Charts were abstracted for clinicopathologic variables, therapy, and cause of death. Variables were analyzed by ␹ 2 and t tests. Progression-free interval was calculated by the Kaplan–Meier method. Results. Sixty-one patients were identified with a median age of 70 years (range 32–90). The median number of symptoms present prior to diagnosis was 3 (range 0 – 6), with a median duration of symptoms of 60 days (range 3–365). Comorbid conditions were identified in 62%. Prior to surgery, 61% were hospitalized for a median of 3 days (range 0 –13). The median length of stay after surgery was 12 days (4 –71). Ninety percent underwent radical debulking with 60% optimal. Carcinomatosis was found in 23%. Stage IIIC disease was present in 62% and stage IV disease in 23%. Therapeutic thoracentesis or paracentesis was required in 18% of patients prior to hospital discharge. Thirty-eight percent received chemotherapy prior to discharge while 18% never received chemotherapy. Survival ranged from 6 to 358 days postoperatively. Thirty-two percent died as a result of complications after surgery, 30% from progressive disease, 13% from chemotherapy complications, 9% from comorbidity, and 17% from other causes. Older patients were more likely to die as a result of surgical complications (59% vs 8%, P ⫽ 0.003). There was no significant correlation between reason for death and comorbidity, procedure, hospital, residual disease, postoperative complications, or need for preoperative admission. Patients requiring chemotherapy prior to discharge had shorter survival than those who did not require inpatient chemotherapy (7 weeks vs 27 weeks, P ⫽ 0.002). Patients operated on at community hospitals tended to be hospitalized longer prior to surgery (P ⫽ 0.06). Conclusions. It is important to identify factors associated with poor prognosis so that alternate therapies may be considered. Late consultation with gynecologic oncologists may be more common at community hospitals. Patients dying within a year tend to be older and die more often of surgical complications. The need to administer chemotherapy prior to discharge identifies patients at increased risk for poor survival. 77. Serum MMP-2 and TIMP-2 Expression in Ovarian Carcinoma. Laura Graves, Heather Matzel, Alfred W. Rademaker, Kenny Bozorgi, Diljeet Singh, John Lurain, and David A. Fishman. Northwestern University, Chicago, Illinois. Objective. Ovarian cancer accounts for more deaths in the United States than all other gynecologic malignancies combined, and it remains the fourth leading cause of cancer death among women. The large number of deaths due to ovarian cancer results largely from the lack of accurate detection markers for early stage disease. Given the significant improvement in mortality and morbidity associated with early stage disease, the identification of clinically relevant early detection markers is critical to improve women’s healthcare. Ovarian carcinoma pathogenesis involves metastasis of cancer cells throughout the abdominal cavity and this process is facilitated by various extracellular matrix degrading proteinases, including the matrix metalloproteinases (MMPs). Elevated levels of serum MMPs have been reported for a variety of cancers, suggesting that these molecules may serve as useful markers for early disease detection. Method. We have previously demonstrated that MMP-2 and its inhibitor, tissue inhibitor of metalloproteinases-2 (TIMP-2), play important roles in ovarian metastasis. We therefore sought to determine whether serum MMP-2 or TIMP-2 levels differed between ovarian cancer patients and healthy controls (normal women at increased risk for ovarian cancer enrolled in the National Ovarian Cancer Early Detection Program). These proteins were analyzed in over 100 serum samples from each group by an enzyme-linked immunosorbent assay. Results. Our results show no significant difference in serum MMP-2 levels for women with cancer compared to controls. Using

gelatin zymography to assay MMP-2 activity, we were unable to detect active MMP-2 in any samples. We do detect a statistically significant decrease in serum TIMP-2 levels in cancer patients compared to healthy controls; however, the values for each group overlapped extensively. Dividing the cancer samples by stage, we found no significant differences between stage I and late-stage (III and IV) or early-stage (I and II) and late-stage patients with respect to MMP-2 or TIMP-2 levels. Conclusions. While our previous studies clearly demonstrate a role for MMP-2 and TIMP-2 in ovarian metastasis in vitro, our results do not agree with prior clinical studies that indicate serum levels of these proteinases correlate with early disease detection. 78. Molecular Profile May Predict Survival Pattern in Ovarian Cancer. Dan Grisaru, Igor Jurisica, Pascale F. Macgregor, Monique Albert, Barry Rosen, Joan Murphy, Stephane Laframboise, Patrica A. Shaw, and Jeremy A. Squire. University of Toronto, Toronto, Ontario, Canada. Objective. The aim of this study was to combine advanced computational techniques for analysis of large, multidimensional datasets of gene expressions obtained from microarrays with clinical outcome parameters in order to discover patterns of tumor behavior and possibly predict prognosis. Methods. Snap-frozen tissue samples of ovarian cancer (OC) were obtained from a tissue bank and selected for histologic type (serous), grade (2 or 3), and early (I or II; EOC) vs advanced stage (III or IV; AOC). Clinical data were available on all cases, with a mean follow-up of 25 months. Normal controls included normal ovarian tissue samples from the same bank and two commercially available normal ovarian RNA samples (Stratagene, Ambion). Total RNA was extracted, reverse-transcribed in the presence of fluorescent dyes, and cohybridized to 19-k microarrays. Data preprocessing comprised quality control, background subtraction, and normalization. Data analysis techniques included statistical analysis, self-organizing map, iterative k-means clustering, and case-based reasoning. Results. The mean disease-free and overall survival was 18.8 and 28.3 months, respectively, in EOC and 9.1 and 13.4 months in AOC. Analysis of microarray data shows that we can reliably separate normal (n ⫽ 14) from OC samples (10 EOC, 9 AOC). In addition, commercial normal ovaries cluster together with normal ovary samples from our tissue bank. Four EOC samples also correlate with normal ovaries. The best correlating EOC samples are all grade 2 and 3 and include 1 from a patient who is alive with disease and 3 from patients without evidence of disease. All AOC samples are grade 2 and 3 and include 3 from patients who are alive with evidence of OC, 3 from patients who died from OC, and 2 from patients who died from a cause other than OC. The only AOC sample that correlated with EOC is from a patient who died from a cause other then OC. The two-dimensional hierarchical clustering shows that these tissues cluster in normal, EOC, and AOC groupings and that they are distinguishable from each other. Conclusion. Computational techniques used to analyze microarray data reliably segregated normal from OC tissue and were also successful in identifying different clustering patterns of EOC and AOC. This suggests that EOC has patterns of gene expression which are different from those of AOC. The differences found may offer new targets for treatment and early diagnosis. 79. Efficacy and Toxicity of Low-Dose Topotecan in Second-Line Treatment of Epithelial Ovarian Cancer. Bo Gronlund, Claus Hogdall, Heine H. Hansen, and Svend A. Engelholm. Departments of Oncology and Gynecology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark. Objective. The aim of this study was to evaluate the treatment results and toxicity of a low-dose topotecan regimen as second-line treatment of epithelial ovarian cancer (EOC). Methods. A retrospective analysis of 203 consecutive patients with primary EOC referred in the period June 1996 to June 2000 was performed. Eligibility criteria included the following: histopathologically documented FIGO stage IC–IV EOC; first-line treatment with paclitaxel and a platinum compound; second-line treatment with topotecan (1.0 mg/m 2, 5 days, q3w) intravenously. Efficacy and toxicity were compared with published results from pivotal trials using the approved dose of topotecan of 1.5 mg/m 2 for the same indication. Results. A total of 56 patients received second-line

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS treatment with the reduced-dose topotecan regimen because of refractory, persistent, or recurrent disease. In the subgroup of platinum- and paclitaxelresistant patients (n ⫽ 43), 11.6% (95% CI: 3.9 –25.1%) responded compared with 12.3% (95% CI: 6.9 –19.9%) in pivotal trials using standard-dose topotecan (P ⬎ 0.05). In patients with platinum- and paclitaxel-resistant disease, progression-free and overall survival from the first day of second-line topotecan treatment were a median of 2.7 (range 0.7–19.5) and 6.0 (range 1.0 –32.8) months, respectively. In a multivariate Cox analysis, initial performance status (0 vs 1–2; P ⫽ 0.040, HR ⫽ 2.05) and performance status at time of second-line treatment (0 vs 1–2; P ⬍ 0.001, HR ⫽ 4.50) were identified as independent prognostic factors for overall survival from the start of secondline treatment. Neutropenia grade 4 was noted in only 5.1% (95% CI: 2.8 – 8.4%) of reduced-dose topotecan cycles compared with 33 and 57% of standard-dose cycles in pivotal studies (P ⬍ 0.05). Conclusion. Low-dose topotecan (1.0 mg/m 2, 5 days, q3w) has similar efficacy regarding response rate with reduced toxicity compared to the approved schedule of 1.5 mg/m 2 in second-line treatment of EOC. However, the comparison of different topotecan doses and schedules should preferably be made in a randomized setting in well-characterized populations with regard to established prognostic factors.

80. Weekly Low-Dose Carboplatin and Paclitaxel in the Treatment of Recurrent Ovarian, Primary Peritoneal, and Fallopian Tube Cancer. Laura J. Havrilesky, Robyn Sayer, Angeles A. Alvarez, John T. Soper, Andrew Berchuck, Daniel L. Clarke-Pearson, Johnathan M. Lancaster, Gustavo C. Rodriguez, and Michael E. Carney. Duke University Medical Center, Durham, North Carolina; and University of Hawaii, Honolulu, Hawaii. Objectives. Weekly paclitaxel alone has moderate activity in the salvage treatment of recurrent ovarian cancer; however, the combination of weekly paclitaxel and carboplatin has not been studied. The purpose of this study was to prospectively evaluate the response of patients with heavily pretreated recurrent ovarian, primary peritoneal, or fallopian tube cancer to a weekly regimen of low-dose carboplatin and paclitaxel. Methods. Patients with recurrent ovarian, primary peritoneal, or fallopian tube cancer who had previously been treated with at least one chemotherapeutic regimen were eligible. Patients had assessable disease as defined by clinical exam, radiographic studies, or serum CA-125 values greater than 75 U/ml. One cycle of treatment consisted of carboplatin at an area under the concentration-time curve of 2 and paclitaxel at 80 mg/m 2 weekly for 3 weeks followed by 1 week off treatment. Clinical responses were defined by World Health Organization criteria when measurable disease existed by physical exam or radiography. In the absence of measurable lesions, clinical responses were defined as partial (reduction in serum CA-125 value of 50%) or complete (to a level less than 35 U/ml). Results. Twenty-six patients were treated. The median number of prior treatment regimens was 2, with a range of 1 to 3. There were 15 complete responses and 6 partial responses, for a total response rate of 80.8% (95% confidence interval 69.8 to 95.9%). Among 8 platinum-refractory patients, the response rate was 37.5%, while 18 platinum-sensitive patients had a 100% response rate. Median time to progression was 13.7 months among platinum-sensitive patients and 3.2 months among platinum-refractory patients, resulting in an overall median time to progression of 10.5 months. The median duration of response was 8.1 months. Hematologic toxicity was common (30% grade 3 neutropenia, no grade 4 neutropenia, 19% grade 3 or 4 thrombocytopenia) and was managed by treatment delay, dose reduction of paclitaxel, or discontinuation of carboplatin. Two patients withdrew from the study because of neutropenia. There were no drug-related fatal events. Conclusions. Weekly lowdose carboplatin and Taxol has significant activity in both platinum-sensitive and platinum-resistant recurrent ovarian cancer. Toxicities are acceptable and can usually be managed by dose adjustment.

81. Lack of Adverse Outcome in Cancers Found during Laparoscopic Management of Pelvic Masses Thought to Be Benign Preoperatively. Laura J. Havrilesky, Damla Dryden, Gustavo C. Rodriguez, John T. Soper, Daniel

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L. Clarke-Pearson, and Andrew Berchuck. Duke University Medical Center, Durham, North Carolina. Objective. Resection of pelvic masses frequently is performed using laparoscopy despite the lack of prospective trials documenting the merits of this approach. In our department laparoscopy has been used exclusively for the management of masses thought to be benign preoperatively. The aim of this study was to review our experience with particular attention to whether the unexpected finding of cancer was associated with adverse outcomes. Methods. We reviewed the records of all 282 patients who underwent laparoscopic management of a pelvic mass in our department during the 5 years after we began to utilize this approach (7/94 – 6/99). Multivariate analysis was used to determine factors predictive of cancer. Results. The average age of patients was 43 years, 34% were postmenopausal, and 59% had undergone prior abdominal surgery. The median mass size was 5.5 ⫾ 2.3 cm (range 2–15 cm) and the median hospital stay was 1.3 days. There were no postoperative deaths and the only life-threatening complication was reexploration for bleeding in 1 patient. Conversion to laparotomy was necessary to complete the procedure in 24% of cases, and there was no difference between cases managed by oncologists (25%) and nononcologists (24%). Cancer was found in 9/282 (3.2%) patients, and all of these were among the cases managed by oncologists (9/132, 6.8%). Only 2/9 women with cancer had a preoperative CA125 level ⬎65 U/ml. Mural nodules were seen on ultrasound in 18 cases (6.4%) and this was the variable most predictive of cancer (OR ⫽ 8.1, P ⫽ 0.014). All of the cancers were diagnosed intraoperatively by frozen section. There were 4 stage IA ovarian tumors (3 serous borderline, 1 granulosa cell), 2 of which were managed exclusively via the laparoscope, and none have recurred. There were 4 stage III ovarian cancers, all of which were converted to laparotomy; 1 patient had a borderline tumor and has survived 5 years without recurrence, while among the 3 patients with invasive disease 2 died at 27 and 36 months and 1 is alive at 66 months. One patient found at laparoscopy to have recurrent colon cancer survived 3 years. None of the 9 patients with cancers had port-site recurrences. Conclusion. Resection of pelvic masses thought to be benign can be accomplished safely in the majority of cases. Malignancy was infrequently encountered and there was no adverse effect on outcome attributable to initial laparoscopic management. 82. Phase II Study of Three-Day Topotecan for Recurrent Primary Peritoneal and Epithelial Ovarian Cancer in Platinum-Sensitive Patients. Thomas J. Herzog, Janet S. Rader, Randall K. Gibb, Matthew A. Powell, Lynne T. Lippmann, Chrisann Accario, and David G. Mutch. Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to assess the efficacy and toxicity profile in patients treated with topotecan at 2.0 mg/m 2/day ⫻ 3 days every 3 weeks. Methods. Eligibility criteria included patients with recurrent primary peritoneal or epithelial ovarian cancer with ⱖ6 months elapsed from time of prior platinum treatment. Patients were required to have a performance status of ⱕ2 and normal hepatic and renal function. Response to therapy and subsequent toxicity were assessed using standard criteria. ␹ 2 and Student’s t tests were used as appropriate. Results. Of 28 patients enrolled, 26 are currently assessable for response. All patients received prior platinum- and taxane-based therapy with the exception of 1 patient who had received platinum and cyclophosphamide. The medium age of the patients was 61.6 years (average 64.2; range 44 – 85). Medium time to progression from initial treatment was 12 months. A total of 156 cycles of chemotherapy were administered with an average of 6.3 cycles per patient. Overall median time to progression (TTP) with 3-day topotecan treatment was 21 weeks (range 6 – 43 weeks.) The best response is summarized in Table 1. The median TTP (CA-125) for CRs was 40.5 weeks and it was 30.0 weeks for those with a PR. Assessment of toxicity by cycle showed that 20.4% had grade 3/4 leukopenia with 52.8% demonstrating grade 3/4 neutropenia. Anemia (Grade 3/4) was observed in 36% and 3 patients required transfusion, and 1 patient received outpatient antibiotics. The incidence of thrombocytopenia (Grade 3/4) was only 2.2%. A total of 9 patients were treated with an average of 4.25 cycles of recombinant

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TABLE 1—ABSTRACT 82 Response rate Criteria

CR

PR

SD

PD

Measurable disease CA-125

1 (3.8%) 4 (15.4%)

5 (19.2%) 4 (15.4%)

13 (50.0%) 13 (50.0%)

7 (26.9%) 5 (19.2%)

erythropoetin, and 7 patients received G-CSF with an average of 5.3 courses. No severe nonhematologic toxicity was observed. Conclusion. Administration of topotecan as a 3-day regimen is feasible with demonstrable activity and tolerable toxicity. Critical comparison to the 5-day regimen in a randomized fashion is warranted.

83. The Role of Topotecan for Extending the Platinum-Free Interval in Recurrent Ovarian Cancer. An in Vitro Study. Thomas J. Herzog, Jun Hua, Neil S. Horowitz, Randall K. Gibb, and David G. Mutch. Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to study the effect of extending the platinum-free interval via an in vitro cell culture model and to assess the molecular genetic alterations associated with intrinsic and acquired resistance. Methods. The human ovarian cancer cell line A2780 and the cisplatin-resistant (CR) cell line A2780-CR were separately seeded in 6-well cell culture plates and then exposed to multiple concentrations of cisplatin plus Taxol or topotecan ⫻ 7 days, after which surviving cells were cultured in drug-free medium ⫻3 weeks and then replated in a 96-well microtiter plate. The LD 50 for these cells was determined by MTT assay after exposure to multiple clinically relevant concentrations of either cisplatin or topotecan. Surviving cells were cultured in drug-free medium ⫻4 weeks at which time the LD 50 was reassessed for each of these cell populations. The molecular profile of these cells in terms of resistance was measured using mRNA expression of the multidrug-resistant gene (MDR-1), multidrug-resistant protein (MRP), topoisomerase-I, and ␤-actin as analyzed by semiquantitative RT-PCR and Northern blot hybridization. Results. The LD 50 to cisplatin was unchanged in A2780-CR cells treated by topotecan. Cells became more resistant to cisplatin in those A2780-CR cells originally exposed to higher concentrations of cisplatin and more sensitive to cisplatin in those cell lines (A2780-CR9) treated by lower cisplatin along with higher concentrations of Taxol (P ⬍ 0.01). The second MTT assay demonstrated that the LD 50 for cisplatin from every cell line decreased significantly after a 4-week drug-free interval (P ⬍ 0.01). There was no difference in mRNA expression in MRP and topoisomerase-I regardless of cell line or type or concentration of chemotherapeutic exposure. The mRNA from MDR-1 was not amplified in A2780 but was overexpressed in a cisplatin-treated population A2780-CR9 (P ⬍ 0.01). Conclusion. Acquired-resistance to cisplatin in A2780 appears to be due to P-glycoprotein-mediated multidrug resistance. This acquired resistance to cisplatin is an unstable phenotype in that some cell populations became sensitive after a drug-free interval and topotecan treatment. This reversal of resistance, however, does not appear to be simply due to loss of MDR-1 expression. Agents with novel mechanisms of action offer a strategy to extend the platinum-free interval.

84. Human Kallikrein 6 Protein and Human Kallikrein 9 Gene in Ovarian Cancer. New Independent Prognostic Markers. Dionyssios Katsaros, Stefano Fracchioli, George M. Yousef, Barry R. Hoffman, Andreas Scorilas, Irene A. Rigault de La Longrais, Manuela Puopolo, Marco Massobrio, and Eleftherios P. Diamandis. Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Canada; National Center for Scientific Research Demokritos, Athens, Greece; and University of Turin, Turin, Italy.

Objectives. During the past 2 to 3 years, new members of the human tissue kallikrein gene family have been identified by us and by other groups. It is now clear that this family contains at least 15 genes. All genes share important similarities, including mapping at the same chromosomal locus (19q13.4). We here report for the first time analysis of human kallikrein 6 protein (hK6) and human kallikrein 9 gene (KLK9) expression in ovarian cancer. Results. We studied the expression of hK6 and KLK9 by specific immunoassay and quantitative RT-PCR, respectively, in 182 consecutive ovarian tumors and correlated it with clinicopathological parameters, response to chemotherapy, and survival of patients monitored over a median interval of 62 months. Thirty percent of tumors were positive for hK6 (⬎35 ng hK6/mg of total protein). hK6 was higher in late stage disease, serous histotype, and suboptimally debulked patients (RT ⬎ 1 cm; P ⬍ 0.05). Patients with positive hK6 tumor levels were more likely to suffer progressive disease and die (P ⫽ 0.015 and 0.022, respectively). hK6 positivity was retained as an independent prognostic variable in subgroups of patients (grade I–II, optimally debulked). Specifically, hazard ratios related to PFS and OS were 4.3 (P ⫽ 0.027) and 4.1 (P ⫽ 0.023), respectively, for the low tumor grade group and 3.8 (P ⫽ 0.019) and 5.6 (P ⫽ 0.011) for optimally debulked patients. KLK9 expression was significantly higher in patients with early stage disease (P ⫽ 0.037) and optimal cytoreductive surgery (P ⫽ 0.011). Patients with KLK9-positive tumors have substantially longer PFS and OS (P ⬍ 0.001 and P ⫽ 0.018). KLK9 expression was found to be a significant predictor of PFS in subgroups of patients with low grade (P ⬍ 0.001), early stage (P ⫽ 0.028), and optimally debulked tumors (P ⫽ 0.018). In multivariate analysis, KLK9 retained its independent prognostic value. Conclusion. We report the differential expression and prognostic implications of two genes (KLK6 and KLK9) of the new members of the human kallikrein gene family recently discovered in ovarian cancer. These data add to the growing recent literature suggesting that many other members (KLK4, KLK5, KLK7, KLK8, and KLK10) also have prognostic value in ovarian cancer. It is conceivable that all of those kallikreins participate in a common pathway that is activated during ovarian cancer initiation and progression. (This work has been supported by the Italian Association for Cancer Research—AIRC.)

85. Human Kallikrein 6. A Potential Serum Marker for Diagnosis and Prognosis of Ovarian Cancer. Dionyssios Katsaros, Stefano Fracchioli, Ignace Vergote, Ate G. J. Van der Zee, Ulf-Hakan Stenman, Andreas Scorilas, Marco Massobrio, and Eleftherios P. Diamandis. Department of Obstetrics and Gynaecology, University Hospital Groningen, Groningen, The Netherlands; Department of Clinical Chemistry, Helsinki University Cent Hospital, Helsinki, Finland; Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Leuven, Belgium; Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, Canada;National Center for Scientific Research Demokritos, Athens, Greece; and University of Turin, Turin, Italy. Objectives. The discovery of new ovarian cancer biomarkers which are suitable for early disease diagnosis and prognosis may lead to improved patient management and outcomes. We and others recently cloned several new members of the human kallikrein gene family which now consists of 15 genes, all localized at the same chromosomal locus (19q13.4). Many new kallikreins (KLK4, KLK5, KLK7, KLK8, KLK10) appear to be disregulated in ovarian cancer, and their transcript levels seem to have either favorable or unfavorable prognostic value. Recently, we reported preliminarily that human kallikrein 6 (hK6) is a potential serological marker for ovarian carcinoma. We here examine in a multicenter study the diagnostic and prognostic value of serum hK6 in ovarian carcinoma. Results. Using an antibody developed by us, we measured the hK6 concentration in the sera of 97 healthy women, 141 women with benign ovarian disease, and 146 patients with primary ovarian carcinoma before and after cytoreductive surgery. We then calculated the diagnostic sensitivity and specificity of this test, comparing it with that of CA125, and examined its association with clinicopathological parameters, response to chemotherapy, and patient survival. The serum hK6 concentration between

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS normal and benign disease was not different. However, hK6 was highly elevated in the sera of ovarian cancer patients and decreased after cytoreductive surgery in most patients. The diagnostic sensitivity of serum hK6 at 90% specificity is 55% (25% in stage I–II disease). When combined with CA125, sensitivity increases to 72% (45% in stage I–II disease). hK6 correlates poorly with CA125, but identifies subgroups of patients with normal CA125 levels. Serum hK6 concentration is a powerful and independent predictor of both disease-free and overall survival at both univariate and multivariate analyses. Conclusions. hK6 concentration is a new serum biomarker for ovarian cancer and has value for both disease diagnosis and prognosis. hK6 alone is more specific than CA125. The diagnostic sensitivity of hK6 and CA125 in combination is superior to the sensitivity of each biomarker alone. hK6 should be further investigated as a tumor or screening marker, alone and in combination with CA125. (This work has been supported by the Italian Association for Cancer Research—AIRC.) 86. The Role of Cyclooxygenase-2 in Epithelial Ovarian Carcinoma. Thomas C. Krivak, Ginger J. Gardner, Jeffrey D. Seidman, Joseph Hamel, Ilona Linnoila, Jay Carlson, G. Scott Rose, and Michael J. Birrer. National Cancer Institute, Rockville, Maryland; Walter Reed Army Medical Center, Washington, DC; Walter Reed Army Medical Center, Bethesda, Maryland; andWashington Hospital Center, Washington, DC. Objective. Recent studies have established the presence of two forms of cyclooxygenase. Cyclooxygenase-1 is ubiquitously expressed; however, cyclooxygenase-2 (Cox-2) has a selective tissue distribution and increased levels are frequently detected in epithelial cancers. This study was designed to evaluate the role of Cox-2 in human epithelial ovarian carcinoma. Methods. Western immmunoblotting was performed on 14 epithelial ovarian cancer cell lines, 2 immortalized ovarian surface epithelial (IOSE) cell lines, and 5 human ovarian surface epithelial (HOSE) cell cultures. Immunohistochemical staining was performed on 34 invasive ovarian carcinomas, 15 ovarian tumors of low malignant potential, and 6 normal ovaries. The effect of TPA stimulation on Cox-2 expression was evaluated by Western immunoblotting. MTT growth assays were performed on 3 ovarian cancer cell lines and the IOSE 80 cell line utilizing various concentrations of selective and nonselective Cox-2 inhibitors (NS-398, Nimesulide, Sulindac). Cells treated with Cox-2 inhibitors were assessed for apoptosis by a caspase-3 assay and DNA laddering. Results. Western immunoblotting demonstrated a statistically significant increase in Cox-2 expression in 9/14 ovarian cancer cell lines compared to the level of Cox-2 expression in IOSE and HOSE cells. Immunohistochemistry revealed minimal expression of Cox-2 in normal ovarian epithelium (6/6). In contrast, Cox-2 was overexpressed in 8/15 (53%) ovarian tumors of low malignant potential and 17/34 (50%) epithelial ovarian cancers. Treatment of IOSE 80 cells with TPA, a phorbol ester tumor promoter, caused a threefold increase in Cox-2 expression such that Cox-2 protein levels in IOSE cells closely approached those seen in ovarian cancer cells. Ovarian cancer cells treated with Cox-2 inhibitors demonstrated cell growth inhibition by MTT assays. The inhibition of ovarian cancer cell growth was due to the induction of apoptosis as measured by caspase-3 activation and DNA laddering. Further, the caspase inhibitor, ZVAD, blocked ovarian cancer cell death induced by Cox-2 inhibitors. Conclusion. Cox-2 is overexpressed in ovarian cancer cell lines and tumor specimens. Treatment of ovarian cancer cells with Cox-2 inhibitors effectively induces growth inhibition and apoptosis. Based on these data, Cox-2 inhibitors have a putative role in the treatment or prevention of ovarian cancer. 87. Expression of Insulin-Like Growth Factor Binding Protein 2 Is Associated with Poor Outcome in Advanced Serous Ovarian Cancers. Johnathan M. Lancaster, Laura J. Havrilesky, Robert Wenham, Robyn Sayer, Holly Dressman, Joseph Nevins, Jeffrey Marks, and Andrew Berchuck. Duke University Medical Center, Durham, North Carolina. Objective. Molecular alterations predictive of outcome in advanced stage serous ovarian cancers (OCs) have not been identified. The aim of this study

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was to determine whether microarrays can define gene expression patterns predictive of survival in advanced serous OC. We also sought to validate the significance of the insulin-like growth factor binding protein 2 (IGFBP2) gene, which was found using microarray analysis to be a promising marker of virulent behavior. IGFBP2 has been postulated to adversely affect behavior of other cancer types either directly or by decreasing availability of IGF-I, which rescues cells from chemotherapy-induced apoptosis. Methods. We analyzed 6800 genes in 46 advanced (stage III/IV) serous OCs and 4 normal human ovarian surface epithelial (HOSE) samples using Affymetrix expression microarrays. There were 24 patients with OC who lived ⬍2 years (short-term survivors) and 22 who lived ⬎7 years (long-term survivors). We also used quantitative real-time PCR (QRT-PCR) to validate expression of IGFBP2 in these samples. IGFBP2 serum levels were measured in 53 women with OC and 38 controls using a radioimmunoassay. Results. Patterns of gene expression were discerned that distinguish between HOSE and OC and high- vs low-grade OC. We were unable to define a pattern of expression that distinguished between long- and short-term survival in advanced serous OC, but several promising individual genes were identified including IGFBP2. We found using arrays that IGFBP2 expression was upregulated 3.2-fold in OC relative to HOSE (P ⫽ 0.07) and was 1.9-fold higher in short-term survivors relative to long-term survivors (P ⫽ 0.01). Comparison of IGFBP2 expression by microarray and QRT-PCR revealed a correlation coefficient of 0.63. Mean serum IGFBP2 levels were 471 ng/dl in 38 control women compared to 860 ng/dl in 10 women with stage I/II OC and 1461 ng/dl in 43 women with stage III/IV OC (P ⬍ 0.05). Among those with advanced serous OC, mean serum IGFBP2 levels in short-term survivors (2387 ng/dl) were 1.9-fold higher than in long-term survivors (1227 ng/dl) (P ⫽ 0.05). Conclusion. Array technology can facilitate the identification of genes such as IGFBP2 that are involved in determining clinical outcome and these may represent appealing therapeutic targets. High tissue and serum IGFBP2 levels may serve as a marker for the most virulent advanced stage serous OC.

88. Role of Laparoscopy on Staging and Survival after Early Ovarian Cancer. Fabrice R. Lecuru, Patrice G. Desfeux, Sophie S. Camatte, Jean Philippe Jais, Bernard Blanc, and Denis Querleu. Conception Hospital, Marseille, France; Center Oscar Lambret, Lille, France; European Hospital Georges Pompidou, Paris, France; and Necker Hospital, Paris, France. Objective. Today laparoscopy is the standard access for treatment of benign ovarian cysts. Conversely, laparoscopy has been discussed for the management of early ovarian cancer since adverse effects such as port-site metastases or tumor seeding have been reported. The aim of our study was to compare the results of laparoscopy and laparotomy for stage I ovarian cancer, in terms of staging accuracy and survival. Methods. We conducted a national retrospective survey in France. A form was mailed to centers involved in gynecological oncology. Inclusion criteria were patients with proved ovarian cancer up to stage Ic, operated on between January 1, 1993, and December 31, 1997. Data were recorded and analyzed with SPSS6.1 and SAS (␹2 test (or Fisher’s exact test when appropriate), ANOVA, and the log-rank test). A total of 105 cases were included, from 17 different centers (1 case to 14 cases). Fourteen patients were primarily operated on by laparoscopy (13%) and 78 patients by laparotomy (74%) and 13 patients (13%) had a conversion from laparoscopy to laparotomy (50% due to diagnosis of cancer, 50% due to operative difficulties). Patients initially operated on by laparoscopy were younger (laparoscopy: 46.1 ⫾ 11.5; laparoscopy ⫹ laparotomy 41.9 ⫾ 17.1) than those initially operated on by laparotomy (58.8 ⫾ 16.5) (P ⫽ 0.05). Results. Cyst punctures were most likely carried out during laparoscopy ⫹ laparotomy (23%), when compared to laparoscopy (7%) or laparotomy (2%) (P ⬍ 0.05). Ovarian cystectomies were more frequently carried out during laparoscopy (23%) than during laparotomy (7%). Bilateral adnexectomy was significantly more frequent during laparotomy (67%) than conservative approaches (33%) (P ⬍ 0.05). Initial staging was significantly less accurate with laparoscopy, because lymphadenectomies and omentectomies were less frequent (P ⬍ 0.05). Finally, survival was similar for all surgical approaches. One hundred percent of

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patients were without disease after laparoscopy, 85% after laparotomy, and 100% after laparoscopy ⫹ laparotomy (follow-up: 1232 ⫾ 841 days) (P ⫽ 0.1). Conclusion. Laparotomy appears to be more accurate than laparoscopy for staging of early ovarian carcinomas. However, patients operated on by laparoscopy or by laparotomy had a similar outcomes. 89. Outcome after Intraperitoneal) Chemotherapy for Stage IV Epithelial Ovarian Carcinoma. Douglas A. Levine, Richard R. Barakat, Paul J. Sabbatini, Dharmendra Bhaskaran, Margarita Rizvin, Alex Smith, Carol A. Aghajanian, Martee L. Hensley, Stephen L. Soignet, Carol L. Brown, Maurie Markman, and David R. Spriggs. Memorial Sloan-Kettering Cancer Center, New York, New York; and Cleveland Clinic Foundation, Cleveland, Ohio. Objective. Although Phase II trials have analyzed the role of intraperitoneal (IP) therapy as treatment in patients with epithelial ovarian carcinoma (EOC), little is known about IP therapy for patients with stage IV disease. The purpose of this study was to compare the outcome of patients with stage IV EOC treated with IP therapy with similarly treated stage III patients. Methods. Between 1987 and 1998, 52 patients with stage IV EOC received IP therapy either as consolidation following negative second-look evaluation (n ⫽ 7) or for persistent/recurrent disease (n ⫽ 45). Records were reviewed to determine demographics, tumor characteristics, recurrence patterns, and site of metastases. A contemporaneously treated cohort of 310 stage III EOC patients treated with IP therapy over a similar time period was used as a comparison group. Survival was calculated from the initiation of IP therapy and standard statistical methods were used for data analysis. All tests were two sided. Results. The mean age of the study population was 52 years (range 34 –76). Thirty (58%) had serous tumors while 8 (15%) were endometrioid, 5 (10%) adenocarcinoma, NOS, and 9 (17%) of other histologic subtype. The sites of stage IV metastases were pleural effusion (PE), 29 (56%); liver parenchyma, 9 (17%); and other extraperitoneal sites, 8 (15%). Residual disease at the initiation of IP therapy was none, 7 (14%) patients; microscopic, 19 (37%); ⬍1 cm, 21 (40%); and ⬎1cm, 5 (10%). Of the 18 patients with negative secondlook evaluation (n ⫽ 7) or a complete response to IP therapy (n ⫽ 11), 14 patients recurred at a median of 21 months; 11 abdominal, 3 distant. There was a trend toward longer survival in patients with no gross residual disease at the time of second-look evaluation (41 months vs 22 months, P ⫽ 0.08). Median survival for patients with stage IV disease (median f/u—29 months) was significantly less than for those with stage III disease (40 months vs 45 months, P ⬍ 0.01). The median overall survival was 30 months for stage IV patients with PE compared to 41 months for other metastatic sites (P ⫽ 0.32). Conclusions. Site of metastasis and size of residual disease at initiation of IP therapy may be prognostic factors for stage IV EOC patients treated with IP therapy. Surgical stage was the strongest predictor of survival after IP therapy.

age (59.0 vs 59.8 years) or preoperative hemoglobin (11.5 vs 11.7) in patients with and without thrombocytosis. Patients with thrombocytosis were found to have greater elevations of preoperative CA-125 levels (1711 vs 1008, P ⫽ 0.026), more advanced stage disease (III or IV vs I or II, P ⫽ 0.016), higher grade tumors (3 vs 1 or 2, P ⫽ 0.010), more frequent lymph node metastases (P ⫽ 0.018), and greater volume of ascites (2908 ml vs 898 ml, P ⬍ 0.0001). Overall, 160/183 (87.4%) patients underwent optimal cytoreduction; however, patients with thrombocytosis demonstrated a greater likelihood of residual disease greater than 1 cm (19/41 vs 4/142, P ⬍ 0.0001). No statistical differences were found in CA-125 levels between patients optimally and suboptimally cytoreduced (1153 vs 1647). No correlations were seen with estimated blood loss or postoperative thromboembolic complications. Patients with thrombocytosis had a significantly shorter disease-free interval (37.9 vs 48.9 months, P ⬍ 0.0001) and overall survival (48.6 vs 63.75 months, P ⫽ 0.034). Conclusions. Thrombocytosis is a frequent preoperative finding in women with ovarian or peritoneal carcinoma and may be associated with a more aggressive tumor biology. Further investigation of platelet secretory factors may identify targets for therapy as well as patients less amenable to primary surgical cytoreduction. 91. Positron Emission Tomography Predicts Early Recurrence of Ovarian Cancer. Correlation with Secondary Cytoreductive Surgery. Wei-Chien M. Lin and Scott M. Eisenkop. Women’s Cancer Center, Tarzana, California. Objective. Secondary cytoreductive surgery has been shown to extend survival in patients with recurrent ovarian cancer. The following study was undertaken to compare the usefulness of preoperative positron emission tomography (PET) scan with conventional CT scan in patients undergoing secondary cytoreductive surgery. Methods. Thirty-one patients with elevated CA-125, preoperative CT scan, and PET scan underwent secondary cytoreductive surgery between 1996 and 2001. All patients had completion of primary surgery and chemotherapy with a clinical, radiographic, and serologic disease-free interval of at least 6 months after primary adjuvant chemotherapy. Whole body fluorodeoxyglucose (FDG)-PET scans were performed. CT and FDG-PET findings were compared to intraoperative results. Results. Thirty of thirty-one (97%) patients had histologic confirmation of recurrence and were cytoreduced to no visible disease. The sensitivity and positive predictive value for the FDG-PET scan was 93 and 98%, respectively. The sensitivity and positive predictive value for the conventional CT scan was 48 and 91%, respectively. The FDG-PET scan generally correlates well with intraoperative findings by quadrants. Conclusion. FDG-PET scans are more sensitive than conventional CT scans in documenting recurrence in ovarian cancer patients with elevated CA-125. Furthermore, the FDG-PET scan predicts early recurrence and enables early surgical intervention.

90. The Prognostic Significance of Thrombocytosis in Epithelial Ovarian Cancer. Andrew J. Li, Alison C. Madden, Ilana Cass, Ronald S. Leuchter, Leo D. Lagasse, and Beth Y. Karlan. Cedars-Sinai Medical Center, Los Angeles, California.

92. Toxicity of Systemic Delivery of Adenoviral Mediated Gene Therapy of VEGF Antagonist sFLT-1. Parameshwar Mahasreshti, Manjula Kataram, Sharmila Makhija, Ronald D. Alvarez, and David T. Curiel. University of Alabama at Birmingham, Birmingham, Alabama.

Objective. Thrombocytosis is a poor prognostic factor in lung, colon, breast, and cervical cancers, although the etiology of platelet counts ⬎400 ⫻ 10 9/L remains unclear. It has been postulated that platelet-secreted factors may contribute to metastasis, invasion, and primary tumor growth. The objective of this study was to determine the incidence of thrombocytosis in ovarian cancer and examine its association with clinicopathologic features. Methods. A total of 183 consecutive patients with invasive epithelial ovarian or primary peritoneal carcinomas who underwent primary surgical cytoreduction at our institution were identified between January 1996 and December 2000. Records were retrospectively reviewed and comparisons of clinicopathologic features were made between patients with and without thrombocytosis. Results were analyzed using ␹ 2 and Student’s t tests. Survival analyses were determined by the method of Kaplan and Meier. Results. Forty-one of 183 (22.4%) patients demonstrated preoperative thrombocytosis. No differences were seen in patient

Objective. The angiogenic role of VEGF in diverse pathological conditions, such as tumor angiogenesis, retinal neovascularization, and rheumatoid arthritis, has been established. Further, it has been reported that VEGF is essential in the physiological process of endothelial cell growth and for the survival of endothelial cells. Therefore, withdrawal of VEGF leads to endothelial cell apoptosis in vitro and in vivo. Attempts to enhance the effects of VEGF using VEGF gene therapy or recombinant VEGF for therapeutic angiogenesis in ischemic heart disease and peripheral vascular disease and for the prevention of coronary restenosis have been reported. However, overexpression of VEGF in vivo resulted in systemic toxicity. On the other hand, attempts to suppress angiogenesis in order to suppress tumor growth using anti-VEGF agents such as antibodies against VEGF and VEGF antisense oligonucleotides have been reported. We have reported the ip delivery of adenovirus-mediated antiangiogenic sFLT-1 (naturally encoded anti-VEGF agent) gene therapy to

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS inhibit VEGF action in ovarian carcinoma. This finding predicated that systemic delivery of sFLT-1 might allow an approach for disseminated tumors. Such a blockade of the VEGF axis, however, might potentially confound vascular integrity as noted above. On this basis, we hypothesized that overexpression of anti-VEGF sFLT-1 in normal tissues or organs such as the liver and kidney will inhibit VEGF necessary for endothelial cell survival, leading to vasculopathy and systemic toxicity. Methods. E1A/B-deleted, infectivityenhanced recombinant adenovirus AdRGDGFPsFLT-1 encoding cDNA for sFLT-1 and GFP AdRGDGFP encoding GFP alone was delivered either by ip or by iv in a murine model and toxicity was evaluated by histopathology of the liver. Results. Histopathological evaluation of liver tissues suggested that delivery of AdRGDGFPsFLT-1 iv in murine ovarian tumor model resulted in severe hemorrhages in the liver whereas iv delivery of control virus did not result in hemorrhages in the liver. Further, toxicity resulting due to iv and or ip delivery of these vectors in murine models without tumors will be reported. Conclusion. Our results suggest that systemic delivery of adenovirus-mediated sFLT-1 gene therapy will result in the overexpression of sFLT-1 in murine livers leading to hepatotoxicity and vasculopathy.

93. p53 Expression in Early Stage Epithelial Ovarian Cancers. A Gynecologic Oncology Group Study. John W. McBroom, Thomas C. Krivak, R. I. Linnoila, Kathleen Darcy, Chungiao Tian, Eugene Sobel, G. Scott Rose, and Jay W. Carlson. National Cancer Institute, Rockville, Maryland; and Walter Reed Army Medical Center, Washington, DC. Objective. Mutations of the p53 gene are seen in 50% of all human cancers and have been extensively studied in advanced ovarian carcinomas. The most common class of mutation observed in p53 is the single nucleotide substitution, with the majority (greater than 80%) involving exons 5 through 8. Missense mutations are often associated with increased stability of the p53 protein and an immunohistochemistry assay can be used to visualize the intracellular accumulation of p53. Overexpression of the p53 protein has been associated with poor prognosis in advanced ovarian carcinomas in some studies but the precise role remains to be defined. This study sought to examine the associations between increased intracellular levels of p53 and clinical characteristics and/or outcome in women with early stage ovarian carcinomas. Methods. One hundred forty-five specimens of stage I and II epithelial ovarian cancer from women treated on Gynecologic Oncology Group Protocol 157 were evaluated for the presence of p53 protein. One section was stained with hematoxylin and eosin and reviewed (L.L.) to confirm the pathologic diagnosis. The slides then underwent immunohistochemical staining (using the ABC Vectastain kit) for p53 protein utilizing a monoclonal mouse, anti-human p53 protein (Dako, clone DO-7). This antibody recognizes an epitope known to reside between amino acids 19 and 26 and reacts with both wild-type and mutant forms of the p53 protein. Three investigators (L.L., J.M., M.B.) independently reviewed the tissue sections by light microscopic examination to quantify the presence of p53 in the tumor cells using a semiquantitative scoring system. Slides were scored by the percentage of nuclei staining positive (1, few; 2, ⬍10%; 3, 10 – 49%; 4, 50 –74%; 5, 75–100%) and the intensity of staining (⫺, 0 staining; ⫹, weak; ⫹⫹, moderate; ⫹⫹⫹, strong staining). The average scores were utilized for the statistical analyses. The reviewers were blinded to clinical outcome. The clinical associations of p53 in this study will be examined using the Kaplan–Meier method with the log-rank test and Cox hazard regression models with the Wald test. Results. Immunohistochemical staining of p53 was examined in serial sections from 147 early stage ovarian cancers. The presence of p53 in each staining group (described above) was as follows: Group 1 (24.8%), Group 2 (23.5%), Group 3 (19.3%), Group 4 (11.7%), and Group 5 (20.7%). Scoring the intensity of p53 staining indicated that 21.4% of specimens had no staining, 8.3% demonstrated weak staining, 44.1% had moderate staining, and 26.2% showed strong staining. Investigators in the literature often dichotomize immunohistochemical expression of p53 using the cutpoint of 10% p53-positive tumor cells. There were 51.7% of early stage ovarian cancers that exhibited p53 overexpression in ⱖ10% of tumor cells and 48.3% with ⬍10% p53-positive tumor cells. Conclusion. This is the largest study of p53

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expression in early stage ovarian carcinoma to date. The incidence of the overexpression of p53 protein in early stage epithelial ovarian carcinoma in this study is 51.7%, which indicates that intracellular accumulation of p53 is an early event during the development of epithelial ovarian cancer. Additional statistical analyses will examine the clinical associations of p53 overexpression in women with early stage ovarian cancer. 94. Phase II Evaluation of Three-Day Topotecan in Recurrent PlatinumSensitive Ovarian or Primary Peritoneal Cancer. A Gynecologic Oncology Group Study. David S. Miller, John A. Blessing, Samuel S. Lentz, and Robert S. Mannel. Gynecologic Oncology Group, Buffalo, New York; University of Oklahoma, Oklahoma City, Oklahoma; University of Texas Southwestern Medical Center, Dallas, Texas; and Wake Forest University School of Medicine, Winston–Salem, North Carolina. Objective. Topotecan (1.5 mg/m 2/day iv ⫻5 days q21-day cycle) is an approved therapy for recurrent ovarian cancer. Alternative dosing strategies have been investigated in an effort to reduce hematologic toxicity. We examined the efficacy and tolerability of a 3-day topotecan regimen in recurrent epithelial ovarian or primary peritoneal cancer patients. Methods. From February 1 to June 16, 2000, a phase II, open-label, multicenter trial of topotecan was carried out in patients with recurrent platinum-sensitive ovarian or primary peritoneal cancer. Thirty patients were treated with topotecan (1.0 to 2.0 mg/m 2/day iv ⫻3 days q3 weeks) until disease progression or intolerable adverse effects. Of 30 enrolled patients (median age 56 years; range 41– 81 years), 29 had received prior chemotherapy and none had received prior radiotherapy. Results. A median of 5 courses (range 1–11) of topotecan were administered. Grade 4 neutropenia was reported in 18 of 30 (60%) patients; there was 1 report each of grade 4 thrombocytopenia, anemia, and gastrointestinal manifestations. Ten patients developed grade 3 leukopenia and 9 developed grade 3 neutropenia. Grade 3 nonhematologic events were rare: Of 29 patients evaluable for response, 2 (7%) achieved a complete and 2 (7%) a partial response (overall response rate ⫽ 14%), 16 (55%) patients had stable disease, and 9 (31%) experienced increasing disease. Conclusion. The 3-day topotecan regimen was well tolerated but less active than the approved 5-day schedule in this group of patients. Notably, the rate of stable disease in the present study was similar to the rate previously reported by the GOG for the 5-day topotecan regimen in patients with platinum-sensitive ovarian cancer. Further study is required to determine the impact of disease stabilization on survival and quality of life in patients with ovarian and peritoneal cancer. The 3-day topotecan regimen may be more convenient and appropriate for combination chemotherapy. 95. Increased Expression of the Extracellular Membrane Protein Tenascin in Ovarian Tumors Suggests That Ovarian Stroma May Play a Role in Tumorigenesis. B. Hannah Ortiz, Ross S. Berkowitz, and Samuel C. Mok. Brigham and Women’s Hospital, Boston, Massachusetts. Objective. Tenascin is an extracellular matrix (ECM) glycoprotein expressed transiently in developing tissues and in the stroma of various benign and malignant conditions. Increased expression of tenascin may correlate with tumor adhesion, migration, and invasion. We studied the expression of tenascin ovarian epithelial tumors to identify a potential role for the stroma in ovarian tumorigenesis. Methods. Immunohistochemical staining of paraffin-embedded tissue sections from 35 ovarian tumors was performed using mouse anti-human tenascin antibody. Staining intensity was measured using a 0 –3 scale (0 ⫽ no stain; 3 ⫽ intense staining) in (i) the basement membrane or matrix immediately adjacent to tumor, (ii) stroma up to 15 ␮m from the cell group (“near stroma”), (iii) remote stroma (⬎15 ␮m), (iv) vessels, and (v) perivascular stroma (to 15 ␮m). Six grade 1 papillary serous carcinomas (PSCA), 6 grade 2–3 PSCA, 8 serous borderline ovarian tumors (SBOT), 4 clear cell carcinomas (CC), 3 endometrioid adenocarcinomas (EM), 4 benign tumors (1 simple cyst, 2 endometriomas, 1 endosalpingiosis), and 4 normal ovaries. Staining was performed at least twice per case. Results. Increased expression (any staining ⬎ 0) of tenascin was seen in both carcinoma and benign tumors.

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Basement membrane or intercellular matrix expression was seen in 5/8 cases of SBOT, 5/6 cases of grade 1 PSCA, 3/4 cases of CC, 3/3 cases of EM, 2/6 cases of grade 2–3 PSCA, and 3/4 benign cases. Near stroma (⬍15 ␮m) expressed tenascin in 6/8 SBOT, 5/6 grade 1 PSCA, 1⁄4 CC, 3/3 EM, 1/6 grade 2–3 PSCA, and 3/4 benign tumors. Near expression faded out with distance in many cases. Vascular endothelium stained positive in 3/8 SBOT, 1/6 grade 1 PSCA, 2/5 CC, 0/3 EM, 2/6 grade 2–3 PSCA, and 1/4 benign tumors. Perivascular staining was noted in 1/7 SBOT, 3/6 grade 1 PSCA, 1/4 CC, 1/3 EM, 2/6 grade 2–3 PSCA, and 0/4 of benign tumors. Normal postmenopausal ovaries (n ⫽ 3) had no tenascin expression. One premenopausal ovary demonstrated expression adjacent to a developing follicle. Conclusions. Focal increased expression of tenascin adjacent to tumor cells and vessels may suggest a paracrine role for tenascin in ovarian tumorigenesis. We conclude that the stroma may play a more active role in ovarian tumorigenesis than previously assumed and that this may be mediated, in part, by the ECM protein tenascin. 96. Structural Characterization of the Ovarian Tumor Marker CA125. Richard L.. Easton, Anne Dell, Howard R. Morris, Jamie Morrison, Frank A. Lattanzio Jr., Gary F. Clark, and Manish S. Patankar. Eastern Virginia Medical School, Norfolk, Virginia; and Imperial College of Science, Technology, and Medicine, London, United Kingdom. Objectives. Elevated levels of CA125 are found in the serum of ovarian cancer patients. Previously published observations indicate that CA125 is a high-molecular-weight mucin. However, the exact structure of CA125 is currently unknown. In this study we initiated characterization of the glycans and mapping of glycosylation sites of CA125 using conventional and modern tools for glycomic and proteomic analysis. Methods. CA125 from OVCAR-3 cells was isolated by size exclusion chromatography and its purity was determined by SDS–PAGE and Western blot analysis. Preliminary characterization of CA125-associated glycans was carried out by screening with a panel of lectins. Extensive characterization of these oligosaccharides was performed by utilizing fast atom bombardment mass spectrometry (FAB-MS) and MS/MS methodologies using a quadrupole-orthogonal time of flight mass spectrometer. Electrospray mass spectrometry (ES-MS) will be used to map the glycosylation sites of CA125. Results. Initial screening of CA125 with lectins indicated the presence of both complex and high mannose type N-linked glycans. Subsequent FAB-MS analysis also confirmed the presence O-linked oligosaccharides on this tumor marker. Both core 1 (Gal␤1-3GalNAc-) and core 2 (Gal␤1-3(Gal␤1-4GlcNAc␤1-6)GalNAc-) type O-linked glycans were also detected. Extensive modifications of these core structures were also observed. Similarly, the complex type N-linked oligosaccharides were also modified at their terminal ends. Efforts are currently underway to map the precise glycosylation sites of CA125. Conclusions. A thorough structural analysis of CA125 could lead to a better understanding of its biological significance. In addition, it is likely that such analysis could lead to the development of more specific tests for screening ovarian tumors. Data obtained in this study clearly indicate the presence of several oligosaccharide sequences on CA125 that have previously been implicated in significant cellular functions. These findings will be helpful for understanding the functional role of CA125 in tumorigenesis. In addition, mapping the glycosylation sites of this tumor marker by ES-MS will provide significant confirmatory evidence for the sequence of the CA125 gene (now designated MUC16) recently cloned by Yin and Lloyd (J Biol Chem 2001;276:27371–5). (Supported by Grant J-584 from the Jeffress Trust.) 97. Palliative Surgery for Bowel Obstruction in Recurrent Ovarian Cancer. An Updated Series. Bhavana Pothuri, Ami Vaidya, William J. Hoskins, Carol A. Aghajanian, Ennapadam Venkatraman, Richard R. Barakat, and Dennis S. Chi. Memorial Sloan-Kettering Cancer Center, New York, New York. Background. Intestinal obstruction is one of the most frequent sequelae of recurrent ovarian cancer. Previous series have reported median survivals of

4 – 6 months in patients who have undergone surgery for bowel obstruction due to recurrent disease. The purpose of this study was to analyze a contemporary series of patients to determine whether outcomes have changed in patients undergoing palliative surgery. Methods. We performed a retrospective review of all patients undergoing surgery for intestinal obstruction due to recurrent ovarian cancer from 1994 to 1999. Results. During the study period, 69 operations were performed on 64 patients. The mean age at the time of obstruction was 57.3 years (range 28.6 –79.3 years). The mean time from original diagnosis of ovarian cancer to obstruction was 2.8 years (range 0.3– 8.6 years). Surgical correction, defined as intestinal surgery performed for relief of obstruction, was attained in 57/69 (83%) cases. Successful palliation, defined as the ability to tolerate a regular or low-residue diet at least 60 days postoperatively, was achieved in 74% of cases where surgical correction was possible. The rate of major surgical morbidity was 23%. There was 1 death from a pulmonary embolus and 1 from peritonitis. Two other deaths occurred due to progression of disease, for an overall perioperative mortality rate of 6%. Postoperative chemotherapy was administered in 47/69 (68%) cases. The median survival of the entire cohort was 8 months. If surgery resulted in successful palliation, median survival was 10 months versus 4 months for all other patients (P ⬍ 0.01). Conclusions. Our current series reveals that the majority of patients undergoing surgery have successful palliation and are able to receive further chemotherapy. While the median survival of patients with successful palliation was only 10 months, these patients were discharged home and able to tolerate solid food. 98. The Impact of Age on Survival in Advanced Ovarian Cancer. A Reexamination. Jamal Rahaman, Peter Dottino, Thomas S. Jennings, and Carmel J. Cohen. Mount Sinai Medical Center, New York, New York. Objective. In 1993, Markman et al. suggested that elderly patients (⬎65 years old) with ovarian cancer experience a significantly inferior survival. We sought to determine whether all elderly patients were uniformly destined to a poor prognosis. Methods. Between January 1985 and December 1994, 345 patients with primary ovarian cancer were treated at Mount Sinai Medical Center. A total of 230 were stage III and 35 were stage IV and all underwent primary surgical cytoreduction and platinum-based combination chemotherapy. Optimal cytoreduction was defined as residual disease ⬍1 cm. Median follow-up was 68.3 months (8.4 –160). Survival analysis and comparisons were performed using the Kaplan–Meier method and the log-rank test. Multivariate analysis employed the Cox proportional hazards model. Results. Of the 265 advanced stage patients, 241 were evaluable, with 84 elderly patients (age 65– 87) and 157 younger patients (age 27– 64). Elderly patients had a significantly inferior survival (P ⬍ 0.025) with 2-, 3-, and 5-year survivals of 64.3, 53.0, and 34.3% vs 77.9, 64.5, and 49.2% for the younger patients. Multivariate analysis confirmed age as an independent prognostic variable. Of the evaluable patients, 228 were coded for primary cytoreduction. Subset analysis was performed and among the 87 patients with a suboptimal primary cytoreduction the elderly patients had a significantly inferior survival (n ⫽ 34, 5-year ⫽ 5.3%) than their younger counterparts (n ⫽ 53, 5-year ⫽ 21.5%, P ⬍ 0.044). However, among the 141 optimally cytoreduced patients there was no difference (P ⫽ 0.41) in the survival among the younger patients (n ⫽ 98, 5-year ⫽ 64.9%) compared to their older counterparts (n ⫽ 43, 5-year ⫽ 55.8%). Conclusion. Patients with advanced ovarian carcinoma who can be optimally cytoreduced should not be denied surgery and curative chemotherapy on the basis of advanced age. For those elderly patients in whom only a suboptimal cytoreduction appears possible, alternative strategies may be appropriate. 99. A Phase II Study of Docetaxel in Paclitaxel-Resistant Ovarian and Peritoneal Carcinoma. A Gynecologic Oncology Group Study. Peter G. Rose, John A. Blessing, Harrison G. Ball, James Hoffman, David Warshal, Koen Degeest, and David H. Moore. Indiana University School of Medicine, Indianapolis, Indiana; New Britain General Hospital, New Britain, Connecticut; Robert Wood Johnson Medical School, Cooper Hospital/Univer-

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SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS sity Medical Center, Camden, New Jersey; Roswell Park Cancer Institute, Buffalo, New York; Rush Medical College, Chicago, Illinois; University Hospitals of Cleveland, MacDonald Women’s Hospital, Cleveland, Ohio; and University of Massachusetts Medical School and Memorial Medical Center, Worcester, Massachusetts. Objective. Docetaxel is an inhibitor of microtubule depolymerization and has demonstrated activity in paclitaxel-resistant breast cancer and gynecologic cancer. The Gynecologic Oncology Group conducted a study of docetaxel in paclitaxel-resistant ovarian and peritoneal carcinoma to determine its activity, and the nature and degree of toxicity, in this cohort of patients. Methods. Patients with platinum- and paclitaxel-resistant ovarian or peritoneal carcinoma, defined as progression while on or within 6 months of therapy, were eligible if they had measurable disease and had not received more than one chemotherapy regimen. Docetaxel at a dose of 100 mg/m 2 was administered IV over 1 h every 21 days. A prophylactic regimen of oral dexamethasone (8 mg bid) was begun 24 h before docetaxel administration and continued for 48 h thereafter. Hepatic function was strictly monitored. Results. Sixty patients were entered and treated with a total of 256 courses, with all 60 evaluable for toxicity and 57 evaluable for response. Responses were observed in 22.8% of patients, with 5.3% achieving complete response and 17.5% achieving partial response (95% CI:12.7%—35.8%). Median duration of response was 2.5 months. The likelihood of observing a response did not appear to be related to the length of the prior paclitaxel-free interval or duration of prior paclitaxel infusions. The principal adverse effect of grade 4 neutropenia occurred in 75% of patients. There was 1 treatment-related death. Dose reductions were required in 36% of patients. Conclusions. Docetaxel is active in paclitaxelresistant ovarian and peritoneal cancer, but in view of significant hematologic toxicity, further study is warranted to ascertain its optimal dose and schedule. 100. Insulin-like Growth Factor-1 Upregulation of Heat Shock Protein 27kDa. A Potential Mechanism of Cisplatin Resistance in a Human Ovarian Cancer Cell Line. Robert W. Connelly and Peter G. Rose. University Hospitals of Cleveland, Cleveland, Ohio; and University Hospitals of Cleveland, MacDonald Women’s Hospital, Cleveland, Ohio. Objective. Previously we have shown in an in vitro growth assay that insulin-like growth factor-1 (IGF-1) can protect human ovarian cancer cell lines from cisplatin-induced cell death. Several recent studies have associated heat shock protein expression 27 (HSP27) with inhibition of apoptosis in cisplatin-resistant ovarian cancer cell lines [1]. We studied the role of IGF-1 addition to modulate the expression of HSP27. Methods. The intrinsically cisplatin-resistant human epithelial ovarian cancer cell line SK-OV-3 (derived from ascites) was used for this study. Cellular lysates for Western blot analysis were generated by exposing the cancer cells to cisplatin for 48 h of continuous exposure at the IC 70 (inhibitory concentration at 70%) and concentrations with and without the addition of IGF-1 (40 ng/ml). Western blots were probed with the HSP27 mouse monoclonal antibody to determine HSP27 protein expression levels. Results. Densitometry analysis of the Western blots revealed a sixto sevenfold increase in expression with only IGF-1 (40 ng/ml) versus the control (no treatment) or cisplatin alone. Conclusions. IGF-1 addition can upregulate HSP27 protein expression in the SK-OV-3 cancer cell line. Upregulation of HSP27 by IGF-1 maybe an important molecular pathway of apoptotic inhibition resulting in cisplatin resistance. References. 1. Yamamoto K, Okamoto A, Isonishi S, Ochiai K, Ohtake Y: Heat shock protein 27 was upregulated in cisplatin resistant human ovarian tumor cell line and associated with the cisplatin resistance. Cancer Lett 2001;168:173– 81. 101. A Phase I Study of Sequential Prolonged Oral Topotecan and Prolonged Oral Etoposide as Second-Line Therapy in Ovarian, Peritoneal, or Tubal Carcinoma. Peter G. Rose, Maurie Markman, and Jeffrey Bell. Central Ohio Gynecologic Oncology, Grant/Riverside Methodist Hospitals, Columbus, Ohio; Cleveland Clinic Foundation, Taussig Cancer Center,

TABLE 1—ABSTRACT 101 Dose Escalation Schema Dose level 1 2 3 4 5 6

Topotecan (0.9 mg/m 2 PO)

Days Days Days Days

Days 1–5 Days 1–5 1–5, Days 15–17 1–5, Days 15–19 1–5, Days 15–19 1–5, Days 15–19

Etoposide (50 mg/m 2 PO) Days 8–10 Days 8–12 Days 8–12 Days 8–12 Days 8–12, Days 22–24 Days 8–12, Days 22–26

Cleveland, Ohio; and University Hospitals of Cleveland, MacDonald Women’s Hospital, Cleveland, Ohio. Objective. Preclinical models suggest synergy when topoisomerase I and II inhibitors are given sequentially, but not when they are given simultaneously. In colon cancer xenografts inhibition of topoisomerase I results in upregulation of topoisomerase IIa. [1] Methods. A phase I study was conducted to determine the maximum number of days of oral topotecan and oral etoposide tolerable, which were increased according to the schema in Table 1. Doselimiting toxicities were defined as a neutrophil count ⬍1000/␮l or platelets ⬍50,000 during therapy with VP-16 or topotecan, neutropenic fever, a delay greater than 1 week in starting course 2 for reasons of hematologic toxicity (ANC ⬍1500 or platelets ⬍100,000 on scheduled day of treatment), or any documented platelet count ⬍20,000 Results. Eighteen patients were entered on this protocol. Dose-limiting toxicities occurred at dose level 4. The doselimiting toxicity, asymptomatic neutropenia during therapy, resulted in cessation of chemotherapy with no adverse effects. Conclusion. Oral topotecan and oral etoposide administered sequentially for a maximum of 3 weeks of therapy of every 4 is tolerable. In some cases the therapy may need to be interrupted for neutropenia on therapy. A plan to take this regimen into a Phase II setting is planned. References. 1. Whitacre CM, Zborowska E, Gordon NH, Mackay W, Berger NA. Topotecan increases topoisomerase II alpha levels and sensitivity to treatment with etoposide in schedule-dependent process. Cancer Res 1997;57:1425–1428. 102. Phase I/II Study of High-Dose Paclitaxel and Carboplatin; Topotecan and Etoposide; and Thiotepa with Peripheral Blood Stem Cells Support in the Treatment of Relapsed or Refractory Ovarian Cancer. M. Selleck, D. Hershman, D. Smith, C. Hesdorffer, L. Vahdat, D. Savage, A. Troxel, and A. Tiersten. New York Presbyterian Hospital, College of Physicians and Surgeons, Columbia University, New York, New York. Objectives. Chemotherapy dose and dose-intensity are the subject of investigation in ovarian cancer (OC). Topotecan, a topoisomerase I inhibitor, has significant activity in relapsed OC. Yet, dose escalation is limited by myelosuppression. It has been demonstrated that the combination of topoisomerase I and II inhibitors is synergistic when given sequentially. Methods. Seventeen patients with recurrent/persistent OC were treated with multiple cycles of high-dose chemotherapy (HDC): (i) paclitaxel (250 mg/m 2) and carboplatin (AUC 20), (ii) topotecan over 72 h continuous infusion (starting dose 5 mg/m 2) and etopophos (600 mg/m 2), (iii) thiotepa (500 mg/m 2). Peripheral blood stem cells (PBSCs) were given 72 h after each cycle. The MTD of topotecan has not been reached (DL-V ⫽ 13 mg/m 2). Results. Sixteen of the 17 patients completed therapy, all were evaluable for toxicity, and 14 were evaluable for response. The median age was 50. A total of 71% of the patients were platinum sensitive and 41% had disease ⬎2 cm at the time of HDC. The median times to ANC ⬎ 500 were 11, 8, and 10 days and for platelets ⬎20,000 they were 13, 9, and 12 days for cycles 1, 2, and 3, respectively. Episodes of grade 3/4 nonhematologic toxicity included the following: cycle 1: myalgias (3), diarrhea (2), and nausea (1); cycle 2: mucositis (7) and amylasemia (1); cycle 3: nausea (2) and mucositis (1). The responses included 5 clinical complete remissions

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(CR), 2 partial remissions, 2 minor responses, 2 stable disease, and 3 progressive disease. Two additional patients entered in a CR and remained in CR post HDC. Nine of the 13 patients with elevated CA-125s prior to enrollment normalized their levels after HDC. The median overall follow-up is 17.3 months. The median PFS is 9 months and the median OS is 19.1 months. The 1-year PFS and OS are 44 and 75%, respectively. Conclusions. Tandem cycles of HDC with PBSC support are tolerable and possibly efficacious at these doses. 103. Development of Absorbable Microparticles as Therapeutic Vaccines for Tumor Immunotherapy. Waleed Shalaby, Edward Woo, Heidi Yeh, Samantha Hendren, Shalaby W Shalaby, Stephen Rubin, and Carl H. June. Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, Poly-Med, Inc., Anderson, South Carolina; and University of Pennsylvania, Philadelphia, Pennsylvania. Objective. The aim of this study was the in situ delivery of T cell stimulatory (cd3) and costimulatory (cd28) signals and sustained release of granulocyte–macrophage colony stimulating factor (GM-CSF) to promote tumorspecific memory through local T cell activation and dendritic cell maturation. Methods. Polyglycolide microparticles (PG-MP) were surface-modified with either anti-cd3 and anti-cd28 (cd3/cd28-MP) for in situ T cell activation or GM-CSF (GMCSF-MP) for sustained cytokine release. In vitro and In vivo characterization was performed as described below. Results. PG-MP immobilized with either anti-mouse cd3/cd28 or anti-human CD3/CD28 induced significant proliferation of T cells at levels comparable to antibody-conjugated magnetic beads used as positive controls. Intracellular flow cytometry staining in activated T cells was consistent with a TH1 response. More than 50% of T cells were found to produce IFN-␥. There was no evidence of IL-4 production. In vitro release of GM-CSF from PG-MP was observed for up to 26 days by ELISA under sink conditions at 37°C. Biologic activity of released GM-CSF was confirmed by equivalent growth curves observed with a GM-CSF-dependent cell line (TF-1) compared to cultures supplemented with fresh GM-CSF. The individual and combined immunotherapeutic efficacies of cd3/cd28-MP and GMCSF-MP were studied in a syngeneic mouse tumor prevention model. Coinjection of Meth A fibrosarcoma cells in the flanks of balb-C mice with either cd3/cd28-MP or GMCSF-MP alone resulted in significant prevention. Only 5/16 mice in the cd3/cd28-MP group and 2/8 mice in the GMCSF-MP group developed tumor compared to controls (24/24). Furthermore, those mice exhibiting tumor had an 86% reduction in average tumor diameter compared to controls. However, when cd3-cd28-MP and GMCSF-MP were combined, tumor implantation was completely prevented (0/24). Conclusion. Surfacemodified PG-MP show encouraging potential as versatile absorbable carriers of stimulatory/costimulatory molecules and sustained cytokine release for tumor immunotherapy. 104. Prognostic Significance of Tumor-Cell-Lined Vasculature and Absence of Necrosis in Ovarian Carcinoma. Anil K. Sood, Mavis S. Fletcher, Chris Zahn, Elizabeth Seftor, and Mary Hendrix. Uniformed Services University of the Health Sciences, Washington, DC; and University of Iowa, Iowa City, Iowa. Objective. Recently, the term “vasculogenic mimicry” has been used to reflect the plasticity of aggressive tumor cells that express vascular cell markers and line tumor vasculature. The objective of this study is to explore the clinical relevance of tumor-cell-lined vasculature in ovarian carcinoma with respect to disease outcome. Methods. Tumor sections from 77 invasive ovarian carcinomas were evaluated independently in a blinded fashion by two board-certified pathologists for the presence of tumor-cell-lined vasculature and necrosis using routine histological analysis. Results. Tumor-cell-lined vasculature was detected in 23 (29.8%) tumors. Representative tumors revealed that 5–14% of the vasculature was lined by tumor cells. Moderate or extensive necrosis was detected in 25 (32.5%) tumors. All tumors with tumorcell-lined vasculature had either minimal or no necrosis. Conversely, 25 (46%) of all tumors with endothelial-cell-lined vasculature had necrosis (P ⬍ 0.001).

The presence of tumor-cell-lined vasculature was associated with high-stage disease (P ⫽ 0.004), nodal metastasis (P ⬍ 0.05), and ascites (P ⫽ 0.03); there was no association with tumor grade, histologic subtype, or likelihood of optimal surgical cytoreduction. The presence of necrosis was associated with only high-grade disease (P ⫽ 0.02). Detection of tumor-cell-lined vasculature was associated with shorter overall survival (mean 2.56 years versus 6.86 years, P ⬍ 0.001). The Cox proportional hazards model revealed that high stage (P ⫽ 0.01) and tumor-cell-lined vasculature (P ⫽ 0.004) were independently associated with poor survival. Conclusion. This is the first study to evaluate the clinical implications of tumor-cell-lined vasculature in ovarian carcinoma, which is associated with aggressive tumor behavior and poor prognosis. 105. Nuclear Oncogene ETV4 Is Overexpressed in Ovarian Cancer. Monique A. Spillman, Jae-Hoon Kim, Anne M. Bowcock, and Samuel C. Mok. Brigham and Women’s Hospital, Boston, Massachusetts; Dana Farber Harvard Cancer Center, Boston, Massachusetts; and Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to study the expression patterns of the ets oncogene ETV4 in normal and malignant ovarian epithelial cells. Methods. An ovarian-specific cDNA microarray was used to identify differentially expressed genes in ovarian cancer tissues. To validate the differential expression of one of the genes, ETV4, in ovarian tumor cell lines and tissues, semiquantitative reverse transcriptase polymerase chain reaction was performed on 7 normal ovarian surface epithelial cell cultures (HOSE), 5ovarian cancer cell lines, and 38 ovarian tumor tissues, using a primer set designed across exons 7 and 9 of the ETV4 gene. Furthermore, immunohistochemistry was performed on 7 ovarian tumor tissues using an anti-PEA3 antibody (mouse homolog of human ETV4). Results. Low ETV4 transcript expression was detected in 5 of 7 normal HOSE cell lines. The ovarian cancer cell lines 2008, CaOv-3, DOV3, and PEO4 expressed ETV4 by RT-PCR analysis. The 2008 ovarian cancer cell line, derived from an ovarian serous adenocarcinoma, exhibited the highest level of constitutive ETV4 expression. The SKOV-3 cell line did not express ETV4. Furthermore, high levels of ETV4 transcripts were detected in 12/16 serous adenocarcinomas, 4/5 serous borderline tumors, 1/2 mucinous carcinomas, all 3 endometrioid carcinomas, 1/3 primary serous carcinomas of the peritoneum, 1 mixed tumor, and 1/4 benign ovarian tumors. No ETV4 expression was noted in 4 mucinous borderline tumors. Four of 7 ovarian tumor sections stained with the PEA3 (mouse homolog of ETV4) antibody. The PEA3 protein staining exhibited epithelial specificity. The highest level of nuclear PEA3 (ETV4) expression was noted in clear cell ovarian adenocarcinoma specimens. Conclusions. ETV4 is a member of the ets oncogene family. Ets proteins share a common DNA binding sequence motif and function as regulators of nuclear transcription. Ets binding sites are found in the promoters of many genes, including BRCA1, HER-2/neu, and matrix metalloproteinase genes. Our isolation of ETV4 as an upregulated gene in ovarian cancer is the first description of the oncogenic potential of this gene family in ovarian cancer. Furthermore, we also demonstrate ETV4 expression in the majority of primary human ovarian tumors. Finally, we show that the ETV protein product demonstrates an epithelial restriction, as expected for an oncogene important in the pathogenesis of epithelial ovarian cancer. 106. Correlated Reduction of BRCA1 and BRCA2 Protein Occurs in Most Sporadic Epithelial Ovarian Cancers, Regardless of Stage or Grade. Elizabeth M. Swisher, Rachel Gonzales-Hernandez, Rochelle Garcia, Pamela Paley, Barbara A. Goff, and Mary-Claire King. University of Washington, Seattle, Washington. Objective. The role of BRCA1 and BRCA2 in sporadic ovarian cancer is not known. No previous evaluation of their joint expression in sporadic ovarian cancer has been undertaken. Our objective was to evaluate BRCA1 and BRCA2 protein expression in a series of sporadic epithelial ovarian cancers. Methods. Paraffin sections were obtained from ovarian cancers. Tumors were excluded from women with a significant family history of breast and ovarian

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS cancer. BRCA1 protein and BRCA2 protein were detected using the monoclonal antibodies MS110 (Oncogene Research Products) and H-300 (Santa Cruz Biotechnology), respectively. Stromal cells served as an internal positive control. Protein expression was scored for both intensity and quantity of tumor cells stained by a pathology expert blinded to specimen identification. Negative controls were stained with secondary antibody without primary antibody. Results. Eighty-one tumors were stained for both BRCA1 and BRCA2 protein expression. BRCA1 and BRCA2 protein reduction were closely related (P ⫽ 0.004, ␹ 2). Both BRCA1 and BRCA2 protein were moderately or severely reduced (ⱕ of cells staining) in 57% (46) of cases. Both BRCA1 and BRCA2 proteins were severely reduced (ⱕ of cells staining) in 21% (17) of tumors. BRCA1 and BRCA2 protein reduction was equally prevalent in stage I cancers and was unrelated to stage, grade, histology, or patient age. We are currently accumulating survival data and correlating survival with BRCA1 and BRCA2 protein expression. Conclusions. This is the first study to evaluate both BRCA1 and BRCA2 protein expression in a series of sporadic ovarian cancers. Both BRCA1 and BRCA2 proteins are frequently reduced in sporadic ovarian cancers and their loss occurs in a coordinated fashion. Reduction of these proteins in early stage ovarian cancers indicates that BRCA1 and BRCA2 protein reduction is an early event in ovarian tumorigenesis. 107. Preoperative Differentiation of Malignant from Benign Ovarian Tumors. The Efficacy of Morphology Indexing and Doppler Flow Sonography. Frederick R. Ueland, Paul D. Depriest, Edward J. Pavlik, Richard J. Kryscio, and John R. Van Nagell Jr. University of Kentucky Medical Center, Lexington, Kentucky. Objective. The aim of this study was to assess the efficacy of a new morphology index (MI) and Doppler flow sonography as methods to differentiate malignant from benign ovarian tumors. Methods. Risk of malignancy was assessed preoperatively in 442 ovarian tumors using a new MI based on tumor volume and wall structure. Each tumor was assigned a score of 0 to 10 based on increasing volume and morphologic complexity. Doppler flow studies were performed on 371 of these tumors. Pulsatility index (PI), resistive index (RI), and the presence or absence of tumor blood flow was recorded on each tumor. Results. A total of 389 tumors were benign and 53 were malignant. Stages of the malignant tumors were as follows: stage I, 33; stage II, 6; stage III, 14. Of 314 tumors with a MI ⬍ 5, there was 1 malignant tumor, a stage IA granulosa cell tumor ⬍2 cm in diameter. In contrast, there were 52 ovarian malignancies in 127 tumors with a MI ⱖ5. Risk of malignancy was related directly to MI score varying from 0.3% in tumors with a MI ⬍5 to 84% in tumors with a MI ⬎7. A MI value of ⱖ5 as indicative of malignancy was associated with the following statistical parameters: sensitivity 0.981, specificity 0.808, positive predictive value (PPV) 0.409, and negative predictive value (NPV) 0.987. A PI ⬍1.0 as indicative of malignancy was associated with sensitivity 0.528, specificity 0.776, PPV 0.288, and NPV 0.734. A RI ⬍0.4 as indicative of malignancy was associated with sensitivity 0.222, specificity 0.867, PPV 0.222, and NPV 0.500. The addition of Doppler flow indices to MI did not improve the accuracy of predicting malignancy. Likewise, the absence or presence of ovarian tumor blood flow was not a reliable means of differentiating benign from malignant ovarian tumors. Conclusion. Morphology indexing is an accurate and inexpensive method for differentiating malignant from benign ovarian tumors and can be a valuable adjunct in treatment planning. The addition of Doppler flow studies did not improve the diagnostic accuracy of morphology indexing. 108. Apoptotic Pathways Regulating Efficacy of the Novel Epothilone BMS247550 in Drug-Resistant Ovarian Cancer. Denise Uyar, Nagio Takigawa, Alexander W. Kennedy, Maurie Markman, Francis Lee, David Lebwohl, Ronald Bukowski, and Ram Ganapathi. Bristol–Myers Squibb Company, Wallingford, Connecticut,; and Cleveland Clinic Foundation, Cleveland, Ohio. Objective. The epothilone derivatives may represent novel chemotherapeutic agents for advanced ovarian cancer (OC) refractory to platinum and Taxol

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chemotherapy owing to their activity in tumors with paclitaxel resistance mediated by overexpression of P-glycoprotein or tubulin mutations. For this reason, we evaluated the cell death pathways initiated by BMS-247550 in a model of ovarian cancer cells (OC-2) from a patient with progressive stage IIIC papillary serous OC refractory to platinum/Taxol chemotherapy. Methods. Early passage cultures of OC-2 cells (from patient ascites specimen) were treated with BMS-247550 for 60 min with subsequent reincubation in drugfree medium prior to evaluation for apoptosis. OC-2 cells were also continuously treated with BMS-247550 for 12–24 h for determination of NF-␬B activation and caspase activity. Apoptosis was detected by fluorescent microscopy after staining with Hoechst 33342 and propidium iodide. The caspase 3 activity in cell extracts was assayed fluorometrically and utilized the DEVDAFC substrate. Transcriptional activation of NF␬B was determined following transfection with the PathDetect pNF-␬B luc plasmid cis-reporting system. Transfection with pFC-MEKK plasmid was used as the positive control. Results. In OC-2 cells treated with 0.05␮M– 0.5 ␮M BMS-247550 for 60 min followed by reincubation with drug-free medium, apoptosis was detectable by fluorescent microscopy in ⱖ30% of the cells by 24 h. In contrast, topotecan (5 ␮M), a mechanistically different anti-tumor agent, was ineffective at inducing apoptosis in OC-2 cells after 48 h despite the confirmation of measurable topoisomerase I protein by immunoblot analysis. In addition, analysis of proand anti-apoptotic signaling pathways in BMS-247550- treated OC-2 cells revealed transcriptional activation of NF-␬B by BMS-247550 but not topotecan. Evaluation of caspase 3 activity revealed activation of caspase 3 as early as 12 h after treatment followed by a 2-fold increase in activity after 24 h. The increase in activity observed was comparable both in continuously treated cells (0.05 ␮M) and in those cells treated in a 10-fold higher concentration of BMS-247550 for 1 h. Conclusion. Further evaluation of the BMS-247550induced cell death pathways is underway in OC-2 and other platinum/Taxolrefractory OC specimens in view of these results.

109. Age-Related DNA Methylation of the Ovary. Association with Malignant Transformation. Jing Wang, Rae Lynn Baldwin, Rania Ibrahim, and Beth Y. Karlan. Cedars-Sinai Medical Center and UCLA School of Medicine, Los Angeles, California. Objectives. Methylation of promoter-region CpG islands appears to occur in an age-related manner in some normal tissues and may contribute to neoplastic transformation. Our objectives were to determine whether age-related methylation occurs in the normal aging ovary and to investigate possible mechanisms. Methods. Age-associated methylation was characterized using snapfrozen human ovarian tissue from 20 young benign (mean age 44), 20 older benign (mean age 66), and 20 ovarian cancer (OVCA) (mean age 68) specimens. An intraperitoneal SCID mouse human OVCA (hOVCA) xenograft model was established from a hOVCA and “aged” by serial passage for 9⫹ generations. The methylation status of promoter region CpG islands of BRCA1, estrogen receptor ␣ (ER-␣), ER-␤, progesterone receptor A and B (PRA, PRB), and the transcription factor MYOD1 was examined by methylation-specific PCR and methylation-sensitive restriction digestion followed by Southern blot analysis. These genes have promoters shown to be methylated in cancers or in normal tissue in an age-related manner. To examine mechanisms causing age-associated DNA methylation changes, DNA methyltransferase 1, 3A, and 3B (DNMT1, DNMT3A, DNMT3B) gene expression levels were determined by RT PCR. Results. A significant increase in MYOD1 promoter methylation was detected in advanced-age ovaries (95%) and OVCA (90%) compared to young ovarian tissue (55%) (P ⫽ 0.003). A significant decrease in PRA methylation was detected in OVCA (40%) versus old and young benign ovaries (both 75%) (P ⫽ 0.03). Mechanisms of age-associated methylation were investigated using our hOVCA xenograft model. Xenograft 986 (X986) was established from hOVCA with a methylated BRCA1 promoter. BRCA1 methylation was retained in early generations of X986 but underwent complete loss in later passages. ER-␣, PRA, and MYOD1 methylation were gained coinciding with BRCA1 methylation loss in X986. A statistically significant decrease in DNMT3B mRNA expression level correlated with

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xenograft aging and loss of BRCA1 methylation, while DNMT1 and DNMT3A mRNA levels were unchanged. Conclusions. Age-related changes of DNA methylation occur in the normal ovary, are gene specific, and can occur independent of malignant transformation. The regulation of aberrant BRCA1 promoter methylation is independent of the other genes investigated and may be associated with DNMT3B gene expression level. 110. Clinical Implications of a Rising Serum CA 125 within the Normal Range in Patients with Epithelial Ovarian Cancer. James L. Wilder, Edward J. Pavlik, John M. Straughn, Robert V. Higgins, Richard J. Kryscio, Ronald J. Whitley, and John R. Van Nagell Jr. Carolinas Medical Center, Charlotte, North Carolina; University of Alabama at Birmingham, Birmingham, Alabama; and University of Kentucky Medical Center, Lexington, Kentucky. Objective. The aim of this study was to determine the clinical implications of progressively rising serum CA 125 levels in the normal (⬍35 u/ml) range. Methods. A multi-institutional investigation was undertaken to identify patients with CA 125 producing epithelial ovarian cancers who experienced progressively rising antigen levels in the normal (⬍35 u/ml) range after completion of therapy. All patients had (i) histologic documentation of epithelial ovarian cancer, (ii) complete clinical remission (CR), i.e., normal (⬍35 u/ml) serum CA 125 values after completion of therapy, negative imaging, and/or normal exams. All patients had serum CA 125 determinations at 1- to 4-month intervals after treatment. A rising serum CA 125 level was defined as a progressive increase in at least three CA 125 values above the coefficient of variance for the assay. No patient had a known episode of pelvic or gastrointestinal inflammatory disease during the period when the progressive rise in serum CA 125 took place. Results. Twelve patients with rising serum CA 125 levels in the normal range were identified. Stage of disease was as follows: stage I, 0; stage II, 1; stage IIIC, 11. Cell type was as follows: endometrioid adenocarcinoma 4; serous adenocarcinoma 7; clear cell carcinoma 1. Of the 12 patients identified, all developed recurrent ovarian cancer. This was documented either by the appearance of new lesions on imaging studies (7 of 12) or by histologic confirmation (5 of 12). The mean time from clinical CR to recurrence was 20.4 months (median ⫽ 20, range 6.4 –33.3 months). The mean interval of time from the observed rising pattern to recurrence was 5.9 ⫾ 1.2 months (median ⫽ 4.4, range 2.5–17.3 months). The mean lead-time gained from early rising serum CA 125 levels was 14.5 ⫾ 1.9 months (median ⫽ 14.5, range 4 –24.4 months). All recurrences were intraabdominal with the exception of 1 axillary recurrence. Conclusion. In the absence of known systemic inflammatory disease, progressively rising serum CA 125 levels in the normal (⬍35 u/ml) range in patients with epithelial ovarian cancer are associated with a high likelihood of recurrence. Patients with such a pattern should undergo immediate investigation to rule out and/or identify recurrent cancer. 111. Ovarian Germ Cell Tumor Survivors. Beliefs about Cancer Recurrence. Stephen Williams, Anna M. Miller, David Gershenson, Martee L. Hensley, David Cella, Cynthia Johnson, and Victoria Champion. Evanston Northwestern Healthcare, Evanston, Illinois; Indiana University Cancer Center, Indianapolis, Indiana; Memorial Sloan-Kettering Cancer Center, New York, New York; and University of Texas M. D. Anderson Cancer Center, Houston, Texas. Objective. Little is known about the long-term outcome of women successfully treated for ovarian germ cell cancer. This study addresses quality of life in a group of women successfully treated for ovarian germ cell tumors. Methods. Survivors (N ⫽ 133) were 2.6 to 21 (median ⫽ 10) years posttreatment on GOG and M. D. Anderson Cancer Center prospective clinical trials involving treatment with surgery followed by cisplatin-based chemotherapy. Quality of life issues of psychological, physical, and sexual functioning were measured with scales having documented validity and reliability. Data were gathered with mailed questionnaires and follow-up computer-assisted telephone interviews. Survivors were ages 19 to 64 (median ⫽ 36) at time of interview and from 11 to 54 at the time of diagnosis (median ⫽ 24); 42% were

infertile from cancer surgery; 81% were Caucasian; 59% were married or in a stable relationship; and 47% had a college education or greater. Results. An unexpected study finding was that 82% of survivors responded to questions about the possibility of cancer recurrence with “very likely” or “extremely likely” to recur. Also, 89% reported that they “often,” “very often,” or “constantly” think about their cancer returning, while only 27% regarded the thought of having their cancer return as either “very upsetting” or “extremely upsetting.” There were no significant correlations between these beliefs and age at diagnosis, years since diagnosis, current age, fertility, gynecologic symptoms, or social support systems. There was a strong negative correlation between belief in recurrence and depression scores (P ⫽ ⬍ 0.01) and the degree of being “upset” about cancer returning was a significant predictor (negative association) for overall sexual functioning (P ⫽ ⬍ 0.05). Conclusions. Health care providers should be even more vigorous in educating and reassuring survivors about the extremely low risk of recurrence. This education should be an important part of the follow-up of such patients. 112. Identification of the Haptoglobin ␣ Chain as a Diagnostic Ovarian Cancer Biomarker by Enhanced Laser Desorption/Ionization Mass Spectrometry. Bin Ye, Daniel W. Cramer, Vanessa Pratomo, Steven Skates, Sau-Mei Leung, Ross Berkowitz, and Samuel Mok. Brigham and Women’s Hospital, Dana-Farber Harvard Cancer Center, Harvard Medical School, Boston, Massachusetts. Objective. The aim of this study was to identify potential biomarkers for the early detection of ovarian cancer by surface enhanced laser desorption/ionization (SELDI)-mass spectrometry and liquid chromatography. Methods. Four different types of surface specific ProteinChip arrays were used to screen for protein markers of molecular weight less than 50 kDa in a total of 87 age-matched serum samples (37 cases and 50 normal controls). A candidate protein was purified by affinity chromatography and subsequently sequenced by ion trap tandem mass spectrometry. A polyclonal antibody against the protein was generated and used for validation by Western blot analysis and ELISA. Results. By comparing mass spectra profiles generated from serum samples, several protein peaks were identified as potential markers for different histological subtypes of ovarian cancer. Using the copper surface (IMAC3) chip, one protein peak at about 11,700 Da was identified. This protein appeared in all histological types of ovarian cancer cases, but less so in controls. Using the protein intensity of 0.2 as a cutoff, the sensitivity and specificity of this biomarker for ovarian cancer was 83 and 70%, respectively. The purified protein was sequenced and was determined as the ␣ chain of haptoglobin. The elevated level of haptoglobin ␣ chain in sera from ovarian cancer patients was confirmed by Western blotting. The preliminary ELISA screening, with our purified polyclonal haptoglobin ␣ antibody, showed a sensitivity and specificity of 68 and 82%, respectively, in a total of 87 cases and 100 normal controls. Conclusions. Using SELDI mass spectrometry and liquid chromatography techniques, we have successfully identified haptoglobin ␣ chain, as well as other proteins as candidate biomarkers for ovarian cancer detection. Haptoglobin has previously been found to be elevated in ovarian cancer patients. We first suggest that the ␣ chain of haptoglobin may be a more sensitive biomarker. More sensitive assays and mechanisms for haptoglobin ␣ subunit elevation in ovarian cancer patients are currently under investigation. This study clearly indicates that combined techniques of mass-spectrometry and liquid chromatography provide us with new strategies in ovarian cancer biomarker discovery. 113. 3D Conformal vs Intensity Modulated Radiotherapy for the Adjuvant Treatment of Gynecologic Malignancies. A Comparative Study of Dose– Volume Histograms. Dwight E. Heron, Kristina Gerszten, John T. Comerci, Holly Gallion, Robert P. Edwards, Gwendolyn King, Raj Selvaraj, and Andrew Wu. University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania. Purpose. The aim of this study was to evaluate the feasibility of pelvic intensity modulated radiotherapy (IMRT) in the adjuvant treatment of gyne-

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS

TABLE 1—ABSTRACT 113 Percentage Volume Receiving Doses of 30 Gy Organ

IMRT

3D

Small bowel Bladder Rectum Target

14.8 59.7 32.0 100

30.3 86.4 92.8 100

cologic malignancies and to compare the dose–volume histograms (DVHs) to determine the potential impact on acute/late toxicity based on the dose to pelvic tissues. Methods. Ten patients referred for adjuvant RT for gynecologic cancers were selected for CT-based treatment planning using the ADAC v4.2g and the NOMOS Corvusv4. The regions of internal, external, and common iliac nodes, rectum (REC), vagina, bladder (BLAD), and small bowel (SB) were contoured on axial CT slices on both systems with the aid of a gynecologic radiologist. Three-dimensional (3D) planning used a four-field box with 18-MV photons designed to treat a standard pelvic field with shaped blocks to minimize the dose to the REC and SB. A seven-field technique using 6-MV photons was used for IMRT. Limits on SB for IMRT were set at 23.0 Gy ⫾ 5%, 35.0 Gy ⫾ 5% for the REC, and 37.5 Gy ⫾ 5% for the BLAD while delivering 45.0 Gy to the pelvic nodal groups at 1.8 Gy QD. The DVHs were compared for both techniques. Results. The volume of each organ of interest receiving doses in excess of 30 Gy was compared in the 3D and IMRT treatment plans. The mean volume of SB, RECT, and BLAD receiving doses in excess of 30 Gy was significantly reduced with IMRT compared to 3D (see Table 1). Conclusions. IMRT appears to offer many advantages over the 3D technique for the adjuvant treatment of gynecologic malignancies. These include a significant reduction in dose to normal tissues. This could translate into an overall reduction in acute and late treatment-related toxicity. This improvement may be even more evident in light of the significant SB/REC toxicities that are observed in many patients. Concurrent and concomitant boost techniques could significantly improve the treatment course of gynecologic patients requiring primary treatment. 114. Hand-Assisted Laparoscopic Surgical Staging of Ovarian Cancer. Thomas C. Krivak, Michael Sundborg, G. Scott Rose, John C. Elkas, Jay W. Carlson, and Paul Mackoul. Walter Reed Army Medical Center, Bethesda, Maryland; Walter Reed Army Medical Center, Washington, DC; and Washington Hospital Center, Washington, DC. Objective. The aim of this study was to evaluate the use of hand-assisted laparoscopy (HALS) in the performance of surgical techniques that characterize ovarian cancer cytoreductive surgery. Methods. The surgical approach of HALS consists of placement of laparoscopic ports and a laparoscopically directed minilaparotomy incision for the use of an intraabdominal hand. Patients consented for advanced laparoscopic techniques. HALS was used for surgical staging and tumor debulking in patients referred with unstaged or preoperatively suspected ovarian cancer. Data regarding the estimated blood loss, surgical complications, operative times, and procedures performed were collected by review of patient records. Results. Twenty-two of 25 patients (88%) had their surgeries completed with the HALS technique; of these 18 patients had preoperatively suspected ovarian cancer, and 7 patients were referred with unstaged disease. All advanced stage patients were optimally cytoreduced to less than 1 cm. Of the 17 unstaged patients referred with “early stage disease,” 29% were upstaged. Procedures performed with HALS included hysterectomy (n ⫽ 11), modified radical hysterectomy (n ⫽ 1), bilateral salpingo-oophorectomy (n ⫽ 13), omentectomy (n ⫽ 22), pelvic and paraaortic node dissection (n ⫽ 19), appendectomy (n ⫽ 17), small bowel resection (n ⫽ 3), partial colectomy (n ⫽ 2), and low anterior resection (n ⫽ 2). Surgical complications included 1 small bowel enterotomy and 1 postoperative small bowel obstruction which required a laparotomy and small bowel resection.

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Three of 25 patients were converted to laparotomy in order to optimize cytoreduction. With a mean follow-up of 17 months, no port site recurrences have been detected. The mean operative time was 200 min (90 –350), mean estimated blood loss was 265 cc (50 –1500), and mean hospital stay was 1.8 days (1– 8). Conclusion. Hand-assisted laparoscopic surgery is a feasible alternative to laparotomy in carefully selected patients with ovarian cancer. HALS allows a complete evaluation of the abdominal cavity through laparoscopic visualization and hand-assisted palpation. This technique offers several advantages over laparoscopy in that it returns tactile sensation and manual dissection to the surgeon, which results in the ability to detect and resect disease typically cytoreduced by laparotomy. Additional investigation into the validity of this approach is warranted. 115. Two Different Categories of Vulvar Cancer Patients? Joanne A. De Hullu, Harry Hollema, Matthe Burger, A. P. Heintz, Sietske Lolkema, Jan G. Aalders, Marian J. Mourits, and Ate G. Van der Zee. Acad Medical Center Amsterdam, Amsterdam, The Netherlands; University Hospital Groningen, Groningen, The Netherlands; and Utrecht University Medical Center, Utrecht, The Netherlands. Objectives. In the past decades treatment for vulvar cancer has changed from standard radical vulvectomy with “en bloc” inguinofemoral lymphadenectomy into more individualized treatment. No randomized studies comparing standard radical with modified surgery have ever been performed. The aim of the present study was to evaluate the consequences of treatment modification in our own institution with respect to locoregional recurrences and survival. Methods. Data from all patients with T1 and T2 vulvar cancer, treated between 1982 and 1998 at the Groningen University Hospital, were prospectively collected in a database. The incidence of local and locoregional recurrences and survival was compared between group 1, patients treated from 1982 to 1992 with standard radical vulvectomy with en bloc inguinofemoral lymphadenectomy, and group 2, patients treated from 1993 to 1998 with individualized therapy (tailored excision primary tumor, separate incisions). The date of last follow-up was set at 24 months after therapy of the last patient in each group. Results. For the present study 253 patients [median age 72 years (range 28 –94)] were analyzed. In group 1, 168 patients underwent radical vulvectomy, while in group 2 wide local excision was performed in 45, and modified radical vulvectomy was performed in 40 patients (because of multifocal tumor and/or abnormal aspect of the remainder of the vulva). After individualized therapy the frequency of locoregional recurrences was increased [23/85 (27%) vs 24/168 (14%) (P ⫽ 0.01)], but no difference in diseasespecific survival was observed [median follow-up: 49 months (range 3–129)]. Interestingly, in group 2 the frequency of local recurrences was higher after modified vulvectomy [11/40 (28%)] compared with standard radical vulvectomy in group 1 [23/168 (14%) (P ⫽ 0.03)], but was not significantly increased after wide local excision [8/45 (18%)]. Conclusion. Our study confirms the previously observed increase of locoregional recurrences of vulvar cancer after individualized therapy without compromising overall prognosis. However, our data on local recurrences may point to two different categories of vulvar cancer patients: one category where the entire vulvar region is at high risk for development of de novo recurrent vulvar cancer and a second category of patientsin whom the remainder of the vulva appears normal, with a low risk for recurrent disease, and who therefore are especially suited to less extensive surgery. 116. Vulvar Cancer. Patterns of Surgical Care and Lymph Node Dissection in Early Disease. Janice L. Falls, Robert E. Bristow, Carol Kosary, Edward L. Trimble, and F. J. Montz. National Cancer Institute, Bethesda, Maryland; and Johns Hopkins Medical Institutions, Baltimore, Maryland. Objective. The aim of this study was to evaluate patterns of surgical care for early stage vulvar carcinoma and survival effect of lymph node dissection (LND) in those patients undergoing partial/simple vulvectomy (e.g., radical local excision, RLE) in a population-based data set. Methods. The National Cancer Institute’s Surveillance, Epidemiology, and End Results database

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(1988 –1995) was evaluated for surgical approach used for clinical T1/T2 N0 disease (n ⫽ 858). Five-year survival was also examined with respect to T1 disease, comparing RLE with and without LND, and radical vulvectomy. Results. Women with clinical T1/T2 N0 disease received the following surgeries: incisional (2.8%) and excisional (18.4%) biopsies, RLE with LND (39.2%) and without LND (28.5%), and radical vulvectomy (11.1%). The 5-year cumulative survival for these patients was 89% for T1 N0 and 79% for T2 N0 disease, which compares unfavorably with prospective clinical trial data, although this is not statistically significant. Only 50.2% of patients received optimal surgical care (i.e., LND). When RLE was performed with LND in clinical T1 disease, the 5-year survival was significantly improved when compared with RLE without LND (P ⫽ 0.004). No survival effect was observed comparing RLE with LND and radical vulvectomy. Conclusions. LND appears to be of benefit in patients with T1 vulvar carcinoma undergoing RLE. However, LND is performed in only 50% of patients with T1/T2 N0 disease. 117. Long-Term Survival for Primary Squamous Cell Carcinoma of the Vulva with and without Inguinal Involvement. Jesus Gonzalez Bosquet, Javier F. Magrina, Thomas Gaffey, Maurice J. Webb, J. Hernandez, and Karl C. Podratz. Mayo Clinic, Rochester, Minnesota; and Mayo Clinic, Scottsdale, Arizona. Objective. Limited information exists regarding long-term disease-specific survival and recurrence rates (exceeding 10 years) for carcinoma of the vulva. Therefore, the objective of this study was to compare long-term survival and failure rates in patients with squamous cell cancer of the vulva according to inguinal nodal involvement. Methods. A retrospective review of 446 patients with primary squamous cell carcinoma of the vulva treated between 1950 and 1990 was conducted. Clinical and follow-up data were abstracted from the patient records. A single pathologist reviewed all histology slides. The Kaplan–Meier method was used to estimate rates and univariate comparisons of the survivorship curves were evaluated via the log-rank test. Associations between time to death (or recurrence) and various clinical factors were assessed using a Cox proportional hazards model. Results. Follow-up information was informative for 99% of the subjects. Of 193 patients alive at the time of censor, follow-up was less than 5 years in only 13 patients (2.91% of the total). During the study period, 253 patients died: 73 from disease, 11 from treatment complications, 162 from other causes, and 1 unknown. The mean follow-up for the entire patient population was 9.90 years. Metastases were documented in the inguinal–femoral nodes in 113 patients (25.3%). Survival and recurrence rates, at 5 and 10 years, were markedly disparate among patients in the absence versus the presence of groin node metastases (survival: 92 and 87% vs 62 and 59%, recurrence: 13 and 22% vs 39 and 48%). Disease-specific survival, even in patients with negative nodes, continues to decrease through 10 years after treatment. For patients with positive nodes, attrition is dramatic during the first 2 years, but also continues, albeit at a lesser rate, through 10 years. For patients with negative nodes there is a steady decrease in disease-specific survival even through 20 years. New reoccurrences continue to be witnessed in both groups 10 to 20 years after initial treatment. Conclusions. Disease-related deaths from squamous cell carcinoma of the vulva continue through 20 years following initial diagnosis and presumed definitive treatment. These observations suggest reexpression (possibly environmental regulated) of the etiopathogenic factors of vulva carcinoma after prolonged periods of dormancy.

of the vulva with and without lymph node metastases (LNM) and to evaluate the sensitivity and specificity of computerized morphometry in predicting LNM in patients with SCC of the vulva. Methods. Histological samples obtained from 20 consecutive cases of SCC of the vulva with positive inguinal lymph node metastases were morphometrically assessed and compared to samples from 20 cases of vulvar SCC negative for LNM. Computerized morphometry was performed on tumor cells and on adjacent nonneoplastic epithelial cells located 2– 4 mm from the tumor margins. Results. Computerized morphometric variables of tumor cell nuclei in patients with negative LNM significantly differed from the LNM-positive cases. In the LNM-positive group, tumor cell nuclei were significantly smaller than those of the LNMnegative group (area ⫽ 31.9 ⫾ 10.2 vs 51.7 ⫾ 27, respectively, P ⫽ 0.002). Significant differences between the groups were also found when comparing the nuclear perimeter (P ⬍ 0.001), nuclear diameter (P ⫽ 0.022), and nuclear axes (P ⬍ 0.001). Morphometric differences in nuclear size and contour regularity were detected when comparing the nonneoplastic nuclei adjacent to the tumor in both groups (roundness: 1.56 ⫾ 0.88 in the LNM-positive group vs 2.61 ⫾ 1.49 in the LNM-negative group, P ⬍ 0.001). There was no significant difference between the two patient groups regarding age, age at menopause, parity, macroscopic appearance of the tumors, or tumor size. Multivariate analysis showed that the only independent predictors of LNM were the depth of invasion and the mean nuclear roundness of the nonneoplastic nuclei adjacent to the tumors (P ⬍ 0.0001 for both variables). Using these variables, a discriminant score revealed a sensitivity of 90% and a specificity of 86.4% for predicting LNM in SCC of the vulva. Conclusions. Our data suggest that the primary tumors with LNM differ morphometrically from primary tumors with no LNM. The results of our study provide an additional tool for assessing the need for inguinal lymph node dissection in cases of early stage vulvar carcinoma. 119. Perineural Invasion Is an Adverse Prognostic Factor in Invasive Squamous Cell Carcinoma of the Vulva. Vikas Mahavni, Michael Woltman, Mavis S. Fletcher, and Anil K. Sood. University of Iowa, Iowa City, Iowa. Objective. There are no published data evaluating the impact of perineural invasion (PNI) on the clinical behavior of invasive squamous cell carcinoma of the vulva. This study examined the effects of PNI on clinical outcome. Methods. All patients diagnosed and treated for invasive squamous cell carcinoma of the vulva by modified or radical vulvectomy with groin dissection between 1990 and 1998 were included. Each pathologic sample was reviewed in a blinded fashion by a gynecologic pathologist for the following characteristics: histology, grade, depth of invasion, lymph–vascular invasion (LVSI), histologic pattern of invasion (spray vs pushing), and perineural invasion. Clinical factors pertaining to patient outcomes were collected in parallel. Results. Eighty-eight patients met the entry criteria. The median age of diagnosis was 68 (range 31–91). PNI was detected in 33% of the samples reviewed and was not significantly associated with age of diagnosis, body mass index, or pretreatment serum albumin. PNI was significantly associated with greater depth of invasion (P ⫽ 0.006), LVSI (P ⬍ 0.001), spray pattern of invasion (P ⫽ 0.002), positive inguinal nodes (P ⫽ 0.005), high stage (P ⫽ 0.03) and tobacco use (P ⫽ 0.02). PNI was also associated with a shorter median survival approaching statistical significance (P ⫽ 0.05). Conclusions. This is the first study to evaluate the role of PNI in the clinical behavior of invasive squamous cell cancer of the vulva. PNI is associated with advanced disease and poor outcome.

118. Computerized Nuclear Morphometry for Prediction of Inguinal Lymph Node Metastases in Squamous Cell Carcinoma of the Vulva. Ofer Lavie, Marzia Maini, Giuseppe Comerci, Edmond Sabo, Paul A. Cross, Shlomy Sagie, Alberto Lopes, and John M. Monaghan. Carmel Medical Center, Haifa, Israel; and Queen Elizabeth Hospital, Gateshead, United Kingdom.

120. Sentinel Node Identification and the Ability to Detect Metastatic Tumor to Inguinal Lymph Nodes in Vulvar Malignancies. Richard G. Moore, Stephen E. Depasquale, Margaret M. Steinhoff, Walter Gajewski, Michael A. Steller, and Stephen Falkenberry. Women and Infants’ Hospital/ Brown University, Providence, Rhode Island.

Objective. The aim of this study was to investigate morphometrical differences in the primary tumors of patients with squamous cell carcinoma (SCC)

Objective. The aim of this study was to identify inguinal sentinel nodes (SLN) in patients with vulvar malignancies using technetium-99 (Tc-99) and

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS lymphazurin dye and to determine the sensitivity of this technique in detecting inguinal lymph node metastases. Methods. Patients were enrolled in an IRBapproved study from January 2000 to June 2001. Tc-99 was injected at the tumor margins 90 –180 min prior to surgery, followed by an injection of lymphazurin blue dye in the operating room. At the time of inguinal dissection a gamma counter was used to identify the SLN; as well, the lymphatic tracts stained with blue dye and their corresponding SLN were identified. All SLN were removed and a completion inguinal dissection was performed. The SLN were serially sectioned along the short axis and submitted for histologic evaluation. From each block, five slides were cut at 100-␮mintervals and stained with hematoxylin and eosin. Non-SLN were processed in their entirety with one slide per block. The patients were treated with current standard of care protocols according to the completed inguinofemoral dissection results. Results. Twenty-one patients were entered into the study with a total of 34 inguinal node dissections, 31 of which were SLN dissections. Of the 34 groin dissections, 10 patients had bilateral groin dissections with a SLN, 8 had a unilateral groin dissection with a SLN, and 3 had bilateral groin dissections with a SLN dissection on one side alone. The average number of SLN identified was 2.6 nodes per groin with a total of 9.6 nodes sampled per groin. Four groins had metastases to the SLN alone and 5 groins had disease in both the SLN and the non-SLN. There were 22 groins with no metastatic disease. Eight patients had T1 lesions, 11 had T2 lesions, and 2 had T3 lesions. Surgical staging revealed 7 stage I, 5 stage II, 5 stage III, and 4 stage IV cases. The utilization of Tc-99 identified a SLN in all 31 (100%) groins. Nine groins had metastasis, all of which had a SLN that was labeled with Tc-99 and contained metastatic disease. Lymphazurin blue dye detected a SLN in 19/31 (61%)of the groins. Blue dye identified 3 of the 9 groins with metastatic disease. The other 6 groins did not have a SLN identified by the blue dye. Conclusions. The technique of Tc-99 and lymphazurin lymphatic mapping for SLN detection is a sensitive and accurate method for evaluating the inguinal lymphatic beds for metastatic tumor in patients with vulvar cancer.

POSTER SESSION II—TUESDAY, MARCH 19, 7:00 AM–5.00 PM AND WEDNESDAY, MARCH 20, 8:00 AM–11.00 AM Abstracts 121–195 121. The Efficacy of 9-Cis Retinoic Acid as a Chemopreventive Agent for Cervical Dysplasia. Results of a Randomized Double-Blind Clinical Trial. Ronald D. Alvarez, Michael G. Conner, Heidi L. Weiss, Patricia M. Klug, Santosh Niwas, James Bacus, Val Kagan, Upender Manne, Katherine C. Sexton, and William E. Grizzle. Bacus Labs, Inc., Lombard, Illinois; and University of Alabama at Birmingham, Birmingham, Alabama. Objective. 9-Cis retinoic acid (9CRA) binds to both RAR and RXR retinoid receptors in squamous cells and has been demonstrated in preclinical models to have chemopreventive effects. The purpose of this study was to determine the utility of 9CRA as a chemopreventive agent in cervical dysplasia. Methods. Patients with histologic evidence of CIN 2/3 after colposcopic evaluation were randomized in a double-blind manner to receive either a high dose (HD) of 9CRA (50 mg), a low dose (LD) of 9CRA (25 mg), or placebo daily for 12 weeks. Compliance and clinical and laboratory side effects were monitored at various time points during therapy. At the completion of therapy, patients underwent a loop procedure. Histology of pretreatment biopsies was compared to that of loop specimens. Cytomorphometric measurements and expression of other surrogate biomarkers were also assessed on pre- and posttherapy histologic specimens. Results. A total of 114 patients with histologic CIN2/3 were enrolled in the HD 9CRA, the LD 9CRA, and the placebo groups. A total of 106 patients completed the treatment regimen and underwent the loop procedure. Headache and nausea were more frequent in the HD 9CRA regimen. Regression of CIN 2/3 in the pretreatment biopsy specimen to ⱕCIN1 in the loop specimen was similar in the HD 9CRA, LD 9CRA, and placebo groups (36, 32, and 32%, respectively; P ⫽ NS). Analysis of the effect of treatment on cytomorphometrics and other surrogate endpoint biomarkers is in process.

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Conclusion. 9CRA at these dosages and schedules does not result in significant regression rates in CIN 2/3 patients when compared to placebo. These limitations suggest that a different 9CRA dose schedule or alternative retinoic acid should be investigated as potential chemopreventive agents in patients with CIN2/3. (Supported by NCI Contract N01-CN-65024-32.) 122. Immune Responses to Human Papilloma Virus in the Genital Tracts of Women with Cervical Cancer. Huan H. Nguyen, Huong L. Vu, Lorie R. Brewer, Ge Jin, Louise T. Chow, Ronald D. Alvarez, and Jiri Mestecky. University of Alabama at Birmingham, Birmingham, Alabama. Objective. Cervical carcinoma (CC) is associated with HPV 16, HPV 18, and other HPV genotypes that infect the mucosal surface of the genital tract. Until recently most work on HPV immunology has focused on immune responses in systemic compartments. In this study, we have analyzed local immune responses in the genital tracts of women who underwent radical hysterectomy for cervical cancer (HCC) and compared these responses to that in women who underwent loop for cervical dysplasia (LOOP) or who had hysterectomy for reasons other than cervical neoplasia (HNN). Methods. These studies were accomplished using ELISA to assess HPV-specific humoral response and using oligonucleotide arrays to assess immunoglobulin and cytokine gene expression. Although levels of HPV-16 E7 specific antibodies in vaginal washes were significantly higher than the antibody levels in the sera of all study objects, the levels of the HPV-specific antibodies (mainly IgA) detected in vaginal washes of women with CC are lower compared with patients in other groups (LOOP and HNN). Results. Analysis of immunoglobulin gene expression revealed that the gene specific for the IgA molecule was down regulated in tumor tissues compared to that in the normal tissues of the same individuals. The data also show that the expression of genes specific for Th1-type and Th2-type cytokines related to cell-mediated immune and antibody responses, respectively, is not enhanced at the site of tumor growth. Conclusion. The results suggest that diminished mucosal humoral and cellular immune responses to HPV in patients with cervical cancer may contribute to more aggressive HPV-related tumor growth. (Supported by a Cancer Research Institute grant and in part by US PHS Grants K12HD01402-02 and AI 28147.) 123. Clinicopathological and Prognostic Implication of Cripto, HGFR, nm2,3 and CD44v6 Proteins in FIGO Stage IB Cervix Carcinomas. Ayþe Ayhan, Cem Baykal, Atakan Al, Kunter Yu¨ ce, and Aly´ Ayhan. Department of Obstetrics and Gynecology and Department of Pathology, Hacettepe University School of Medicine, , Ankara, Turkey; and Department of Gynecologic Oncology, SSK Ankara Maternity Hospital, Ankara, Turkey. Objective. This study evaluates the expression of several oncogenes which participate as growth factors, growth factor receptors, or molecules playing a role in the metastatic cascade in matched sets of nonneoplastic cervical epithelium, primary cervical carcinoma, and metastatic tumors in the lymph nodes in order to investigate their role in cervical cancer development, progression, and prognosis. Methods. Eighty-eight primary cervical carcinomas with stage IB disease, treated primarily with surgery, were examined. cripto (CR-1), HGFR (c-met), nm23, and CD44v6 protein expressions were determined immunohistochemically. The conventional clinicopathologic variables for cervical cancer such as grade, tumor size, depth of invasion, parametrial and endometrial extension, lymphovascular space involvement, and lymph node status were also compared with the above-mentioned protein expressions in the primary tumors. Results. Strong cripto immunopositivity was significantly correlated with lymphatic space and parametrial involvement. HGFR (c-met) overexpression was found in 51% of cases and was significantly associated with recurrent tumor. CD44v6 nonbasal expression was significantly correlated with the size of the primary tumor. Interestingly, univariate survival analysis using the Kaplan–Meier method showed that beside tumor size, depth of invasion, existence, and number of lymph node metastases and recurrence, c-met and CD44v6 nonbasal expressions were significantly correlated with overall survival, while recurrent tumor and c-met overexpression

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were correlated with disease-free survival. Furthermore, multivariate analysis of the above-mentioned variables showed that c-met overexpression is an independent factor for disease-free survival (DFS), while CD44v6 nonbasal staining is an independent parameter for overall survival (OAS). Conclusion. These results indicate that while cripto (CR-1) and nm23 proteins are important for disease progression and metastasis; c-met overexpression and CD44v6 nonbasal staining are independent factors for DFS and OAS in cervix carcinomas. 124. Patient Acceptance of Self-Sampling for Human Papillomavirus in Rural China. Suzanne E. Belinson, Yan Hong Shen, Donna Fife, Jean M. Goycoolea, Cong-Ping Ma, Youlin Qiao, and Jerome L. Belinson. Cancer Institute/Hospital of the Chinese Academy of Medical Sciences, Beijing, China; Cleveland Clinic Foundation, Cleveland, Ohio; UPMC Health System, Pittsburgh, Pennsylvania; Veterans Administration Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and YangCheng Cancer Hospital, Shanxi Province, China. Objectives. The aims of this study were to test a recently developed measure of self-sampling for high-risk HPV, to determine the barriers associated with self-sampling in rural Chinese women, and to determine the level of acceptance of the self-sampling procedure. Methods. This survey is a component of the Shanxi Province Cervical Cancer Screening Study II. Subjects were identified through a systematic random sample. Thirteen survey questions assessed the overall acceptance of the procedure. Pain, comprehension, and cultural beliefs were potential barriers evaluated by the survey. Two pilot testing phases and a focus group established content validity while interrater reliability and responsiveness of the measure were measured by a test –retest procedure. The subjects received verbal instructions regarding the self-sampling procedure from a local health care worker who spoke the dialect of their village. After performing the procedure, they were interviewed by a Chinese research assistant who was also fluent in the local dialect. Results. A total of 1560 women were surveyed. Ninety-nine percent were married, 79.6% completed nine years of school, and 25.4% were high-risk HPV positive. When surveyed, the women recalled five of the seven steps of the self-sampling procedure. A total of 12.5% reported pain and bleeding after doing self-sampling. A total of 2.4% reported feeling uncomfortable touching their genitals. Ninety-one percent said that they would prefer to perform the test at a clinic versus in their home. The major barrier encountered was related to the educational level of the women. Forty-two percent responded that most women would not perform the test unless they felt ill. Seventeen percent said that the test was embarrassing. Eighty-seven percent had heard of cervical cancer; of these, 92% were afraid of getting cervical cancer, 16.7% were worried about having HPV, and 85% did not know why testing for HPV was important. Conclusion. The measure performed well in this population. The self-collection brush was well accepted by these women. They reported little pain or bleeding associated with using the self-test. However, a trained and trusted medical person needed to be present for the women to feel comfortable enough to perform the test. Education is clearly the largest hurdle to overcome in implementing a self-sampling screening program. Future research will gather additional data from diverse environments to aid in developing screening programs for cervical cancer that are culturally, religiously, and educationally tailored to the at-risk women. 125. Modulation of Radical Surgery in Early Invasive Cervical Cancer Based on Intraoperative Assessment. Pierluigi Benedetti Panici, Giuseppe Cutillo, Ludovico Muzii, Marzio A. Zullo, Silvia Longhitano, and Roberto Angioli. University Campus Biomedico, Rome, Italy. Objective. Radical hysterectomy with systematic pelvic lymphadenectomy is the standard treatment of FIGO stage IB cervical cancer. Recently, the pathological status of pelvic nodes assessed by intraoperative frozen-section analysis (IFSA) has been shown to predict parametrial status reliably. In node-negative patients the risk of parametrial involvement is about 2%. We report the preliminary results of a pilot study evaluating the feasibility and safety of modulation of surgery based on intraoperative assessment of pelvic

nodal status. Methods. Eligible patients were submitted to systematic lymphadenectomy of obturator superficial, external iliac, and interiliac nodal groups. Node-negative patients upon IFSA underwent a type I or II radical hysterectomy (RH), and positive-node patients underwent a type III–IV radical hysterectomy with completion of pelvic lymphadenectomy up to the common iliac nodes. Diagnostic accuracy of IFSA, operative data, complications, and pattern of relapse were recorded. Results. From November 1997 to July 2001, 70 women (median age 52 years, FIGO stage IA2: 13; IB1:57) were enrolled into the study. Seventeen (24%) patients were positive at IFSA and underwent a type III–IV RH plus systematic pelvic lymphadenectomy, 53 were negative at IFSA and underwent a type I (13) or a type II (40) RH. A median number of 16 (range 9 –34) nodes were counted at IFSA. The sensitivity, specificity, and negative predictive values of IFSA were 94, 100, and 97%, respectively. In patients submitted to type I and II RH a remarkable reduction in operative time, estimated blood loss, postoperative stay, and complications was observed. After a median follow-up of 26 months (range 2– 43), the 2-year DFS of patients submitted to type I–II and type III–IV RH was 96 and 91%, respectively. Conclusions. Radical hysterectomy and pelvic lymphadenectomy may be tailored on the basis of intraoperative assessment of pelvic nodal status. These results must be confirmed by longer follow-up and a larger number of patients.

126. Telomerase Activity and hTERT Gene Expression Increase with Dysplastic Cervical Change. David M. Boruta II, Karen A. Moller, Chunxiao Zhou, and John F. Boggess. University of North Carolina, Chapel Hill, North Carolina. Objective. Telomerase activation is important in cellular immortalization and carcinogenesis. Reports utilizing the TRAP assay, which suggest that telomerase activity increases as the grade of cervical dysplasia worsens, may be limited by the assay’s poor sensitivity. Because hTERT gene expression is the rate-limiting determinant of telomerase enzyme activity, its measurement may allow for improved detection of telomerase. We quantified hTERT gene expression in cervical biopsy specimens using an extremely sensitive real-time PCR technique. TRAP assays were also performed and the results of both were examined with respect to grade of dysplasia. Methods. Colposcopically directed biopsy specimens were obtained from visible cervical lesions in 37 women at the time of referral evaluation for abnormal screening cytology. Telomerase enzyme activity was measured using a commercially available TRAP assay. The hTERT mRNA copy number was determined using a real-time PCR assay developed in our lab. Copy number was standardized to total RNA. Results were stratified according to histologic findings. Results. Median (range) telomerase activity by TRAP assay was as follows: specimens with no CIN, 0.8 (0 –230); CIN 1, 0.75 (0 –30.2); CIN 2, 3.0 (0 –310); and CIN 3/carcinoma, 74.9 (13.2– 439) TPG units. The median hTERT copy number was as follows: specimens with no CIN, 0.005 (0 – 0.36); CIN 1, 0.021 (0 – 0.19); CIN 2, 0.024 (0 – 0.26); and CIN 3/carcinoma, 0.039 (0 – 0.29). Median telomerase activity and hTERT copy number were higher in specimens with dysplasia or changes indicative of HPV infection when compared to specimens without these histologic findings [6.7 (0 – 439) vs 0.8 (0 –230) TPG units and 0.024 (0 – 0.29) vs 0.0012 (0 – 0.36), respectively]. Conclusion. These are the first reported measurements of hTERT mRNA copy number in cervical epithelium using an ultrasensitive, real-time PCR technique. Similar to the trend seen with telomerase activity using the TRAP assay, hTERT mRNA is detectable in biopsy specimens with increasing copy number as the grade of dysplasia worsens. The presence of hTERT expression and telomerase activity in specimens lacking any histologic change indicative of HPV infection or dysplasia is of special interest and will be the subject of further research.

127. Hematologic Toxicity in Gynecologic Malignancies. Patients Treated with Intensity-Modulated Pelvic Radiation Therapy. Clark Brixey, John Roeske, Jacob Rotmensch, Steve Waggoner, Diane Yamada, and Arno J. Mundt. University of Chicago, Chicago, Illinois.

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS Objective. Hematologic toxicity (HT) is common in gynecology patients treated with concomitant chemotherapy (CTX) and whole pelvic radiation therapy (WPRT). HT may limit the dose of CTX delivered and, if severe, prevents the delivery of CTX and protracts radiation therapy (RT). HT is not surprising given the large volume of bone marrow (BM) within the pelvis encompassed in the WPRT fields. Intensity-modulated RT (IMRT) is a novel approach which conforms the radiation dose to the shape of the target tissues, reducing the volume of normal tissues irradiated. Recent data have shown that intensity-modulated WPRT (IMWPRT) minimizes the volume of small bowel irradiated and the severity of bowel toxicity in gynecology patients. The purpose of this study is to evaluate whether IMWPRT reduces the volume of pelvic BM irradiated and the severity of hematologic toxicity in gynecology patients. Methods. A total of 124 pts (68 cervix, 54 uterine, 2 other cancers) received pelvic RT (45 Gy in 1.8-Gy daily fractions) (88 WPRT, 36 IMWPRT). Target tissues included the tumor (or bed), parametria, presacral region, and pelvic lymph nodes (to the L4 –L5 interspace) in both groups. WPRT was delivered with a four-field “box” approach and IMWPRT with nine coplanar fields. Thirty-six patients (16 IMWPRT, 20 WPRT) received CTX (cisplatin, 40 mg/m 2/week). No differences were seen in clinical features between the two groups. HT was scored using NCI toxicity criteria. The volume of pelvic BM was calculated in a sample patient with both WPRT and IMWPRT. Results. Twenty-seven patients developed grade ⱖ2 WBC toxicity. Grade ⱖ2 WBC toxicity was more common in RT ⫹ CTX patients (46% vs 11%, P ⬍ 0.0001) than RT-alone patients. In RT-alone patients, grade ⱖ2 WBC toxicity was seen in 11 and 10% of the WPRT and IMWPRT patients (P ⫽ 0.78). In RT⫹CTX patients, grade ⱖ2 WBC toxicity was more common in patients receiving WPRT (60 vs 31%, P ⫽ 0.08) than IMWPRT. Median WBC nadirs were 2.8 and 3.6 in the WPRT and IMWPRT patients receiving CTX (P ⫽ 0.05). Corresponding ANC nadirs were 1874 and 2669 (P ⫽ 0.04). While platelet and hemoglobin toxicities were less common in the IMWPRT patients, the differences did not reach statistical significance. The percentage volume of pelvic BM irradiated to the prescription dose was higher with WPRT (68 vs 32%) than IMWPRT in the sample patient. Conclusion. IMWPRT reduces the volume of pelvic BM irradiated and the risk of HT. IMWPRT may improve the tolerance of concomitant CTX and allow higher CTX doses to be delivered in these patients.

128. Self-Assessment for Human Papillomavirus DNA Is a Feasible Method for Cervical Cancer Screening in a Nongynecological Outpatient Population—Preliminary Results. Christian Dannecker, Christian J. Thaler, David Kiermeir, Rainer Kimmig, Hermann Hepp, and Peter Hillemanns. Department of Obstetrics and Gynecology, University of Munich– Gro␤hadern, Munich, Germany. Objective. The aim of this study was to evaluate prospectively the feasibility of self-assessment for human papillomavirus DNA (HPV) as a screening method for cervical neoplasia within a population of an outpatient clinic for internal medicine. Methods. For self-collection of HPV tests, 560 women were asked to insert a cytobrush into the vagina and then to place it into a specimen collection tube. Instructions were provided in a one-page leaflet. Recruitment of patients was carried out in an outpatient clinic for internal medicine. HPV testing was performed with the Hybrid Capture System II (Digene) which detects high-risk HPV types. Patients were asked to answer a standardized questionnaire. All HPV-positive and an appropriate number of HPV-negative patients were scheduled for follow-up (colposcopy, Pap smear, HPV testing, biopsy). Results. Of 560 recruited patients, 93 (17%) denied performing a self-assessment; for a further 5% self collection was not possible, resulting in a self-collection rate of 78%. High-risk HPV was detected in 134 patients (31%), indicating that patients of an internal medicine clinic should be considered a high-risk population for HPV. The mean age of HPV-positive and -negative patients was 44 and 48 years, respectively (not significant). The return rate of the questionnaires was 87%. The interim analysis evaluation of the questionnaires showed no statistical significant differences between the HPV-positive and -negative groups in respect to educational level, age of

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menarche and cohabitarche, number of sexual partners, use of oral contraceptives, smoking, having ever had a malignancy, and participating in a cervical cancer screening program on a regular basis. Follow-up was possible for 34 HPV-positive women: 13 patients (38%) had an abnormal colposcopy. Cytology was abnormal in 7 patients (21%): 5⫻ LSIL, 2⫻ HSIL. Histologically proven CIN was detected in 7/34 cases (21%): 5⫻ CIN 1, 2⫻ CIN 2. All of the HPV-positive and 88% of the HPV-negative patients considered HPV self-assessment easy to perform. Conclusion. Self-assessment for HPV DNA seems to be an easy, feasible, and well-accepted method of testing for HPV and cervical cancer. Since the majority of women see a doctor within a 3-year period, HPV self-assessment in a nongynecologic setting should be further evaluated to enhance attendance rates in countries with opportunistic screening. 129. Human Papillomavirus-like Particle Assay for Assessing Serologic Response to Cervicovaginal HPV 16, 18, and 45 Infection. Mark H. Einstein, Zhenya Studentsov, Morgan Marks, Gloria Ho, Anna Kadish, Patrick S. Anderson, Abbie L. Fields, Gary L. Goldberg, Carolyn D. Runowicz, and Robert D. Burk. Albert Einstein College of Medicine, Bronx, New York; and Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York. Objective. Antibodies to conformational epitopes on human papillomavirus (HPV) virions or synthetically produced virus-like particles (VLPs) develop in response to type-specific infection. It has been shown that persistent HPV infection is an independent risk factor for developing CIN. Most patients with persistent HPV infection eventually develop a type-specific antibody response. We evaluated the clinical utility of an HPV VLP ELISA for HPV 16, 18, and 45 antibodies and their association with CIN. Methods. HPV VLPs were produced using a baculovirus vector expressing the L1 open reading frame of HPV 16, 18, and 45 and VLPs were isolated by isopycnic centrifugation. Using these highly purified VLPs, an improved ELISA test was developed. Sera from cases with biopsy-confirmed CIN (n ⫽ 341) and controls (n ⫽ 351) with normal Pap smears and HPV DNA (-) by PCR analysis were tested for HPV 16, 18, and 45 VLP IgG antibodies. Log-transformed OD values for seropositivity cutpoints were determined from a panel of samples that were positive for HPV 16, 18, or 45 and a group of HPV negatives. Statistical analyses were performed using SAS software package. Results. A total of 177 (52%), 184 (54%), and 124 (36%) of 341 CIN cases were seropositive for HPV 16, 18, and 45, respectively. In contrast, 132 (38%), 131 (37%), and 81 (23%) of 351 controls were seropositive for HPV 16, 18, and 45, respectively (compared to seropositive CIN patients, P ⬍ 0.01). Antibody titers showed a strong association with disease status. However, there was no correlation between OD levels and severity of disease. Conclusions. These data suggest that three type-specific VLP assays show a correlation with the presence of CIN. High specificity for HPV VLP antibodies in the presence of CIN suggests that the HPV VLP reactivity may be a surrogate marker for persistent HPV infection. Women who are HPV DNA and VLP ELISA positive might represent a group with persistent HPV, which could be identified at a single visit. The use of HPV serology may have a clinical role in determining which HPV DNA positive patients require early intervention. (Supported by an ACOG/3M Pharmaceuticals Award in Lower Genital Tract Infections.) 130. Long-Term Complications of Concomitant Chemoradiotherapy for Locally Advanced Cervical Cancer. Mark H. Einstein, Bhupesh Parashar, Brij Sood, Noah Goldman, Gary L. Goldberg, Carolyn D Runowicz, Patrick A. Anderson, and Abbie L. Fields. Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, New York. Objectives. With the standard use of concomitant chemoradiotherapy (CRT) resulting in prolonged disease-free survivals, the evaluation of the late complications is timely. The objective of this study is to describe the long-term complications of CRT in the treatment of locally advanced cervical carcinoma. Methods. Charts of all patients (pts) with locally advanced cervical carcinoma treated with CRT from 1986 to 1994 at Albert Einstein College of Medicine

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and Montefiore Medical Center were reviewed. The data set included pt demographics, high risk factors associated with radiation complications (obesity, smoking, PID, diverticulosis, comorbid medical conditions), treatment field and dose, including parametrial boost (when appropriate), chemotherapy dose and delays, and chemotherapy complications. Late complications were defined as those occurring ⬎60 days after treatment. Toxicities were graded by standard ECOG criteria. Comparisons were made using ␹ 2 analysis. Results. Ninety pts were identified: 14 were lost to follow-up and 76 were eligible for evaluation. Of these, 34 died and 42 were NED (median follow-up of 6 years, range 2–15 years). Stage distribution was as follows: stage IB (14); stage II (24); stage III (30); and stage IVA (8). Twenty-five pts (33%) had a parametrial boost. Obesity was identified in 28/76 (37%), smoking in 36 (47%), history of PID in 3 (4%), diverticulosis in 3 (4%), and comorbid medical conditions in 24 (32%). Obese patients (BSA ⬎30) had a higher incidence of overall complications (P ⫽ 0.07). Except for obesity, there was no significant association noted between these risk factors and the late complication rate. Pts with one or more risk factors had a higher incidence of overall complications (P ⫽ 0.029). Nine late complications ([greater than or equal to]grade 3) occurred in 9 pts (11.8%). Complications included 3 pts with small bowel obstruction second to radiation fibrosis, 1 requiring surgery; 1 radiation-induced hemorrhagic cystitis; 1 long-term urinary retention second to urethral stricture, 3 pts with complex fistulae requiring surgical diversion, And 1 pt who developed radiation enteritis and pancreatitis. Conclusions. Obese pts have a higher incidence of late complications. The late complication rate in pts treated with CRT followed up to 15 years is acceptable and does not impact the survival benefit.

131. Evaluation of p27 Expression in Preinvasive and Invasive Malignancies of the Cervix. Barbara A. Goff, Joshua Salin, Garcia L. Rochelle, Amy Vanblaricom, Pamela J. Paley, and Howard G. Muntz. University of Washington School of Medicine, Seattle, Washington. Objective. p27 is a cell cycle inhibitor whose loss is commonly found in epithelial tumors. Low levels have been associated with poor prognosis. Our goal was to determine whether p27 expression could be used to screen for dysplasia and whether it is a prognostic factor for cervical malignancies. Methods. Ten normal cervices, 51 consecutive cone biopsies for preinvasive disease, and 128 consecutive hysterectomies for invasive cervical cancer (1994 –1999) were stained for p27 using standard immunocytochemical techniques. All of the cervical cancer patients were managed with radical hysterectomy and lymph node dissection except for 14 women who underwent adjuvant hysterectomy with lymph node sampling after chemoradiation. Results. There was no significant difference in p27 staining between normal cervices (all stained 4⫹) and preinvasive lesions (46/51 stained 4⫹ and 5/51 stained 3⫹). For the invasive lesions, 47 women had no residual disease in the hysterectomy specimen, due to prior cone biopsy (41) or radiation (6). All had 4⫹ p27 staining in the residual cervix. None of these women recurred. Eighty-one women had residual disease in the hysterectomy specimen; 25/81 (31%) had p27 staining of ⬍50%. Loss of p27 was not significantly associated with invasion ⬎50% (32% vs 27%), size ⬎4 cm (20% vs 13%), or use of postoperative radiation (36% vs 20%). Loss of p27 was associated with LVSI (44% vs 20%, P ⫽ 04). Only 4 women had nodal metastasis; all 4 had p27 staining less than 50%. Six of 81 (7%) women with residual disease developed recurrences and died. Of the women who died, 3/6 had p27 staining less than 50% (P ⫽ ns). Conclusion. p27 is not lost in preinvasive cervical lesions and therefore cannot be used to screen for dysplasia. In cervical cancers p27 staining was ⬍50% in 31% of cases and is associated with increased risk of LVSI. Perhaps because of the excellent overall survival of this group of women with stage I cervical cancer, loss of p27 staining was not associated with poor prognosis.

132. Does Histology Influence Prognosis in Early Stage Cervical Carcinoma? Dan Grisaru, Allan Covens, William Chapman, Patricia Shaw, Terence Colgan, Joan Murphy, Denny Depetrillo, Gordon Lickrish, Stephane

Laframboise, and Barry Rosen. University of Toronto, Toronto, Ontario, Canada. Objective. The aim of this study was to examine the influence of histology on the outcome of patients with surgically treated stage IA/IB carcinoma of the cervix. Method. All patient information was collected prospectively and was subsequently extracted from our cervical cancer surgery database. Selection criteria for surgery were based upon tumor size and were independent of histology. Adenocarcinomas were separated into two groups: mucinous/endometrioid (M/E AC), and adenosquamous/clear cell (AS/CC AC). Statistical analysis used the Wilcoxon rank, Mantel–Haenzel, and ␹ 2 tests and Cox regression analysis. Results. Between July 1984 and January 2000, 880 patients with stage IA/IB cervical cancer underwent radical surgery including pelvic lymphadenectomy as the primary treatment. A total of 255 patients had M/E AC (29%), 81 pts had AS/CC AC (9%), and 544 had SCC (62%). Compared to SCC, the M/E AC tumors had significantly more favorable prognostic characteristics: age (39 years vs 41 years, P ⬍ 0.03), depth of invasion (3.7 mm vs 5.5 mm, P ⬍ 0.001), vascular space involvement (24% vs 57%, P ⬍ 0.0001), grades 2/3 (40% vs 78%, P ⬍ 0.0001), and pelvic lymph node metastases (4% vs 8%, P ⬍ 0.04), respectively. AS/CC AC tended to be similar to SCC (or intermediate between M/E AC and SCC): age (38 years), depth of invasion (6 mm), vascular space involvement (40%), grades 2/3 (70%), and pelvic lymph node metastases (6%). The 2 -and 5-year recurrencefree survival was similar between M/E AC and SCC (95% vs 94% and 90% vs 90%, respectively); however, both were significantly superior to that of AS/CC AC (86 and 81%, P ⬍ 0.03 and P ⬍ 0.03). There were no differences in the pattern of first recurrence by histology. Conclusions. Surgically treated stages IA/IB M/E AC and SCC histology have a similar prognosis. For AS/CC AC patients, we feel that our results and the literature indicate sufficient evidence that these patients with uncommon histologies have an inferior recurrence-free survival. Although the optimal therapy is as yet undefined, there is no obvious rationale or evidence to alter the treatment strategies from those currently employed for M/E AC and SCC.

133. Comparison of Laparoscopic Assisted Radical Vaginal Hysterectomy and Radical Abdominal Hysterectomy for Early Cervical Cancer. Kenneth D. Hatch and Ina F. Steinmetz. University of Arizona, Tucson, Arizona. Objective. The aim of this study was to perform a comparison of laparoscopic assisted radical vaginal hysterectomy and radical abdominal hysterectomy for early cervical cancer with regard to operation, postoperative recovery and long-term patient outcome. Methods. We performed a clinical trial, nonrandomized prospective study. Between 1990 and 2001, 99 subsequent patients underwent a radical hysterectomy and lymph node dissection for early cervical cancer. Of these, 57 had a laparoscopic assisted and 42 an abdominal procedure. Age, Quetelet index, surgical risk, and histological type of tumor were similar in both groups. The percentage of stage IA tumors was significantly higher for patients undergoing abdominal surgery. Results. All procedures were completed. Operating time was significantly longer for laparoscopic assisted hysterectomies (244 ⫾ 8 vs 173 ⫾ 6 min, P ⬍ 0.0001). There was no difference in intraoperative complication rates or in PACU time. The estimated blood loss was significantly less for laparoscopic assisted procedures (472 ⫾ 41 cc vs 937 ⫾ 84 cc, P ⬍ 0.0001), as well as the rate of intraoperative transfusions (5% vs 26%). Significantly fewer patients underwent paraaortic lymphadenectomy as part of their procedure in the abdominal group, and the number of removed pelvic and paraaortic lymph nodes was significantly higher in the laparoscopy group. There was no difference in postoperative transfusion rates. Other postoperative complications were more common in the laparotomy group. Patients were discharged from the hospital significantly earlier following laparoscopic assisted hysterectomy (3.0 ⫾ 0.2 vs 5.7 ⫾ 0.5 days, P ⬍ 0.0001). Recurrence rates are not significantly different. Conclusions. Laparoscopic assisted radical vaginal hysterectomy for early cervical cancer is feasible. Although it still requires longer operating times, blood loss and

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS hospital stay are significantly reduced. Long term follow-up by randomized studies is necessary.

134. Promoter Hypermethylation of Multiple Genes in Carcinomas of the Uterine Cervix. Hy-Sook Kim and Seung M. Dong. Department of Otolaryngology–Head and Neck Surgery, Head and Neck Cancer Research Division, Johns Hopkins University School of Medicine, Baltimore, Maryland; and Department of Pathology, Samsung Cheil Hospital, Sung Kyun Kwan University College of Medicine, Seoul, Korea. Objective. Promoter hypermethylation is an important pathway for the repression of gene transcription in cancer. Methods. We investigated promoter hypermethylation of six genes, p16, APC, HIC-1, death-associated protein kinase (DAPK), O6-methylguanine-DNA-methyltransferase (MGMT), and Ecadherin, in uterine cervical carcinoma from 53 patients including 31 cases of squamous cell carcinoma (SCC) and 22 cases of adenocarcinoma (AC). Results. Aberrant methylation of at least one of these genes was detected in 79% (42/53) of cases including 71% (22/31) of SCC and 91% (20/22) of AC cases. No aberrant methylation was detected in normal cervical tissue from 24 control hysterectomy specimens. There was no correlation between promoter hypermethylation at any gene and the presence of HPV16 or HPV18 E7 DNA. In AC cases, promoter hypermethylation of the APC and HIC-1 genes was detected at a statistically significant higher frequency than in the SCC cases: APC (60% vs 13%, P ⬍ 0.001), HIC-1 (63% vs 32%, P ⬍ 0.03). Conversely, promoter hypermethylation of p16 and DAPK was more common in SCC cases than in AC cases. Conclusions. Our results suggest that promoter hypermethylation is a frequent epigenetic event in cervical carcinoma. The pattern of gene promoter hypermethylation is distinctly different between AC and SCC. The absence of these epigenetic alterations in normal cervical tissue suggests that they may also be valuable as cancer markers.

135. Prevalence of Cervical Intraepithelial Neoplasia and HPV in HIV patients with ASCUS Pap Smears. Tyler O. Kirby, Warner K. Huh, Craig Hoesley, M. Elaine Allen, J. Michael Straughn, Ronald D. Alvarez, and Santosh Niwas. University of Alabama–Birmingham, Birmingham, Alabama. Objective. The purpose of this study is to characterize various degrees of cervical dysplasia and analyze the prevalence of HPV in a group of HIVseropositive women with ASCUS Pap smears. Methods. Since 1996, a cohort of 200 HIV-infected women was prospectively followed at a university HIV clinic. These patients underwent biannual Pap smears with cervicovaginal lavage and HPV typing, physical examinations, and blood sampling. Eightynine women with ASCUS smears during the follow-up period were selected for this study. HPV DNA typing, CD4 count, plasma HIV RNA titer, type of anti-retroviral therapy, and rates of progression and regression of cervical cytology were recorded. Thirty-nine patients had colposcopy and indicated biopsy within 6 months of an ASCUS Pap. Results. In 39 patients, colposcopy and biopsy revealed a normal exam or negative histology in 59% (23) of patients, 28% (11) with CIN1, 7.7% (3) with CIN2, and 5.1% (2) with CIN3. The combined prevalence of CIN2/3 was 12.8%. Only 2 of the 89 patients progressed to HGSIL while 52 of 89 (58%) patients regressed to normal cytology. HPV typing revealing HPV prevalence at the time of ASCUS Pap was 78%, with 56% of these having multiple HPV types. This cohort was a well-controlled HIV population with only 34% having a CD4 ⬍300 and 28% with an HIV RNA titer of ⬎10,000 at last evaluation. A trend of regression of ASCUS to normal was more likely with CD4 counts ⬎300 and RNA titers ⬍10,000. Conclusions. Recent data on HIV negative patients suggest reflex HPV testing in ASCUS with subsequent colposcopy for HPV positivity due to the high rate of CIN2/3. This study demonstrates a high prevalence of HPV, thus negating the usefulness of HPV screening. Also, although having an increased prevalence of ASCUS cytology, the rate of clinically significant CIN2/3 appears to be the same as in the HIV-negative population.

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136. Identification of Micrometastases in Histologically Negative Lymph Nodes of Early Stage Cervical Cancer Patients. Scott E. Lentz, Jennifer J. Dizon, Laila I. Muderspach, Juan C. Felix, and Charles A. Amezcua. University of Southern California School of Medicine, Los Angeles, California. Objective. Despite histologically negative lymph nodes, approximately 15% of patients with early stage cervical cancer will develop recurrence. Micrometastases have been shown to be important in staging and treatment of breast cancers and melanoma and have been identified by PCR analysis in cervical cancers. This study sought to determine the frequency of micrometastases identified by immunohistochemistry in histologically negative lymph nodes and compare this to other known risk factors for recurrence of cervical cancer. Methods. Early stage (stage 1A1–2A) cervical cancer patients were selected from the surgical logs of the LAC⫹USC Medical Center Division of Gynecologic Oncology for the period 1994 –2000. One hundred thirty-three (133) patients were identified as having histologically negative lymph nodes. Immunohistochemical assay was performed on 3097 lymph nodes using an antibody against cytokeratin AE-1 and CAM 5.2 in combination according to standard protocols. The stained nodes were then evaluated for the presence of micrometastases and compared against the respective clinicopathologic information in each case. Results. Micrometastases were detected in 19 of 133 (14%) patients and found in 29 of the 3097 (0.9%) lymph nodes evaluated. Vascular space invasion was seen in 50 of 133 cases (38%) and in 7 of 19 (37%) cases with micrometastases. Surgical margins of the resected specimen were negative in 123 of 133 cases (92%) and in 17 of 19 (89%) of those cases with micrometastases. The number of lymph nodes removed did not appear to differ between those cases with micrometastases (mean 14.6; range 4 – 61) and those without (mean 10.5; range 1– 63). The mean tumor volume of positive cases (13,445 mm 3; range 70 –30,000 mm 3) was no different than in negative cases (mean 12,965 mm 3; range 50 –94,500 mm 3). Micrometastases were seen most frequently in pelvic lymph nodes (26/29, 89%). Conclusions. Micrometastases are identifiable in histologically negative lymph nodes in 14% of early stage cervical cancer patients, a frequency which approximates the recurrence rate for patients with negative nodes. There appears to be no relationship between the number of nodes sampled or tumor volume in identifying micrometastases. While micrometastases can be identified in histologically negative lymph nodes, their presence is not highly associated with other known factors of cervical cancer recurrence. 137. Isolation of Human Papillomavirus Type 18 Genomic Integration Sites in Squamous Cell Carcinoma of the Cervix. Richard G. Moore, Emmanuel N. Soultanakis, John Pepperrel, Michael A. Steller, and Umadevi Tantravahi. Women and Infants’ Hospital/Brown University, Providence, Rhode Island. Objective. The aim of this study was to identify human genomic integration sites of human papillomavirus type 18 (HPV-18) and map the junction fragment sequence and chromosomal location in squamous cell carcinoma of the cervix. Methods. Fresh-frozen tissue samples from two patients with squamous cell carcinoma of the cervix were obtained. DNA was extracted from the tissue samples and Southern blot analysis was performed to confirm the presence of HPV-18. The genomic DNA was digested with the EcoRI restriction enzyme to produce fragment sizes ranging from 9.0 to 20 kb. Human genomic libraries were created with the DNA fragments utilizing a lambda phage cloning kit. The phage libraries were screened using a complete HPV-18 radiolabeled probe to identify phage plaques that contained the genomic–viral DNA inserts. Positive phages for HPV-18 sequences were plaque purified. The lambda DNA was isolated, restriction mapped, and further subcloned, and the fragments of interest were sequenced. The junctional genomic sequences flanking the HPV-18 inserts were then compared to the human genome database to map the location of these genomic sequences. Corresponding bacterial artificial chromosome clones were identified from the human genome databases and used in fluorescent in situ suppression hybridization (FISH) analysis to confirm the chromosomal location. Results. Two unique human

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genomic/HPV-18 containing inserts from two primary cervical squamous cell carcinomas were isolated. Sequence analysis using the human genome project databank mapped the two inserts to chromosome 4 and 14. This was confirmed through FISH analysis. The flanking sequences for the two inserts were completely sequenced and did not disrupt any known oncogenes. Conclusion. HPV-18 integration into the human genome does not appear to involve any known human genes. The insertion points seem to take place in A–T-rich domains. Further investigation of these two insertion sites is being performed to determine whether these integration sites occur at random or are shared in other HPV-18-positive cervical carcinomas. 138. Major Complications Associated with Cisplatin Radiosensitization for the Treatment of Cervical Carcinoma. Wilberto Nieves-Neira, Nicholas Lambrou, Katie Davis, Giselle Ghurani, Luis Mendez, Ramin Mirhashemi, Aaron Wolfson, and Manuel Penalver. University of Miami School of Medicine, Miami, Florida. Objective. The aim of this study was to evaluate major complications associated with the use of cisplatin radiosensitization for the treatment of cervical carcinoma. Methods. A retrospective analysis of consecutive patients undergoing radiation treatment for cervical carcinoma at the University of Miami between 1/1998 and 12/2000 was performed. Patients who received radiation only or cisplatin radiosensitization either for primary treatment or adjuvant treatment were included. ␹ 2 statistics and Fisher’s exact test were calculated for comparisons. Results. A total of 75 patients were identified. Thirty-eight (51%) patients received radiation alone and 37 (49%) had concurrent cisplatin (40 mg/m 2 weekly) for radiosensitization. The median number of cisplatin cycles was 5. Major complications were defined as fistula formation, radiation proctitis or cystitis requiring blood transfusion or hospital admission for intervention, and small bowel obstruction not responding to conservative management. Nine patients in the chemoradiation group had major complications compared to 3 patients in the radiation-only group (P ⫽ 0.06). Patients who received chemoradiation had a significant increase in the total number of major complications as well as the number of admissions for these complications (P ⫽ 0.02 and P ⫽ 0.03, respectively). There was no significant difference in minor complications (anemia, urinary complaints/ retention, nausea/vomiting). There was no significant difference in the complication rate between primary treatment and adjuvant treatment. Conclusion. Radiosensitization with weekly cisplatin was associated with an increased number of major complications. Further analysis will be performed to identify subgroups of patients at increased risk for major complications. 139. Anemia before and during Concurrent Chemoradiotherapy in Patients with Cervical Carcinoma. Effect on Progression-Free Survival. Andreas Obermair, Robyn Cheuk, Keith Horwood, Martin Neudorfer, Monika Janda, James L. Nicklin, Lewis C. Perrin, and Alex J. Crandon. Center for Public Health Research, Queensland University of Technology, Kelvin Grove, Brisbane, Australia; Queensland Radium Institute, Herston, Brisbane, Australia; Royal Brisbane Hospital, Herston, Brisbane, Australia; Royal Womens Hospital, Herston, Brisbane, Australia; and University Hospital Vienna, Vienna, Austria. Objective. Anemia is associated with an impaired outcome in patients undergoing radiation therapy for cervical carcinoma [1]. Patients undergoing chemoradiation have an impaired response to treatment if they become anemic during treatment [2] but no data are available regarding the influence of anemia on the prognosis of these patients. The aim of this study was to examine the impact of anemia before and during chemoradiation on progression-free survival (PFS). Methods. We collected data on hemoglobin (Hb) levels before and during treatment from 62 unselected patients with cervical carcinoma FIGO stage IB to IVA treated at the Queensland Centre for Gynaecological Cancer between 1/1996 and 3/2001. All patients were treated with concurrent chemoradiation with the aim of cure. PFS was evaluated by univariate and multivariate analyses. Hb values were dichotomized and the lower quartile (Q1) was used as the cutoff level. Results. After a median follow-up of 18.7

TABLE 1—ABSTRACT 139 Multivariate Cox Model with Regard to Progression-Free Survival in 62 Patients with Concurrent Chemoradiation for Cervical Carcinoma

Covariates Stage (IB, IIA vs IIB vs III, IVA) Hb nadir (continuous) Parametrial involvement (none vs unilateral vs bilateral)

Odds ratio

95% confidence interval

P value

4.62 0.63

1.6 to 13.0 0.4 to 0.9

0.004 0.028

1.42

0.5 to 4.0

0.512

months, 13 patients developed disease progression. The lowest Hb during chemoradiation (nadir Hb), stage of disease, and parametrial involvement were significantly associated with shortened PFS. The Hb before treatment, tumor size, histological grade, and cigarette smoking were prognostically not relevant. On multivariate analysis, the nadir Hb [continuous] (relative risk [RR] 0.63), and tumor stage [IB,IIA vs IIB vs III,IVA] (RR 4.6) remained the only prognostically relevant factors predicting PFS. At 30 months the PFS was 23.6% for anemic patients (nadir Hb ⱕ 9.4 g/dL) and 78.9% for nonanemic patients (Hb nadir ⬎9.4 g/dL) (P ⬍ 0.0002). Conclusions. In patients undergoing chemoradiation for cervical carcinoma, a low nadir Hb is highly predictive of shortened PFS, whereas the Hb before treatment is prognostically not significant (Table 1). References. 1. Grogan et al. Cancer 1999;86:1528 –36; 2. Obermair et al. Cancer 2001;92:903– 8. 140. Treatment Failure in Stage IIB Cervical Carcinoma with High Risk Factors after Concurrent Chemotherapy and Radiotherapy. Tchan K. Park, Sang W. Kim, Ja Y. Kwon, Jin R. Roh, Soo N. Kim, Gwi E. Kim, and Chang O. Seo. Department of Obstetrics and Gynecology, Kunkuk University College of Medicine, Seoul, South Korea; and Department of Obstetrics and Gynecology and Department of Radiation Oncology, Yonsei University College of Medicine, Seoul, South Korea. Purpose. The aim of this study was to evaluate treatment failure in stage IIB cervical carcinoma patients with high risk factors treated by concurrent chemotherapy and radiotherapy. Methods. A retrospective analysis of 359 stage IIB cervical carcinoma patients with at least one of the high risk factors (lesion size ⱖ4 cm, lymph node metastasis on CT or MRI, small cell carcinoma, adenocarcinoma or adenosquamous cell carcinoma) treated with cisplatinbased concurrent chemotherapy and radiotherapy at Yonsei University College of Medicine from 1989 to 1999 was performed. Sites of recurrence were categorized as central, pelvic, pelvic plus distant, and distant alone. Central recurrence was defined as recurrence in the area of the uterus, vagina, bladder, and rectum without involvement of the pelvic sidewall. Pelvic recurrence was defined as recurrent tumor limited to the pelvis and distant recurrence as tumor identified outside of the true pelvis. Results. The five-year disease-free survival rate was 75.6%. Forty-six patients (12.8%) had persistent disease and 33 patients (9.2%) recurred. The median interval from initial treatment to diagnosis of recurrence was 23.1 months (range 6.2– 89.0 months). Among 33 patients with cancer recurrence, central, pelvic, pelvic plus distant, and distant recurrences occurred in 27.3, 27.3, 15.2, and 30.3%, respectively. Distant recurrences most often involved the lymph nodes (15.2%), followed by the bone (6.1%), abdomen (6.1%), and lung (3.0%). Forty-three patients had small cell carcinoma, adenocarcinoma, or adenosquamous cell carcinoma. In these patients, 32.6% had persistent disease and 9.3% recurred. The incidence of persistent disease and disease recurrence in 280 patients with ⱖ4-cm tumor size was 13.9 and 10.7%. In 30 patients with ⱖ4-cm tumor size who had recurred, 30% had central recurrences, 26.6% pelvic, 16.7% pelvic plus distant, and 26.6% distant. In 103 node-positive patients, 17.5% (18 patients) had

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS persistent disease and 9.7% (10 patients) recurred, and of 10 patients, 20.0% had central recurrences, 20.0% pelvic, 20.0% pelvic plus distant, and 40.0% distant. Conclusion. The five-year disease-free survival rate in 359 patients treated with concurrent chemotherapy and radiotherapy was 75.6%, 12.8% had persistent disease, and 9.2% recurred. In this study, treatment failure rate and patterns were evaluated. 141. Prognostic Relevance of HPV-DNA in Primary Cervical Cancer and Cancer-Free Pelvic Lymph Nodes. Henryk F. Pilch, Berno Tanner, Marcus Schmidt, Uwe Schaeffer, Paul Knapstein, and Michael Hoeckel. Department of Obstetrics/Gynecology, University of Leipzig, Leipzig, Germany; and Department of Obstetrics/Gynecology, University of Mainz, Mainz, Germany. Objective. The aim of this study was to assess whether the presence of human papilloma virus (HPV) DNA and/or several genotypes of HPV DNA in primary cervical cancer and cancer-free pelvic lymph nodes is correlated with several clinicopathological parameters of well-defined prognostic significance and whether virological parameters are predictors of long-term survival in cancer patients. Methods. A total of 223 cases of cervical cancer patients included in this retrospective study underwent follow-up evaluation. Survival and cause of death were examined for 204 (91.4%) patients, with a mean follow-up time of 4.4 years. HPV DNA was detected using the high sensitive polymerase chain reaction (PCR) method followed by HPV DNA sequencing for HPV genotyping. These results were correlated with well-defined clinicopathological parameters and survival data. Results. HPV DNA was detected by PCR in 150 of 203 (73.4%) tissue specimens of cervical cancer patients. DNA sequence analysis revealed the presence of HPV 16 (n ⫽ 68, 45.3%), HPV 18 (n ⫽ 49, 32.6%), and rare HPV types (n ⫽ 33, 22.1%). HPV genotypes correlated significantly with histological tumor types, node status, blood vessel invasion, and lymph space involvement. The presence of HPV DNA in cervical cancer as well as the genotype of HPV 16 could also be confirmed as significant prognostic factors in univariate Cox regression analysis (RR 2.856, P ⬍ 0.003 resp. RR 3.444, P ⬍ 0.0001). The presence of HPV DNA in cancer-free pelvic lymph nodes was significantly correlated to the concomitant manifestation of pelvic lymph node metastases (RR 3.1, P ⬍ 0.0001). In multivariate analysis, however, HPV DNA in primary tumors and in negative pelvic lymph nodes failed to be of prognostic relevance. Exclusively, HPV 16 appears to impact independently on the overall survival in cervical cancer patients (RR 3.653, P ⬍ 0.002). Conclusion. The detection of HPV 16 genotype may play an important adjunct role in assessing the prognosis of cervical cancer patients. The clinical impact of the presence of HPV DNA in primary tumors and cancer-free pelvic lymph nodes remains to be investigated in further studies. The exact mechanisms by which HPV influence the prognosis of cervical cancer patients must be defined. 142. DNA Ploidy as a Prognostic Factor in Surgically Treated Cervical Cancer. Olaf J. Reich Jr., Peter P. Pu¨ rstner Jr., Phillip P. Klaritsch Jr., Josef J. Haas Jr., Manfred M. Lahousen Jr., Karl K. Tamussino Jr., and Raimund R. Winter Jr. University of Graz, Graz, AA Austria. Objective. The aim of this study was to analyze the impact of DNA ploidy level on the 5-year recurrence rate in patients with cervical carcinomas treated with radical surgery. Methods. Sixty-four patients (mean age 50 years, range 19 –76; 31 FIGO stage IB, 12 stage IIA, 16 stage IIB, 5 stage III; 53 squamous cell carcinomas, 7 adenosquamous carcinomas, 4 adenocarcinomas) were analyzed. Flow cytometry was performed with multiple samples of fresh tumor tissue. For controls, tumor tissue slides were stained with hematoxylin and eosin. The following DNA-types were differentiated: diploid, DNA index: 0.97–1.03; near-diploid, DNA index: 0.90 –⬍0.97 and ⬎1.03–1.1; tetraploid, DNA index: 1.94 –2.06; near-tetraploid, DNA index: 1.8 –⬍1.94 and ⬎2.06 – 2.2; aneuploid, DNA index: ⬎1.1–⬍1.8 and ⬎2.2; and hypoploid, DNA index: ⬍0.9. For statistical evaluation tumors were classified as DNA-low-grade (diploid, near diploid, tetraploid, and near-tetraploid carcinomas) or DNAhigh-grade (aneuploid and hypoploid carcinomas). The mean follow-up of

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patients was 3.4 (0.3–9.8) years. Results. Of 64 carcinomas, flow-cytometry showed 9 diploid, 7 near-diploid, 7 tetraploid, 12 near-tetraploid, 25 aneuploid, and 4 hypoploid carcinomas. Patients with DNA-low-grade carcinomas had a significantly lower 5-year recurrence rate than patients with DNA-high-grade tumors (82% vs 45%, P ⫽ 0.02). No statistical relation was found between the ploidy patterns and tumor type, tumor stage, tumor grade, and status of the lymph nodes. Conclusions. DNA ploidy is of prognostic relevance in cervical cancer. Thus, DNA ploidy may be used for the identification of low-risk and high-risk patients within a given stage. 143. Sentinel Node Identification in Uterine Cervix Cancer Stage I. A Pilot Study. Lukas Rob, Marek Pluta, Pavel Strnad, Helena Robova, Martin Charvat, and Dana Schlegerova. Department of Obstetrics and Gynecology and Department of Pathology, Faculty Hospital Motol, Charles University Prague, Prague 5-Motol, Czech Republic. Objective. The aim of this study was to determine the utilization and usefulness of intraoperative lymphatic mapping and sentinel node identification (SNI) in stage I uterine cervix cancer. Methods. In our study 65 patients with cervical cancer were included. There were 12 patients undergoing laparoscopic SNI as a part of conservative treatment (2 stage IA2, 10 stage IB1) and three groups of patients after Wertheim radical hysterectomy (WRH): group A, 13 patients (stage IB1 less than 20 mm), group B, 20 patients undergoing WRH (stage IB1 more than 20 mm), and group C, 20 patients undergoing WRH after three cycles of neoadjuvant chemotherapy stage (NAC) (stage IB2). Immediately after laparoscopic or laparotomic visualization of the pelvis, all patients underwent an intracervical instillation of blue dye (PatentBlau V 2.5%), 4 ccm, at four different sites (9, 12, 3, and 6 o’clock) on the periphery of the lesion. We carefully inspected the lymphatic channels and SN and performed a histopathology examination of preoperative frozen section (FS) of all SN. Finally, complete pelvic lymphadenectomy was done (9 laparoscopies as a part of conservative surgery and 56 laparotomies). Results. There were no false-negative results. In 12 patients undergoing the laparoscopic procedure we detected SN in 11 cases (detection rate, 92%). Three FS were positive; in these cases we immediately performed WRH type III. In group A patients after WRH, SN were identified in 11 cases (85%), in group B in 16 cases (80%), and in group C in 12 cases (60%). Visualization is difficult after NAC due the modified dye uptake into the lymphatic channels. Adverse effects were as follows: all patients had blue discoloration of the urine and artificially modified levels of oxygen blood saturation measured by percutaneous pulse oxymetry and 1 patient had an anaphylactic reaction with circulatory collapse (possibly due to antibiotics administered iv at the time of dye administration). Conclusions. Lymphatic mapping at FS of SN is a new strategy for preoperative examination of nodal status. Our pilot study suggests a high performance rate in the group of patients treated by laparoscopy, a good performance rate in the group with “small”–IB1 stage tumors, and a low rate of identification in the group of patients with “bulky” tumor after NAC. The technique and timing of the intracervical injection of dye is very important. The present study supports the concept of SN detection in small cancers of the uterine cervix, especially in the management of conservative surgery. 144. A Randomized, Phase III Study of Oral Isotretinoin or Observation for Low-Grade Squamous Intraepithelial Lesions of the Cervix in Human Immunodeficiency Virus-Infected Women. William R. Robinson III, Janet Andersen, Teresa Darraugh, Michelle Kendall, Rebecca Clark, and Mitchell Maiman. Harvard School of Public Health, Statistical and Data Analysis Center, Boston, Massachusetts; Louisiana State University Medical Center, New Orleans, Louisiana; Staten Island University Hospital, Staten Island, New York; Texas Tech University/Harrington Cancer Center, Amarillo, Texas; and University of California, San Francisco, San Francisco, California. Objective. The aim of this study was to determine the efficacy of oral isotretinoin for the prevention of progression of low-grade squamous intraepithelial lesions (LSIL) of the cervix to high-grade lesions (HSIL) or invasive

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SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS

cervical cancer in human immunodeficiency virus (HIV)-infected women. We also wanted to determine the rate of regression of LSIL with isotretinoin and the toxicity of isotretinoin in this setting and to correlate serum CD4 levels with progression of LSIL. Methods. A randomized, two-armed, phase III, observation-controlled, multicenter trial was performed in which 117 HIVinfected women with LSIL of the cervix received either oral isotretinoin at 0.5 mg/kg for 6 months or observation. Papanicolaou smears and colposcopy/ biopsy were performed at regular intervals during follow up. The primary endpoint was progression to HSIL or cervical cancer. Results. Twenty-one of 102 women (20.6%) completing follow-up experienced progression to HSIL, 13 in the observation group and 8 in the isotretinoin group. This difference was not significant (P ⫽ 0.29). No cases of invasive cancer were seen. Twentyseven of 79 (34.2%) women with postbaseline biopsies showed resolution of SIL. Baseline CD4 levels were lower than anticipated (median-329 cells/mm 3), but did not change over time. CD4 levels were not associated with time to progression (P ⫽ 0.36). One hundred of 114 (88%) women reported Karnofsky performance status of 90 –100. Most subjects (63/102, 61.7%) used highly active antiretroviral therapy (HAART), and almost all (108/114, 95%) used some anti-retroviral agent. Subjects under 30 years of age were more likely to progress than those older than 30 (P ⫽ 0.046). Conclusion. Oral isotretinoin was not associated with longer time to progression of LSIL. In HIV-infected women using HAART, LSIL appears to be a chronic condition. The risk of progression and rate of resolution is similar to that seen in the general population. Observation of LSIL in HIV-infected women for up to 24 months without excisional therapy may be considered.

145. Efficacy of Teleconsultation in Colposcopy. Michel Roy, Yan Ansquer, Renzo Barasso, Lou Benedet, Jean-Claude Boulanger, Daniel Dargent, D. Ferris, M. Marien, and Isabelle Bairati. Hospital Edouard Herriot, Lyon, France; L’Hotel-Dieu de Que´ bec, Quebec, Canada; and Vancouver Hospital, Vancouver, Canada. Objective. The aim of this study was to validate the transfer of colpophotographs via e-mail in obtaining a teleconsultation in colposcopy. Method. For each of 100 patients attending a colposcopy clinic, between four and six colpophotographs of the cervix at different magnifications were sent to four experienced colposcopists by e-mail, using the DIMS program. Their colposcopic evaluations (normal, LGSIL, HGSIL, cancer) were compared with the results of the initial colposcopic evaluation and the final histopathology (biopsy, loop excision) or control cytology done at the time of the examination. Agreement between the consultants and the initial colposcopist was evaluated using the weighted kappa. The sensitivity and specificity of colposcopic exam (normal vs abnormal) for detecting abnormal pathology (SIL, cancer) were estimated for each colposcopist. Results. Using colposcopic impression of the initial examination as the reference, the overall weighted kappa coefficient was 0.77 (95% CI ⫽ 0.72– 0.82). The weighted kappa statistics corresponding to the evaluation of each consultant were, respectively, 0.84, 0.81, 0.76, and 0.60. When histopathology or cytology was used as the reference, the overall weighted kappa coefficient was 0.64 (95% CI ⫽ 0.59 – 0.70). Sensitivities for detecting cervical lesions using colposcopy varied between 0.75 and 0.91, while specificities varied between 0.67 and 0.79. Conclusions. The evaluation of colpophotographs sent by e-mail seems to be valuable for teleconsultation, since there is agreement between colposcopists in close to 80%. Not only can teleconsultation reduce the number of patient transfers for actual colposcopic consultation, but also it could be part of a quality-control process for colposcopic centers and objective evaluation of research program in intraepithelial neoplasia of the lower genital tract.

146. A Comparison of Stage IB1 vs IB2 Cervical Cancers Treated with Radical Hysterectomy. Is Size the Real Difference? Teresa L. Rutledge, Scott Kamelle, Todd D. Tillmanns, David E. Cohn, Jason D. Wright, Janet S. Rader, Thomas J. Herzog, Michael A. Gold, Gary A. Johnson, Joan L. Walker, Robert S. Mannel, and D. Scott McMeekin. University

of Oklahoma Health Science Center, Oklahoma City, Oklahoma; and Washington University School of Medicine, St. Louis, Missouri. Objective. The aim of this study was to compare stage IB1 and IB2 cervical cancers treated with radical hysterectomy (RH) and to define predictors of nodal status and recurrence. Methods. Patients with stage IB cervical cancers undergoing RH between 1990 and 2000 were evaluated and clinicopathological variables were abstracted. The perioperative complication rate, estimated blood loss, and OR time were also tabulated. Variables were analyzed using ␹ 2 and t tests. Disease-free interval (DFI) was calculated by the Kaplan–Meier method. Multivariate analysis was performed via stepwise logistic regression. Cox proportional hazards were used to identify independent predictors of recurrence. Results. RH was performed on 109 stage IB1 and 86 stage IB2 patients. Mean age, EBL, and perioperative complication rates were similar. Overall, 38 patients (14 IB1 vs 24 IB2) had positive nodes (P ⫽ 0.01), including 9 patients with positive para-aortic nodes (2 IB1 and 7 IB2). Parametrial involvement (PI) and outer 2/3 invasion (DOI) were significantly more common in the IB2 tumors as well. Twenty-one IB2 patients received neoadjuvant chemotherapy; however, this did not significantly affect any of the pathologic variables. Patients with IB2 disease received postop radiation more frequently than IB1 patients (52% vs 37%, P ⫽ 0.04). Univariate predictors of nodal status included lymphovascular space involvement (LVSI) (P ⫽ 0.001), DOI (P ⫽ 0.011), PI (P ⫽ 0.001), and tumor size (P ⫽ 0.011). Logistic regression identified only LVSI (RR 6.4, CI 2.4 –17, P ⫽0.0002) and PI (RR 8,CI 3.1–20, P ⫽ 0.0001) as independent predictors of positive nodes. With a median follow-up of 25 months, estimates of DFI at 2 years revealed tumor size (P ⫽ 0.008), nodal status (P ⫽ 0.0004), LVSI (P ⫽ 0.002), PI (P ⫽ 0.004), and DOI (P ⫽ 0.0004) as significant univariate predictors. Neoadjuvant chemotherapy, age, grade, histology, and adjuvant radiation did not predict recurrence. The only significant independent predictor of DFI was LVSI (RR 5.7, CI 2–16, P ⫽ 0.0064). Neither tumor size nor nodal status was a significant predictor of DFI. Conclusions. RH for stage IB cervical cancers is reasonable therapy, regardless of tumor size. This report contains the largest comparison of IB1 vs IB2 patients managed by RH. Tumor size failed to predict recurrence or nodal status when stratified by LVSI, DOI, and PI. Treatment decisions based on tumor size alone should be reconsidered. 147. Characterization of Integration Junction Sequences from Human Papillomavirus-18 Infected Cervical Carcinomas. Emmanuel N. Soultanakis, Richard G. Moore, Michael A. Steller, and Umadevi Tantravahi. Women & Infants Hospital/Brown University, Providence, Rhode Island. Objectives. The association between carcinoma of the uterine cervix and human papillomavirus (HPV) infection is well established. The objective of this study was to isolate and characterize the integration sequences from HPV-18-containing cervical carcinomas. Methods. Recombinant DNA lambda clones containing HPV-18/genomic DNA were isolated and restriction mapped, and fragments of the isolated clones were subcloned into plasmids. DNA sequencing was used to localize the junction sequences of viral to genomic transition. Genomic sequences were compared to known sequences from the Human Genome project. The sequences were then analyzed for motifs consistent with DNA recombination events. Results. Integration sites from two primary cervical carcinomas were obtained. Analysis of the restriction maps and sequence of the isolates was used to determine the physical map of integrated HPV-18 DNA. One carcinoma contained integrated HPV-18 DNA from nucleotides 5245 to 2155. The second isolate included HPV-18 DNA from nucleotides 6137 to 1708. This preserved the E6 and E7 genes and contained a deletion of the E1, E2, E4, E5, and L2 genes. Analysis of the integration junction sequences, as well as the preintegration native sequences, revealed short stretches of nucleotide homology, AT- rich domains, topoisomerase I cleavage sites, and Pu–Py nucleotide domains. These motifs are consistent with the mechanism of nonhomologous recombination. Conclusions. We have successfully cloned the integrated HPV-18 genome with flanking genomic sequences from two primary cervical tumors. Deletion of the E2 gene and preservation of E6 and E7 are consistent findings in HPV-18

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS integration. Integration appears to occur through the event of nonhomologous recombination, which may be facilitated by mutations in DNA repair mechanisms. Integration of HPV DNA is an important event in carcinogenesis. HPV-18 DNA, unlike HPV-16, is found in integrated form in the majority of HPV-18-containing carcinomas. Understanding the mechanism and events that lead to HPV-18 integration will help us design preventative strategies, as well as predict tumor behavior and progression of disease. 148. Chemoradiation in Cervical Cancer with Cisplatin and High-Dose-Rate Brachytherapy Combined with External Beam Radiotherapy—A Phase II Study. Hans Strauss, Gabriele Haensgen, Juergen Dunst, and Heinz Koelbl. Department of Gynecology and Department of Radiotherapy, Martin-Luther-University Halle-Wittenberg, Halle, Germany. Objective. Several studies have demonstrated that chemoradiation has a benefit in locally advanced cervical cancer and in high-risk situations for surgically treated patients. Since April 1999 we evaluated the safety of concomitant chemoradiation with cisplatin in definitive as well as in adjuvant situations. The treatment schedule provided six courses of 40 mg/m 2 weekly cisplatin as recommended in the randomized studies GOG 120 and 123. Methods. Thirty patients were included in our prospective phase II: 13 patients with locally advanced stage II B–IV A, 14 adjuvant patients with stage pT1B1–pT2B following radical hysterectomy with parametrial infiltration of the tumor and/or positive pelvic lymph nodes, and 3 patients with pelvic recurrences without prior radiotherapy. Definitive radiotherapy was performed with a single dose of 1.8 Gy per fraction to a dosage of 45 Gy to point B (middle shielded after 11 fractions). Brachytherapy was delivered at high-doserate (HDR) schedules with 7 Gy to point A per fraction (total dose, 35 Gy) in locally advanced FIGO stage II B to III B. Patients with stage IV A were treated without brachytherapy. Adjuvant radiotherapy was performed with external beam radiotherapy of the pelvis with a 1.8-Gy single dose up to 50.4 Gy. Brachytherapy was delivered at high-dose-rate schedules with two fractions of 5 Gy only in patients with specimens lacking tumor-free margins or tumor involvement of the upper vagina. Results. Twenty of 30 patients (66.7%) completed all six courses of cisplatin chemotherapy. Discontinuation of radiotherapy due to toxicity was not necessary in the whole study group. Myelosuppression was the only relevant acute toxicity. Neither acute nephrotoxicity nor serious bowel symptoms occurred during treatment in the whole study group. Thirteen patients with locally advanced cervical cancer (II B–IV A) were evaluable for response to therapy so far and 12 of these patients (92.3%) showed complete clinical response. Thirteen of 14 adjuvant cases are free of recurrence with a median follow-up of 19.5 months (range 13–26 months); 1 patient progressed under therapy. Only 3 patients (10.0%) experienced late G3/G4 sequelae of chemoradiation (RTOG/EORTC score). Conclusion. Concomitant chemoradiation with 40 mg/m 2 of weekly cisplatin weekly ⫻6 using high-dose-rate brachytherapy represents a promising treatment for cervical cancer with acceptable toxicity. 149. Human hDlg Is Depleted in Cervical Cancer Compared to Normal Cervical Tissue. Tannin Fuja, Devansu S. Tewari, Cecilia De Lorenzo, Fritz Lin, Bradley J. Monk, and Peter J. Bryant. University of California Irvine Medical Center, Orange, California; and University of California, Irvine, Irvine, California. Objectives. hDlg is a human homologue of the Drosophila tumor suppressor protein Dlg. Dlg acts as a molecular scaffold to organize proteins involved in signaling pathways and is required for normal epithelial structure and proliferation control. In vitro assays have shown that HPV tumor-associated E6 proteins bind to hDlg and promote its degradation. We are investigating whether hDlg is expressed in normal cervical tissue, whether it is depleted in aberrant tumorous tissue, and what effect its depletion has on signaling pathways controlling proliferation. Methods. Samples from cervical cancers that had been analyzed for HPV status and histological type were obtained as paraffin-embedded sections and processed for immunohistochemistry. The expression and localization of the hDlg protein was determined with a highly

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specific monoclonal antibody in conjunction with enzymatic immunostaining, as well as immunofluorescence using confocal microscopy. Results. Normal cervical tissue showed strong staining for hDlg in cells at the transition between the columnar and squamous epithelium. In contrast, cancerous tissue showed minimal binding for hDlg, suggesting the depletion or altered expression of this protein in HPV-infected tissue compared to normal cervix. Conclusions. Human hDlg, the homologue of Drosophila tumor suppressor protein Dlg, is highly expressed in normal cervical tissue but depleted in cervical cancer. This suggests that the depletion or mislocalization of hDlg may contribute to the overgrowth of infected tissues caused by HPV. 150. Phase III Clinical Trials in Cervical Cancer through the Gynecologic Oncology Group. An Evaluation of Response, Recurrence, and Toxicity. Todd D. Tillmanns, Michael A. Gold, Scott A. Kamelle, Scott McMeekin, Joan L. Walker, and Robert S. Mannel. Oklahoma University Health Sciences Center, Oklahoma City, Oklahoma. Objective. Only 3% of eligible patients are enrolled in clinical trials. Our objective was to compare the response, recurrence, and toxicity experienced by patients on GOG cervical cancer trials to standard of care results (control arm). Methods. Twenty randomized phase III trials in cervical cancer have been completed and published by the GOG. Data were abstracted from published results. The control arm of the trial was assumed to be the standard of care. The overall response rate, recurrence, and toxicity of all patients enrolled in each trial (experimental plus control arms) were compared to results of the control arm when data were available for comparison. Categorical variables were compared using the ␹ 2 test. Results. Published results from 12/20 studies were available for evaluation, including a total of 3422 patients. A total of 889 patients with early stage cervical cancer were enrolled in three studies (GOG 92, 109, 123). The relative risk of recurrence was 0.77 compared to standard of care (P ⫽ 0.004; 95% CI 0.65– 0.92). The relative risk of grade III and IV toxicity in this group was 1.98 (P ⫽ 0.0002; 95% CI 1.37–2.87). In 1177 patients with locally advanced disease (GOG 4, 24, 56, 85, 120), the relative risk of recurrence was 0.86 (P ⫽ 0.004; 95% CI 0.79 – 0.95). There was no significant increase in grade III and IV toxicity in the protocol patients (RR ⫽ 0.77; P ⫽ 0.13; 95% CI 0.55–1.07). Finally, in 1356 patients with advanced disease (GOG 23, 43, 64, 110) there was a trend toward improved response rate (RR ⫽ 1.19; P ⫽ 0.09; 95% CI 0.97–1.46). There was no significant increase in grade III and IV toxicity in the experimental arm (RR ⫽ 0.87; P ⫽ 0.35; 95% CI 0.65–1.16). The overall response rate was not statistically significant (P ⫽ 0.12; RR ⫽ 1.15; 95% CI 0.96 –1.37) in 1446 experimental arm study patients; however, the relative risk of recurrence was significant with a relative risk reduction of 0.85 (P ⫽ 0.0003; 95% CI 0.78 – 0.93) in 2006 patients. A trend toward increased toxicity (P ⫽ 0.09; RR ⫽ 1.21; 95% CI 0.97–1.50) was found among experimental arm protocol patients. Conclusions. GOG cervical cancer protocols offer patients with early, locally advanced, and advanced/ recurrent disease improvements in their relative risk of recurrence without a significant increase in toxicity overall. These results should encourage the active enrollment of patients into GOG clinical trials. 151. ALTS. ASCUS/LSIL Triage Study; Management of Women with LSIL. Joan L. Walker for the ALTS Group. National Cancer Institute, Bethesda, Maryland; and University of Oklahoma, Oklahoma City, Oklahoma. Objective. Three management strategies were developed to determine the best way to detect CIN 3 as a surrogate for the effective prevention of cervix cancer. Methods. A total of 1572 women with LSIL cytology results were randomized into three management strategies: IC, immediate colposcopy; HPV, HPV triage to colposcopy if HCII was high risk HPV positive or missing or Thin Prep was HSIL⫹; and CM, conservative management which triaged to colposcopy for a HSIL⫹ Thin Prep. All women were then followed for 2 years with Thin Prep Pap tests every 6 months and referred to colposcopy only for HSIL results. Women with cytologic or histologic evidence of CIN 1 were followed with cytology alone. The natural history of histologic CIN I is also under investigation, but is not discussed here. Women with CIN 2 or 3 were

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treated with LEEP. At the 24-month exit visit, women with persistent LSIL or CIN 1 were encouraged to undergo LEEP. Results. Fifteen percent of women with a LSIL Pap test had CIN 3 detected within 2 years. Twenty-five percent of those enrolled were found to have CIN 2 or 3 detected within 2 years of enrollment. After the first 668 women enrolled, the HPV triage arm was closed. This decision was made because 85% of women referred for LSIL Pap were HPV positive. The HPV tests triage utility was limited. The DSMC required early colposcopy of CM patients when it was determined that CIN 3 detection was being delayed in that arm. In the IC arm: 61% of CIN 3 were detected on the first colposcopic exam, 21% during follow-up with cytology, and 18% at exit. This is compared to the CM arm finding of 35% at enrollment. The delay in detection of CIN 3 in all arms including the IC arm was probably due, at least in part, to prevalent disease undetected at enrollment colposcopy (rather than progression from lower grade lesions). Conclusion. We failed to find a useful triage method for women with LSIL cytology. 152. Abnormal FHIT Expression in High-Risk Early-Stage (IA 2, IB, and IIA) Cancer of the Cervix. A Gynecologic Oncology Group Study. William E. Winter III, Thomas C. Krivak, Jay W. Carlson, Scott Rose, Bradley J. Monk, Robert Berger, Kathleen Darcy, Tian Chunqiao, Eugene Sobel, and Michael Birrer. GOG Statistical Office, Buffalo, New York; National Cancer Institute/National Institutes of Health, Bethesda, Maryland; University of California–Irvine, Irvine, California; Walter Reed Army Medical Center, Silver Spring, Maryland; and Walter Reed Army Medical Center, Washington, DC. Objective. Genetic analysis of cervical carcinoma has demonstrated loss of heterozygosity at the chromosomal region, 3p14.2, which contains the FHIT gene. We previously demonstrated reduced or absent levels of the Fhit protein in cervical cancers and preinvasive lesions and showed that these abnormal Fhit levels correlate with a poor clinical outcome in women with stage II and III cervical cancers. The present study sought to examine the clinical and pathological correlations between reduced or absent Fhit protein levels and high-risk early-stage disease. Materials. Tumor levels of the Fhit protein were examined by immunohistochemistry in serial sections of hysterectomy or biopsy specimens from 177 patients with high-risk early-stage cervical cancer who were treated with radical hysterectomy, pelvic lymphadenectomy, and adjuvant radiotherapy alone or combined radiotherapy and chemosensitization as a result of their participation in Gynecologic Oncology Group Protocol 109. Suitable tumor tissue was available from 174 of 177 cases. Preliminary statistical analysis of Fhit associations with clinical characteristics was performed using the t test. The association between Fhit protein level and clinical outcome will be examined using the Kaplan–Meier survival method with the log-rank test and Cox hazard regression models with the Wald test. Results. Normal Fhit staining was observed in 73/174 (42.0%) cases. Reduced or absent Fhit protein levels were present in the remaining 101 (58.0%) cases, with 66/174 (37.9%) cases exhibiting reduced levels and 35/174 (20.1%) cases lacking Fhit protein. Reduced or absent Fhit protein levels were found in 87/138 (63.0%) squamous cell carcinomas and only 9/35 (25.7%) adeno-/ adenosquamous carcinomas (P ⫽ 0.0005). While abnormal Fhit levels were not significantly associated with age, grade, parametrial metastases, or extension to the vaginal margin, a loss or reduction in Fhit protein was associated with lymph node metastases in 77/121 (63.6%, P ⫽ 0.045). Conclusions. Reduced or absent Fhit protein levels are associated with the majority of high-risk early-stage cervical cancer, particularly those with lymph node metastases and squamous cell histology. Additional statistical analyses will examine the association between Fhit and clinical outcome in patients with high-risk early-stage cervical cancer. 153. Microsatellite Instability in Cervical Neoplasm. Yick Fu Wong, Tak Hong Cheung, Kin Yan Poon, Vivian Wang, and Tony Chung. The Chinese University of Hong Kong, Hong Kong. Objective. Microsatellite instability (MSI) has been detected in a wide variety of human tumors, but the influence of this form of genetic instability on

disease initiation and progression remains unclear. Methods. Using 10 microsatellite markers including loci Bat 25, Bat 26, D2S123, D5S346, D17S250, Bat 40, D3S1263, D4S402, D5S406, and D11S912 and a polymerase chain reaction-based method in combination with tumor tissue microdissection, we determined MSI in 83 cases of cervical intraepithelial neoplasia (CIN) and 93 cases of cervical squamous cell carcinoma to characterize the prevalence of MSI in these neoplasms and analyze the correlation of MSI with clinicopathologic features in the malignancy. Results. MSI at 1 locus in 10 loci examined was detected in 0 of 24 grade I CINs and 1 of 59 grade II–III CINs. In cervical carcinoma, 16 cases (17%) displayed a low frequency of MSI (MSI-L), showing MSI at 2 or fewer loci examined, and 11 cases (12%) showed a high frequency of MSI (MSI-H), with MSI at 3 or more loci. Taking MSI-H and MSI-L cases together as MSI-positive, statistical analysis of patient age, tumor grade, stage, and HPV infection and genotyping failed to disclose significant differences or trends between cases that were MSI-positive and MS-negative (P ⬎ 0.05). However, the difference is statistically significant when patients who were alive were compared with those who died of disease (P ⬍ 0.05). The MSI status was not correlated to disease-free survival (P ⬎ 0.05), but there was significant difference in overall survival between cases that were MSI-positive and MSI-negative (P ⬍ 0.05). The overall survival was reduced in patients who were MSI-positive. Conclusions. The results indicate that (i) MSI seems to be a late event in cervical carcinogenesis and (ii) MSI may potentially be a molecular prognostic marker of cervical squamous cell carcinoma. 154. Molecular/Environmental Markers as Prognostic Factors in Early Stage Cervical Carcinoma. Jason D. Wright, Daniela S. Gerhard, Zhengyan Zhang, Phyllis C. Huettner, Kathryn M. Trinkaus, David G. Mutch, Thomas J. Herzog, Randall K. Gibb, and Janet S. Rader. Washington University School of Medicine, St. Louis, Missouri. Objective. Clinical stage is the major predictor of survival in women with cervical cancer. Studies also suggest that high-risk HPV types or variants and lymphovascular space invasion (LVSI) may be important prognostic factors. There is little information on the relationship of other environmental factors such as tobacco abuse and prognosis. The purpose of this study is to identify combined clinical features including tobacco abuse and known molecular markers in cervical cancer that may be important indicators of survival in early stage cervical cancer. Methods. A total of 379 consecutively collected tumors from patients with stage I or II cervical cancer were evaluated. The mean age was 45.0 years and the mean follow-up was 52.0 months. Molecular analysis on a large portion of tumors included loss of heterozygosity (LOH) on 6p and 11q and HPV typing. LOH was analyzed by polymerase chain reaction (PCR) performed using over 20 oligonucleotide primers for each chromosomal arm after laser capture microdissection. HPV typing was performed by PCR methods. Clinical/pathologic information collected included tobacco use (absence/ presence and frequency), clinical stage, histologic type, and presence of LVSI. Results. Univariate Kaplan–Meier analysis indicates that covariates with statistically significant effects on survival time were stage (P ⫽ 0.0003), lymph node metastasis (P ⬍ 0.0001), LVSI (P ⫽ 0.0029), presence of HPV 18 (P ⫽ 0.0009), and adenosquamous histology (P ⫽ 0.0037). Multivariable analysis indicated that adenosquamous histology with LOH of 6p, 11q, or 6p and 11q was associated with significantly poorer overall survival. Greater than 20 pack years with LVSI, adenosquamous histology, or more advanced stage also adversely impacted survival. Finally, the combined effects of greater than 20 pack years in the presence of LVSI and LOH at both 6p and 11q significantly shortened survival. Conclusions. Tumor stage, lymph node metastasis, LVSI, HPV 18, and adenosquamous histology are independent risk factors for decreased survival for patients with early stage cervical cancer. Additionally, there may be significant interactions between tumor suppressor genes on chromosomes 6p and 11q, histologic type, LVSI, and tobacco abuse that portend a poor prognosis. 155. Weekly Cisplatin and Gemcitabine with Concurrent Radiotherapy in Locally Advanced Cervical Carcinoma. A Multicentric Phase I–II Study.

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS Juan J. Zarba, Alejandro V. Jaremtchuk, Liliana Cedaro, Paulina Gonzalez Jaley, Miguel Keropian, Ricardo Castagnino, and Claudia Mina. Getics, Comodoro Rivadavia, Argentina; Getics, Posadas, Argentina; Getics, Tucuma´ n, Argentina; Getics, Yerba Buena, Argentina; and Getics (Grupo de Estudio, Tratamiento e Investigacio´ n del Ca´ ncer del Sur, Posadas, Argentina. Objectives. Concurrent radiotherapy (R) and chemotherapy may be considered the new standard treatment for locally advanced cervical carcinoma (LACC) and weekly cisplatin (C) is probably the best option. Gemcitabine (G) has shown a modest efficacy in cervical cancer but has shown definite radiosensitizing properties in preclinical and clinical studies in cervical carcinoma. The aim of this study was to determine the maximum tolerated dose (MTD) and the antitumor activity of G when it is administrated in combination with concurrent C and R in LACC. Methods. Patients (pts) with histologically confirmed LACC (FIGO IIB–IVA), previously untreated, PS 0 –2, adequate organ function, and signed informed consent were eligible for entry in the study. R was administrated at conventional doses and fields (50.4 Gy in 5 weeks) followed by brachytherapy (30 –35 Gy given on point A). Concomitant, weekly chemotherapy was administrated with 40 mg/m 2 of C in a 1-h infusion and G in a 30-min infusion at increasing doses levels until the MTD was found. Results. Thirty-six pts were included between 7/99 and 3/01. In phase I, 16 pts were entered at four dose levels (75, 100, 125, and 150 mg/m 2). The MTD was 150 mg/m 2 and the recommended dose of G for phase II was 125 mg/m 2. Twenty additional pts were entered at this level for a total of 26. Toxicity at the recommended dose was acceptable with grade 3– 4 toxicity in less than 20% of pts and was mostly nonhematologic (diarrhea 5 pts, mucositis 3 pts, N and V 3 pts, skin toxicity in 3 pts, and astenia in one pt); only 1 pt had grade 4 neutropenia. The combination was active in all dose levels. All pts (36/36) were assessable for response, 35/36 (97.3%) pts achieved an objective response, 32 (88.8%) a CR, and there were 3 (8.3%) RP and 1 (2.7%) SD. At a median follow-up of 14 months, 29/36 (80.5%) pts are in sustained CR and 7/36 (19.4%) relapsed, 4 within the radiation field and 3 with distant disease (1 lung and 2 bone metastases). The median TTP was 8 months. The DFS and OS at 2 years is 67 and 70% (Kaplan–Meier). Conclusion. The association of weekly C and G with concurrent R is a promising two-drug regime in LACC, but its superiority or equivalence in terms of activity or toxicity to other combinations without G must be addressed in a randomized trial. 156. Risk of Cancer in the Offspring of Women Who Underwent in Vitro Fertilization. Curt W. Burger, Helen Klip, Janneke De Kraker, and Flora E. Van Leeuwen. Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands; and Netherlands Cancer Institute, Amsterdam, The Netherlands. Objective. The aim of this study was to determine the risk of cancer in children conceived by in vitro fertilization (IVF). In the past decade, attention has increasingly been focused on the long-term health effects of assisted reproductive techniques (ART), such as in vitro fertilization, on both the women and their offspring. Although the causes of childhood cancer are largely unknown, some studies suggest that prenatal factors (drug exposure) may play a role in the etiology of childhood malignancies. Methods. We used a large population-based historical cohort initially designed to determine gynecological disorders in women who underwent IVF. The offspring of the initial cohort were included in the exposed cohort if they were conceived by IVF or other related fertility techniques (n ⫽ 9484). The unexposed (control) group consisted of 7532 children whose mothers were diagnosed with subfertility disorders but were conceived naturally. Results. A total of 16 childhood cancers were observed in the total study cohort, whereas 15.5 were expected during a median follow-up period of 5.1 years (standardized incidence ratio (SIR) ⫽ 1.0; 95% confidence interval (CI) 0.6 to 1.7). In the group of children conceived after ART, the SIR was 1.1 (95% CI 0.5 to 2.2; 8 observed cases and 7.1 expected cases). Furthermore, a direct comparison between children conceived after ART and naturally conceived children revealed no increased risk for childhood malignancies (risk ratio ⫽ 0.6; 95% CI 0.2 to 1.6). Conclusion.

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Although the number of observed cancer cases is small, these findings demonstrate that children conceived by ART show no increased risk of cancer during childhood compared to the general population and our internal reference group. 157. Decision Making in the Treatment of Ovarian Cancer. Lee-May Chen, Lee A. Learman, Vivian Weinberg, and C. Bethan Powell. University of California at San Francisco, San Francisco, California. Objectives. The aim of this study was to determine the extent to which physician experts use a collaborative versus directive approach to patient decision-making for treatment of primary and recurrent ovarian cancer and whether physician or practice characteristics are associated with decisionmaking approaches. Methods. A five-page questionnaire describing different clinical scenarios of primary and recurrent ovarian cancer was sent to all full members of the Society of Gynecologic Oncologists in two mailings from 1999 to 2000. SGO members were asked about whether they “provide recommendations” for a directive approach or “discuss options” for a collaborative approach to make decisions regarding treatment planning. Results. Two hundred thirty of 508 anonymous questionnaires were returned for a 45% response rate; 218 reported treating ovarian cancer patients. Thirty-nine percent of respondents described themselves as being directive in providing recommendations to their patients, while 61% described themselves as more collaborative in discussing options. Patient preference was cited as a strong influence in both primary and recurrent ovarian cancer treatment decisions by 23% of respondents. There was a shift of an additional 18% of respondents who cited patient preference as a strong influence in recurrent disease only (23 vs 41%, McNemar test, P ⬍ 0.0001). For recurrent disease, there was no significant difference in collaborative versus directive counseling for recommending a surgical approach rather than restarting chemotherapy (52% vs 43%, P ⫽ 0.27). Male respondents were more likely than females to be collaborative (64% vs 45%, P ⫽ 0.06), however, these preferences for decision-making were otherwise unrelated to practice setting (cancer center vs other), geographic location, or years in practice. Conclusions. The majority of gynecologic oncologists report a collaborative approach to ovarian cancer management. Patient preference appears to play a larger role in treatment decisions for recurrent versus primary ovarian cancer. Otherwise, patient preference was not reported to strongly influence decision-making, even among oncologists who endorsed a collaborative approach. Further study is needed to understand the determinants of patient participation in decision-making for ovarian cancer treatment. 158. Factors Affecting Minority Research Participation and Understanding. Shakira Lleras, Lorraine Y. Pan, Linda Franssen, Allan J. Jacobs, and Giuseppe Del Priore. Bellevue Hospital, New York University School of Medicine, New York, New York. Objective. The aim of this study was to describe minority research participation and factors influencing enrollment. Methods. We applied a prospective questionnaire (English, Spanish, Chinese) and retrospective chart review of female patients in oncology clinic over 3 months in 2000 (n ⫽ 716). Results. Responses were obtained from 92 randomly selected patients. Hispanics represented 43.8% of respondents, Asians 24.7%, blacks 15.7%, whites 13.5%, and others 2.2%. Income less than federal poverty levels was reported by 52% of respondents with 36% on public assistance. Hispanics and Asians (10.8 and 19%) were more likely to participate than other ethnic groups (P ⫽ 0.05). Although they were more likely to participate, Asians were less likely to speak English (4.5% vs 49.2%), had more persons in the household (median 3.2 vs 2.2), and had fewer years of residency in the United States (median 8.3 vs 31.7 years) (all P ⬍ 0.05). Asians were no different from other ethnic groups in regard to age, distance to the medical center, years of education, number of children, marital status, and income. Trial participants were more likely to be on public assistance (22.6% vs 2%, P ⫽ 0.004); had advanced stage III/IV disease (29.2% vs 6%; P ⬍ 0.05); had more years of schooling (13.2 vs 10.4, P ⫽ 0.045), and had more household members (4.3 vs 2.2, P ⫽ 0.1). If asked by their physician, 45.5% reported that they would participate, but if paid, only

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27.4% would do so (P ⫽ 0.027). Marital status and country of origin were not associated with participation. According to cancer center records, 10.7% of the respondents (n ⫽ 9) participated in clinical trials. Of these, only 66.7% (6/9) reported being asked to participate in a trial and only 33% (3/9) recalled actually giving informed consent to participate. For comparison, of all patients who had documentation of signing any other informed consent forms (e.g., for biopsy or surgery at our institution), only 40% recalled doing so (P ⬎ 0.05). Among participants in clinical trials or signing other consent forms, only 33% reported that they “understood” the term “informed consent.” Conclusion. Minority participation in clinical trials is low but no different than that reported from other populations. Asian were the most likely to participate, but did not differ from the other ethnic groups with respect to most demographic factors associated with clinical trial participation. Encouragement by physicians and not monetary rewards may improve enrollment. 159. Perioperative Medical Complications in the High-Risk Gynecology Patient. Diane Doerner and Dominic F. Reilly. University of Washington Medical Center, Seattle, Washington. Objective. The aim of this study was to provide a description of medical morbidity associated with high-risk gynecologic surgery and a determination of factors predictive of increased operative risk. Methods. A prospective observational study of 545 women referred for medical evaluation prior to gynecological surgery was performed. Patient factors (e.g., medical illness, hormone replacement therapy (HRT), American Society of Anesthesiology (ASA) class) and surgical factors (e.g., duration of surgery, surgical oncology, use of epidural analgesia) were recorded. Patients were followed for the development of 28 predefined serious complications. The association of patient or surgical factors to postoperative complications was tested using bivariate analysis and multiple logistic regression. Results. The mean age of patients was 61.9 ⫾ 14.6 years (mean ⫾ SD) (range 21–95). Medical factors included the following: 70% had cardiovascular disease, 46% were ASA class 3 or 4, 26% had diabetes, 11% had a prior stroke (CVA), 55% had poor exercise tolerance, 35% reported tobacco use ⬎20 pack years, 25% had HRT. Surgical factors included the following: 60% oncology, duration of surgery 2.5 ⫾ 1.5 h (range 0.2–17 h), 66% peritoneal, 18% vaginal approach, 16% perineal procedure. Total serious complications included the following: 23%: 1% mortality, 9% cardiac, 12% pulmonary, 6% neurologic, 8% infectious. Factors associated with higher risk for all serious complications on bivariate analysis (P ⱕ 0.05) included age, poor exercise tolerance, higher ASA class, tobacco use, prior CVA, surgical oncology, peritoneal procedures, duration of surgery ⬎5 h, and epidural use. With multivariable regression analysis only age, prior CVA, ASA class, and peritoneal procedures were independent predictors of all complications. Coronary disease, congestive heart failure, diabetes, poor exercise tolerance, ASA class, age, and peritoneal procedures were associated with an increased risk for cardiac complications on bivariate analysis. Smoking, ASA class, oncology, and peritoneal procedures were associated with increased pulmonary risk on bivariate analysis. Hormone replacement therapy was not associated with increased risk in any category. Conclusion. Serious perioperative medical complications in this population were independently associated with advanced age, prior stroke, ASA class, and peritoneal procedures. 160. The Use of Telemedicine in Gynecologic Oncology. John C. Elkas, Jay W. Carlson, G. Larry Maxwell, John W. McBroom, William E. Winter III, Thomas C. Krivak, and G. Scott Rose. Walter Reed Army Medical Center, Washington, DC. Objective. The aim of this study was to determine whether telemedicine can be utilized to further gynecologic oncology fellowship training, offer continuing medical education (CME) through distance learning (regional or abroad), improve patient care by allowing primary care providers regular access to subspecialists, and enable patients abroad access to genetic counseling. Methods. We initiated a videoteleconferenced (VTC) gynecologic oncology tumor board and a CME lecture series in July 2000. Attendees included medical

oncologists, radiation oncology staff and residents, oncology nurse specialists, gynecologic oncology staff and fellows, and Ob/Gyn residents and medical students. All patients referred to our tertiary military medical treatment facility (MTF) with gynecologic malignancies were presented at the multidisciplinary conference. Additionally, referrals from military health care providers abroad were presented by the referring physician. VTC presentations included histology and cytology as well as pertinent radiographs which were visualized by all attendees regardless of location. Results. Multiple civilian and military medical facilities both in the continental United States and abroad were regularly able to participate in our VTC tumor board. Numerous patient evacuations to our MTF were obviated through the evaluation of radiographs and pathology at the VTC tumor board. All patients referred from abroad for genetic counseling were initially evaluated and counseled with the use of VTC. Additionally, patient eligibility for local and national protocols was reviewed at the conference. CME credit was given to all participants at all locations. After the tumor board, resident and fellow lectures were given by staff from multiple disciplines at various facilities by VTC. Fellows, residents, and students who were off campus were able to participate in the lecture series via VTC. At the conclusion of the lecture a VTC laboratory meeting occurred between gynecologic oncology and laboratory staff and fellows located at multiple clinical and research sites. Conclusions. Videoteleconferencing was useful to further patient care by allowing primary care providers, off campus and abroad, access to subspecialty physicians. In addition, VTC improved the educational opportunities for residents and fellows by allowing greater participation independent of location. 161. Cost-Effectiveness Analysis of Management Strategies for CIN II and CIN III. Marc J. Kleinberg, J. Michael Straughn Jr., Ronald D. Alvarez, Larry C. Kilgore, Edward E. Partridge, and Jeffery S. A. Stringer. University of Alabama at Birmingham, Birmingham, Alabama. Objective. The aim of this study was to determine the cost-effectiveness of commonly used strategies for the management of CIN II and CIN III. Methods. A decision analysis model compared the following management strategies in a hypothetical cohort of 100,000 women with CIN II and CIN III: observation, cryotherapy (CRYO), CO 2 laser ablation, LEEP, cold knife conization, and total vaginal hysterectomy (TVH). Separate analyses were performed for CIN II and CIN III. Effectiveness measures were (i) immediate cure, defined as normal cytology or normal/CIN I histology at 1 year, and (ii) number of cancers at 1 year. The perspective used was that of a third-party payer. Clinical and cost estimates were derived from published literature and regional reimbursement schedules. Results. Observation and laser ablation were more expensive and less effective than the other strategies for both CIN II and CIN III. In the analysis of CIN II, CRYO was the least expensive ($41 M) and least effective (95% cure rate and 1454 cancers prevented). TVH was the most expensive ($1.2 B) and most effective (99% cure rate and 1475 cancers prevented). LEEP was more effective than CRYO with a 96% cure rate and an additional 19 cancers prevented. Relative to CRYO, LEEP costs $31,394 per additional cure and $1.8 M per additional cancer prevented. In the analysis of CIN III, CRYO was the least expensive ($46 M) and least effective (91% cure rate and 2154 cancers prevented). TVH was the most expensive ($1.2 B) and most effective (99% cure rate and 2206 cancers prevented). LEEP was more effective than CRYO with a 94% cure rate and an additional 44 cancers prevented. Relative to CRYO, LEEP costs $17,564 per additional cure and $1.0 M per additional cancer prevented. Conclusions. CRYO is a costeffective strategy for the treatment of CIN II and CIN III and is an appropriate option in resource-poor settings. Prevention of cancer is maximized by the TVH strategy, but excessive cost makes this approach economically unsound. The additional efficacy of LEEP over CRYO comes at a high price; however, it is a reasonable strategy if policy makers are able to pay $1.8 M (CIN II) or $1.0 M (CIN III) to prevent each cancer. 162. Implementation of Array Comparative Genomic Hybridization for Detection of DNA Copy-Number Changes in Ovarian Cancer. T. Pejovic, J.

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TABLE 1—ABSTRACT 164 Clinical Events during the Year Preceding Death

a

Time prior to death (months)

No. Pts alive during time interval a

No. Pts hospitalized

No. Pts with a significant clinical event

No. Pts receiving chemotherapy

12–9 mo. 9–6 mo. 6–3 mo. 3–0 mo.

21 24 26 27

3 8 16 20

1 1 10 13

18 23 25 16

Patients who progressed with less than 9, 6, or 3 months survival time are not included in all time intervals.

Leamon, J. Lage, T. Rutherford, S. Chambers, J. Costa, P. Schwartz, and P. Lizardi. Yale University School of Medicine, New Haven, Connecticut. Objective. Characterization of DNA copy-number changes is important for both the basic understanding of cancer and its diagnosis. Comparative genomic hybridization (CGH) was developed to survey DNA copy-number changes across a whole genome. With CGH, differentially labeled tumor and normal DNA are cohybridized to normal metaphase chromosomes and fluorescence ratios along chromosomes provide cytogenetic representations of DNA copynumber variation. The resolution of classical CGH is limited to about 20 kb, the size of the chromosome band. Development of microarrays provided an opportunity to achieve a higher resolution of CGH, limited to the size of the printed gene, if adequate performance could be achieved. The performance goals of array CGH (a-CGH) are much more stringent than those of related array methods for measuring gene expression. Human genomic DNA is a far more complex mixture than the mRNAs. Reliable detection of single copy changes relative to normal diploid state requires sensitivity 10 times higher than that of expression arrays. Because of high technical demands of a-CGH, only two groups have been able to publish their CGH results and none of the publications involved gynecologic tumors. Methods. We describe our implementation of a-CGH for the analysis of ovarian carcinoma. The material includes DNA extracted from 10 seropapillary, 3 endometrioid, and 2 clear cell carcinomas of the ovary. The tumor and reference DNA were labeled with Cy3 and Cy5 fluorescent random priming and labeling efficacy was evaluated on a rapid 6% polyacrylamide minigel. Different hybridization and wash conditions were tested to produce optimal signal-to-noise ratio on high-quality cDNA microarrays with relevant cancer genes. An advanced image analysis with precise background subtraction permitted reproducible detection of genetic alterations with known confidence levels. Results. The complete data analysis of 2 stage III seropapillary ovarian carcinomas revealed gene amplification of enoyl-coenzyme A, Williams–Beuren syndrome chromosome 11 mRNA, and H2B histone family gene (case 1) and pregnancy-specific beta-1-glycoprotein 1 (case 2) as well as deletions involving nuclear receptor interacting protein 1 and suppression of tumorigenicity factor 5 (case 1). Conclusion. Under very stringent conditions, a-CGH is a feasible and reproducible method for detection of gene dosage changes in ovarian cancer. 163. Quantitation of the Psychological Trauma in Women Newly Diagnosed with Gynecologic Cancer. Donna M. Posluszny, Robert P. Edwards, John T. Comerci, Sheila McFeeley, Brooke L. Slater, Judith A. Knapp, and Andy Baum. University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania. Objective. Symptoms of traumatic stress include persistent and disturbing reexperiencing of the diagnosis in memories, thoughts, or images, along with avoidance of reminders of the diagnosis and emotional numbness. New cancer diagnosis and subsequent treatment induce stress that may manifest reactions from patients seen in other better studied forms of psychological trauma. This project examined women’s responses to cancer diagnosis by investigating

posttraumatic stress disorder (PTSD) and related symptoms of psychological trauma in women newly diagnosed with early- or advanced-stage gynecologic cancer. Methods. Women with early- and advanced-stage ovarian, uterine, or vulvar cancer were compared to women newly diagnosed with benign gynecologic disease requiring surgery and healthy women undergoing a routine pelvic exam. Participants (n ⫽ 102) completed paper and pencil questionnaires measuring intrusive thoughts and memories, PTSD, and peritraumatic dissociation within 7 days of diagnosis. They were reassessed approximately 6 weeks after surgery. Perceptions of disease threat were measured at both time points. Results. Repeated measures MANOVA showed a significant main effect for group F(6,194) ⫽ 8.108; P ⬍ 0.001, with the three disease groups reporting more distress than the healthy controls. Analysis of dissociation symptoms showed an overall effect for group F(3,98) ⫽ 6.194; P ⬍ 0.001, with the healthy group reporting significantly less distress than the two cancer groups and the benign disease group. For PTSD, 14 –20% of cancer patients met the criteria for PTSD, with a larger percentage of advanced-stage cancer patients (20 –30%) meeting PTSD criteria than patients with early-stage disease (10 –13%). Women with advanced-stage cancer reported the greatest perceived disease threat. Although perceptions of disease threat were correlated with traumatic stress, they were not a strong predictor of later distress. Conclusion. Early-stage cancer, advanced-stage cancer, and benign disease groups reported significantly more traumatic stress than the healthy controls, with the advanced-stage group experiencing the most distress. This suggests that women with newly diagnosed gynecologic disease experience clinically significant levels of traumatic stress, raising new possibilities for intervention. 164. Changes in Clinical Course in Women with Ovarian Cancer Preceding Death. Vivian E. Von Gruenigen, Heidi E. Frasure, and Karen M. Gil. Akron General Medical Center, Akron, Ohio; and Northeastern Ohio Universities College of Medicine, Akron, Ohio. Objective. The aim of this study was to retrospectively describe the last year of life in women receiving chemotherapy for ovarian cancer. Methods. All patients who died during 1/2000 – 6/2001 were included. Medical charts were reviewed to abstract chemotherapy, reason for hospitalizations (including ER visits), and significant clinical events (bowel obstruction, pleural effusion requiring thoracentesis, liver or brain metastases, and abdominal ascites requiring paracentesis). Hospitalizations resulted from some significant clinical events and other cancer-related events. Data were analyzed in 3-month intervals. Chemotherapy during the last 3 months is described in 1-month intervals. Results. Twenty-seven patients died of ovarian cancer during this time period (Table 1). There was an increase in the number of patients hospitalized (␹ 2 ⫽ 20.26, P ⫽ 0.0001) and having a significant clinical event (␹ 2 ⫽ 17.35, P ⫽ 0.0001) in the months preceding death. Some of the common reasons for hospitalizations were DVT, pulmonary embolism, sepsis, dehydration, anemia, and GI bleed. The most common clinical event was bowel obstruction (10). Two months prior to death 11 patients received chemotherapy and during the last month 4 patients received chemotherapy. Conclusion. Frequent hospitalizations and significant clinical events increased greatly during the 6 months

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before death. Administration of chemotherapy during this time may need to be reevaluated, especially in the light of hospice care availability. Patient expectations and goals of chemotherapy may need to be assessed at this time in order to prepare the patient for end-of-life care. 165. Outcome of Patients Undergoing Surgical Resection of Recurrent Leiomyosarcoma. Matthew L. Anderson, Diane C. Bodurka, Kristen White, Charlotte C. Sun, Judith K. Wolf, and Thomas W. Burke. University of Texas M. D. Anderson Cancer Center, Houston, Texas. Objective. The aim of this study was to evaluate the role of surgery in managing recurrent uterine leiomyosarcoma. Methods. We have undertaken a retrospective review of leiomyosarcoma patients evaluated or treated between 1992 and 2001. Statistical analysis was performed using SPSS. Results. To date, we have identified 83 patients treated or evaluated for recurrent leiomyosarcoma. Most patients presented with recurrent disease either in the lung (n ⫽ 56; 59.6%) or in the pelvis (n ⫽ 16; 26.6%). A single anatomic site of metastasis was initially identified in 40 patients (48%). Surgical resection of metastatic disease was performed for 38 patients. Twenty-four of these 38 had recurrent disease localized to a single site. Surgical debulking was optimal (residual disease ⬍1 cm) for 28 and suboptimal (⬎1 cm) in 10. Mean survival for patients who underwent optimal surgical resection of pulmonary metastases was significantly greater than survival for patients who did not undergo surgery for recurrence (1025 days (n ⫽ 12) vs 397 days (n ⫽ 27), P ⫽ 0.027). Optimal debulking at other anatomic sites did not improve survival (475 days (n ⫽ 12) vs 476 days (n ⫽ 11), P ⫽ 0.997). Age at diagnosis and histologic tumor characteristics did not differ significantly between any of the surgical and nonsurgical groups. Conclusions. Preliminary analysis of our data confirms the observation that patients who undergo optimal resection of pulmonary metastases of leiomyosarcoma live longer. However, optimal resection of extrapulmonary disease does not appear to improve patient survival. 166. Viability of Endometrial Carcinoma Cells Disseminated at Hysteroscopy. Gu¨ rkan Arikan, Sabine Reinisch, Olaf J. Reich, Ursula Weiss, Helmuth Pickel, Gernot Desoye, and Raymond Winter. University of Graz, Graz, Austria. Objectives. The aim of this study was to evaluate the rate of transtubal dissemination of endometrial carcinoma cells by hysteroscopy and the functional viability of disseminated tumor cells by assessing cell adhesion in an in vitro model. Methods. We studied 24 uteri obtained at TAH⫹BSO in patients with endometrial carcinoma. Further inclusion criteria were negative peritoneal cytology, no involvement of the uterine serosa, extrauterine disease, or endometrial surface involvement ⬎1 cm in diameter. In vitro fluid hysteroscopy was performed with a 5-mm single-flow rigid hysteroscope. A maximum of 150 ml of saline was infused at a maximum pressure of 100 mm Hg for a maximum of 3 min. Fluid running off through the tubes was collected. The cell suspension was enriched by a density gradient centrifugation. The isolated cells had a mean viability of 90% as judged by trypan blue exclusion. A total of 5 ⫻ 104 viable cells per 2-cm 2 polyvinyl chloride well plate were cultured with equal parts of Dulbecco’s modified Eagle’s minimal essential medium and Ham’s F-12 for 24 h. The endpoint of the analysis was the adherence of tumor cells to the polyvinyl chloride well plate, which was taken as a proxy for functional cell viability. Cytological evaluation was performed separately by two cytologists blinded to the source and date of the smears. Results. Transtubal fluid dissemination was seen in 20 of 24 (83%) uteri. Tumor cells were found in 17 specimens (71%). In 10 (42%) specimens the disseminated tumor cells were functionally viable. Conclusions. Our model suggests that hysteroscopy can cause dissemination of malignant cells into the abdominal cavity from uteri containing endometrial carcinoma and that these cells can be functionally viable and adhere to a matrix. 167. Estrogen Induction of Telomerase Activity by Mitogen-Activated KinaseDependent Pathways in Human Endometrial Carcinoma Cells. John F.

Boggess and Chunxiao Zhou. University of North Carolina, Chapel Hill, Chapel Hill, North Carolina. Objective. Telomerase activation is thought to be a critical step in cellular immortalization and carcinogenesis. Translation of the human telomerase catalytic subunit gene (hTERT) has been shown to be the rate-limiting determinant of human telomerase enzymatic activity. We have previously confirmed that estrogen response elements (ERE) in the hTERT 5⬘-flanking sequence are capable of binding estrogen receptor-␣ in vitro and that estrogen induces hTERT translation and telomerase expression in a dose-dependent manner. It is not known which cell signaling pathways are involved in estrogen-dependent regulation of telomerase expression. This study examines the effects of protein kinase inhibitors on telomerase activity in cultured endometrial carcinoma cells. Methods. An estrogen receptor-␣ positive endometrial cancer cell line (Ishikawa) was used in all experiments. A known quantity of Ishikawa cells was incubated in the presence of estradiol (E2), MEK inhibitor UO126 (inhibits phosphorylation of ERK 1/2 which in turn blocks gene translation), a combination of E2 and UO126, or culture medium alone. ERK-1 and ERK-2 phosphorylation was quantified using Western blot analysis. Telomerase expression was assayed with the TRAPeze technique and quantified using phosphorimaging. Results. Exogenous estrogen induced phosphorylation of extracellular signal-regulated kinases, ERK1 and ERK2, with a maximal level 20 min after stimulation and increased telomerase activity above controls 1.8- and 3.4-fold at 24 and 48 h, respectively. ERK1 and ERK2 MAPKs phosphorylation was abolished with UO126, and telomerase activity was decreased by 5- and 9-fold at 24 and 48 h. Inhibition of telomerase activity by UO126 was partially overcome with the addition of E2 with a decrease in activity below controls of 1.5- and 2.3-fold at 24 and 48 h. Conclusions. A clear association exists between telomerase induction and phosphorylation of ERK1 and ERK2 MAPKs. One mechanism of estradiol induction of telomerase activity appears to be mediated by the ERK1 and ERK2 MAPKs cell signaling pathway. Since E2 could partially abrogate UO126 inhibition of telomerase activity, more than one cell signaling pathway is likely to be involved in E2 induction of telomerase activity. 168. Estrogen Mediates Regulation of the Telomerase Catalytic Subunit Gene (hTERT) in Endometrial Cancer Cell Lines in an Estrogen Receptor-␣ Dependent Manner. John F. Boggess, Chunxiao Zhou, and David Boruta. University of North Carolina, Chapel Hill, Chapel Hill, North Carolina. Objective. Telomerase is expressed by the epithelial glands differentially throughout the menstrual cycle with high levels of expression observed in the proliferative phase and absent levels by the middle of the secretory phase. It has been suggested from observational studies that estrogen stimulates telomerase expression. Given that prolonged exposure to unopposed estrogen is associated with excess development of endometrial carcinoma and that the promoter region of the catalytic subunit of the telomerase enzyme, hTERT, contains an estrogen response element (ERE), we postulate that estrogen receptor mediated induction of telomerase activity may play an important role in endometrial carcinogenesis. This study explores the relationship between estrogen and telomerase activity in cell lines derived from human endometrial cancers. Methods. Two estrogen receptor-␣ positive (ER-␣) cell lines, Ishikawa and ECC-1, and two ER-␣ negative endometrial cancer cell lines, RL-95 and HEC-1B, were cultured in the presence of varying concentrations of estradiol (E2) for varying amounts of time. Lysates from each were assayed for telomerase activity using a commercial TRAP assay, and purified mRNA was assayed for hTERT copy number using a real-time PCR assay developed in our lab. RL-95 cells were transfected with a vector containing ER-␣ in order to assess recovery of E2 mediated telomerase induction. A gel shift assay was used to demonstrate sequence-specific binding of the E2/ER-␣ complex obtained from nuclear extracts from ER-␣ transfected RL-95 cells to the ERE of the hTERT promotor. Results. Estrogen induced both hTERT gene translation and telomerase activity by 24 h with concentrations greater than 1 ⫻ 10 ⫺9 M in ER-␣ positive cell lines, but not in ER-␣ negative cell lines. Transfection of ER-␣ restores induction of hTERT and telomerase activity in RL-95 trans-

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS fected cells. E2 complexed with ER-␣ binds specifically to the ERE within the hTERT promotor. Conclusions. Both hTERT mRNA copy number and telomerase enzyme activity are increased in response to estrogen in an estrogen receptor dependent fashion. Binding of complexed E2 with ER-␣ to the ERE found within the hTERT promotor suggests a possible mechanism for gene induction and enzyme regulation. 169. A Population-Based Study of Patterns of Care for Endometrial Cancer. Who Is Seen by a Gynecologic Oncologist and Who Is Not? Michael E. Carney and Charles Wiggins. University of Hawaii, Honolulu, Hawaii and University of Utah, Salt Lake City, Utah. Objective. The aim of this study was to determine the fraction of patients diagnosed with endometrial cancer and seen by a gynecologic oncologist and to compare treatment differences. Methods. The state population-based cancer registry was used to identify 1282 patients diagnosed with endometrial cancer between 1992 and 1998. Patterns of care were analyzed using Kaplan–Meier curves, log-rank testing, and proportional hazards modeling. Results. Of 1282 endometrial cancer patients diagnosed during the period 1992–1998, a total of 380 (29.6%) were seen by a gynecologic oncologist at some point during their cancer care. The percentage of patients seen by a gynecologic oncologist varied with age: 39% of cases were under 40 years of age and 27% percent were over 70 years of age. The percentage of endometrial cancer cases seen by gynecologic oncologists increased during the study period, from 24% in 1992–1993 to 35% from 1997 to 1998 (␹ 2 P ⬍ 0.001). The vast majority of the state’s population resides within a contiguous, four-county area near the only major city where gynecologic oncology care is available. Endometrial cancer patients who resided within that geographic area were generally more likely to have been seen by a gynecologic oncologist than those who lived in more rural regions of the state (32 and 21%, respectively: ␹ 2 test, P ⬍ 0.0002). Gynecologic oncologists were increasingly involved in the care of higher grade endometrial cancer patients, although fewer than 50% of grade 3 cancer patients were actually seen by gynecologic oncologists. A significantly higher proportion of endometrial cancer patients underwent lymph node sampling when cared for by a gynecologic oncologist. Furthermore, a greater mean number of nodes was sampled by gynecologic oncologists (15 vs 10, respectively, P ⬍ 0.008). There were no overall differences seen in survival between patients treated by gynecologic oncologists when compared to those treated by other physician specialties. Conclusion. Gynecologic oncologists see fewer than one-third of all endometrial cancer patients. Patients over 70 and those living in rural settings are significantly less likely to be seen by a gynecologic oncologist during the course of their treatment. Lymph node sampling is more frequently done and more complete when performed by a gynecologic oncologist. An overall survival advantage was not detected in patients seen by a gynecologic oncologist. 170. Benefits of Cytoreductive Surgery and Taxol- and Platinum-Based Chemotherapy in Uterine Papillary Serous Carcinoma. John K. Chan, Mark Youssef, Scott McMeekin, Bradley J. Monk, Kathryn Osann, Steve Vasilev, Alberto Manetta, Philip J. Disaia, and Michael L. Berman. University of California, Irvine, Orange, California. Objectives. The aim of this study was to determine the benefits of surgical staging, tumor debulking, and Taxol/platinum-based chemotherapy vs radiation and no further therapy for patients with advanced staged uterine papillary serous carcinoma (UPSC). Methods. All patients with UPSC diagnosed between 1985 and 1999 were identified from tumor registry databases at three Southern California hospitals. Data for analysis were collected from hospital charts and clinic follow-up records. Life table analyses were calculated by the Kaplan–Meier method. Results. Of 100 patients diagnosed with UPSC, there were 26 with stage I disease, 9 with stage II, 25 with stage III, 20 with stage IV, and 20 who were unstaged. The median follow up was 32 months (range 2–134). The 3-year cumulative survival for stage I, III, and IV was 78, 43, and 33%, respectively. Patients with stage I and II combined had a 3-year cumulative survival rate of 83% compared to 39% in stage III and IV combined

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(P ⫽ 0.009). Twelve of 16 women with disease confined to the endometrium on the hysterectomy specimen underwent surgical staging and half of them had extrauterine metastases. Twenty-three percent (6/26) of patients with surgically stage I disease recurred. Using criteria typically described for ovarian cancer patients with advanced stage disease, women with stage IV disease were divided into optimal (⬍1 cm) and suboptimal (⬎1 cm) based on residual disease after initial surgery. Eleven stage IV patients who were rendered optimal by cytoreductive surgery had a median survival of 25 months vs 6 months in the suboptimal group of 9 patients (P ⫽ 0.05). For patients with stage III and IV disease, 42% (19/45) received adjuvant chemotherapy with Taxol/platinum-based regimen with a median survival of 28 months compared to 13 months with radiotherapy and 11 months with no treatment (P ⫽ 0.04, treatment stratified by stage). Conclusions. Complete surgical staging is important in patients with noninvasive UPSC. As with ovarian cancer, cytoreductive surgery in stage IV patients and Taxol/platinum-based chemotherapy in stages III and IV disease showed a significant survival benefit over radiotherapy or no adjuvant treatment. 171. Loss of CABLES. A Critical Step in Malignant Transformation of the Endometrium? Robert L. Debernardo Jr., Sandra D. Kirley, James K. Pru, Linda R. Duska, Lawrence R. Zukerberg, and Bo R. Rueda. Massachusetts General Hospital, Boston, Massachusetts. Objective. The purpose of this study was to evaluate normal, hyperplastic, and malignant human endometrium for expression of CABLES, a novel cell cycle protein. CABLES interacts with cyclinE/cdk2, a complex important in regulation of the cell cycle. Recently, loss of CABLES has been reported in approximately 50% of colon and squamous cancers of the head and neck. Using both endometrial tissue samples and endometrial cell lines, expression of CABLES mRNA and protein was analyzed. Methods. Paraffin-embedded sections of endometrium from 21 patients were examined by immunohistochemistry (IHC) to evaluate CABLES expression. To determine whether the absence of CABLES protein correlated with lack of CABLES mRNA, RNA was isolated from normal and malignant endometrium and assessed by Northern blot analysis. Concurrently, protein lysates generated from the same samples were evaluated by Western blot. Similar analyses were performed on RNA and protein derived from both HES and SK-UT2 endometrial cell lines. HES and SK-UT2 tumors generated in nude mice were then analyzed to verify whether in vitro observations mimicked tumor behavior observed in vivo. Results. Twenty one paraffin-embedded specimens were examined by IHC. All normal endometrial samples (n ⫽ 8) expressed CABLES whereas ⬎90% of endometrial hyperplasia and cancer specimens did not. More significantly, none of the endometrial carcinomas expressed CABLES protein (n ⫽ 10). In a subset of samples in which RNA was isolated, CABLES mRNA transcripts were present in normal but were absent in malignant endometrium. Western analysis of these specimens confirmed that the CABLES protein could be identified in normal but not malignant endometrial tissue. HES cells, a line originally derived from benign proliferative endometrium, express CABLES mRNA in vitro. Interestingly, however, tumors generated in nude mice from HES cells do not express CABLES protein. Conclusions. The data provide evidence that functional CABLES protein may be important for regulation of the cell cycle in normal endometrium. The loss of protein expression is associated with the transition from normal to hyperplastic endometrium. In all endometrial cancers examined, CABLES protein is absent. In addition, cultured cells that express CABLES mRNA fail to express protein in tumors when generated in nude mice. Together these findings suggest that the loss of CABLES may be a critical step in the development of endometrial cancer. 172. Analysis of Survival Following Laparoscopic Surgery in Women with Endometrial Cancer. Gamal H. Eltabbakh. University of Vermont/ Fletcher Allen Health Care, Burlington, Vermont. Objective. Laparoscopic surgery has recently been applied among women with early stage endometrial carcinoma (EC) with favorable results. However, the effect of such surgical approach on survival is still unclear. The objectives

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of the current study were to assess the effect of laparoscopic surgery on the survival of women with early stage EC and analyze the factors that affect such survival. Methods. A retrospective review of women presenting with clinical stage I EC over the past 5 years was performed. Women managed by laparoscopy were compared to those managed by laparotomy in their characteristics, surgical procedure, treatment, surgical stage, histology, tumor grade, and 2- and 5- year recurrence-free and overall survival. Factors affecting survival (surgical approach, histology, grade, and surgical stage) were evaluated using multivariate analysis and survival curves were constructed using Kaplan– Meier analyses. Results. One hundred women underwent laparoscopy and 86 underwent laparotomy. Both groups were similar in age, parity, menopausal status, lymphadenectomy, surgical stage, tumor grade, histology, and postoperative radiation therapy. Women who underwent laparotomy had a significantly higher body mass index than those who underwent laparoscopy (33.6 ⫾ 10.0 versus 28.8 ⫾ 7.1, P ⬍ 0.001). Women who underwent laparoscopy had similar 2- and 5-year recurrence-free and overall survival to those who underwent laparotomy (93% versus 94%, 98% versus 96%, 90% versus 92%, and 92% versus 92%, respectively). There was no significant difference in the sites of recurrence between both groups. Patients with grade 3 tumors, unfavorable histology (papillary serous, clear cell, or adenosquamous adenocarcinoma), and surgical stage III and IV had significantly lower survival than those with grade 1 and 2 tumors, favorable histology (endometrioid adenocarcinoma), and surgical stage I and II in both groups. In univariate and multivariate analysis, surgical stage, tumor grade, and histology (but not the surgical approach) were significant predictors of survival. Conclusions. Survival of women with early stage EC does not seem to be worsened by laparoscopic management. Surgical stage, tumor histology, and grade significantly affect survival regardless of the surgical approach.

173. Cyclooxygenase-2 (COX-2) Expression in Endometrial Cancer. Correlation with Clinicopathological Parameters and Clinical Outcome. Gabriella Ferrandina, Francesco Legge, Franco Oreste Ranelletti, Gian Franco Zannoni, Nicoletta Maggiano, Antonella Evangelisti, Salvatore Mancuso, Giovanni Scambia, and Libero Lauriola. Catholic University– Rome, Rome, Italy. Objective. COX-2 has been found to be overexpressed in several human cancers and has been associated with clinicopathological parameters of aggressiveness and unfavorable prognosis. Using immunohistochemistry we studied the expression of COX-2 and its association with clinicopathological features and clinical outcome in a single institutional series of primary untreated endometrial cancer patients. Microsatellite instability (MI) was also investigated. Methods. This study was conducted on 69 primary untreated endometrial cancer patients. All patients were submitted to total abdominal or modified radical hysterectomy plus bilateral salpingo-oophorectomy. Tumor tissues biopsies were obtained at first surgery in all cases. Sections were incubated with normal rabbit serum and then with rabbit polyclonal antiserum against human COX-2. MI was assessed by PCR analysis in 47 stage I–II endometrioid endometrial cancer patients without a familial history of cancer. Results. Twenty-seven cases (39.1%) were scored COX-2 positive. COX-2 positivity was higher (60.8%) in endometrial cancer with cervical or extrauterine involvement than in tumors limited to the corpus (28.3%; P ⫽ 0.0174). COX-2 positivity increased from grade 1 (13.6%) through grade 2 (41.7%) to grade 3 (60.9%) endometrial cancer (P ⫽ 0.0049). Interestingly, considering early FIGO stage patients (n ⫽ 53), the percentage of COX-2 positivity was higher in cases with deep myometrial invasion (66.7%) than in cases without or with less than 50% myometrial invasion (15.6%) (P ⫽ 0.0003). No association between COX-2 and MI status was found. COX-2-positive cases showed a trend to a shorter disease-free survival than COX-2-negative cases (P ⫽ 0.09). Conclusions. COX-2 is expressed in a high percentage of a large series of primary endometrial tumors and its expression seems to be closely associated with parameters of tumor aggressiveness The possible prognostic role of COX-2 in endometrial cancer deserves further investigation.

174. The Role of Omentectomy during the Surgical Staging of Uterine Papillary Serous Carcinoma. Paola A. Gehrig and Linda Van Le. University of North Carolina at Chapel Hill, Chapel Hill, North Carolina. Objective. Uterine papillary serous carcinoma (USC) has a propensity for extrauterine spread and is associated with a poorer prognosis than the endometrioid histology. Some proponents suggest that this disease be staged and treated in a similar fashion to serous ovarian carcinoma, thereby including omental sampling. However, given the primary organ involved, the International Federation of Gynecology and Obstetrics does not recommend omental sampling. The aim of this study is to evaluate the role of omental sampling during the surgical staging of USC. Methods. We retrospectively identified cases of USC at our institution from January 1990 to June 2000 and abstracted patient demographics, surgical procedure, stage, and sites of metastasis. Only those cases that contained ⬎25% USC on final pathology were included. Fisher’s exact test was used to calculate sensitivity, specificity, and positive and negative predictive value with a two-sided P value ⱕ0.05 considered statistically significant. Results. We identified 633 women with endometrial adenocarcinoma during the study period and 65 (10.3%) had USC histology. Fifty-two women underwent omental evaluation by either partial or total omentectomy. Thirty-four (65.4%) omentums were visually normal and benign on histologic review. Two (3.8%) were visually negative and histologically positive for metastatic USC. The remaining 16 (30.8%) omental specimens were grossly involved with histologic confirmation of disease. The sensitivity of a visually negative omentum is 0.89 (P ⬍ 0.0001). Conclusions. Microscopic omental metastasis from USC is rare and when the omentum is involved, thereby upstaging the patient to stage IVB disease, the disease is generally diagnosed by gross visualization. Therefore, omental sampling does not need to be included in the routine surgical staging of USC. 175. Pelvic and Para-Aortic Lymphadenectomy in Endometrial Cancer. Hans E. Geisler, John P. Geisler, Greg A. Miller, Michael C. Wiemann, Zhen Zhou, and William Crabtree. St. Vincent Hospitals and Health Services & Seraphim Cancer Research Foundation, Indianapolis, Indiana. Objective. The value of pelvic and para-aortic lymph node sampling, let alone lymphadenectomy, is questioned by some. The purpose of this study was to determine the rate of positive lymph nodes detected by complete lymphadenectomy in patients with endometrial carcinoma. Methods. Two hundred twenty-six consecutive patients with endometrial cancer from 1991 to 1996 were studied. Complete pelvic and para-aortic lymphadenectomy was performed in all cases studied. Pelvic lymphadenectomy was defined as complete clearing of all lymph-bearing tissues along the external, internal, and common iliac vessels as well as in the obturator space. Para-aortic lymphadenectomy was defined as complete clearing (bilaterally) of all lymph-node-bearing tissue from the aortic bifurcation to the renal vessels. Only patients with extrauterine disease received adjuvant therapy. Results. One hundred seventy-seven patients had endometrioid adenocarcinomas, 21 had papillary serous carcinomas, 12 had adenosquamous carcinomas, 10 had clear cell carcinomas, and 6 had undifferentiated carcinomas. One hundred forty-nine patients had stage I disease, 6 had stage II, 65 had stage III, and 6 had stage IV. Nine of 57 patients (15.8%) with grade 1 disease had positive lymph nodes, 16 of 103 (15.5%) with grade 2 disease had positive lymph nodes, and 18 of 66 (27.3%) with grade 3 disease had positive lymph nodes. There was not a significant difference in the rate of nodal positivity between patients with grade 1 or grade 2 tumors and those with grade 3 tumors (P ⫽ 0.061). There was also not a statistically significant difference in nodal positivity in patients with endometrioid versus nonendometrioid histology (P ⫽ 0.065). Thirty-six of 43 (83.7%) patients with nodal metastases had a depth of invasion of at least one-third of the myometrial thickness (P ⬍ 0.001). Conclusion. In this series of 226 patients with endometrial carcinoma undergoing complete pelvic and para-aortic lymphadenectomy, positive lymph nodes appear to be much more common than previously thought. A large multicenter trial comparing lymph node sampling to lymphadenectomy and its effect on survival should be undertaken.

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS 176. Nuclear and Cytoplasmic myc Staining in Endometrial Carcinoma and Their Relationship to Survival. Hans E. Geisler, John P. Geisler, Greg A. Miller, Zhen Zhou, Michael C. Wiemann, and William Crabtree. St. Vincent Hospitals and Health Services & Seraphim Cancer Research Foundation, Indianapolis, Indiana. Objective. The role of the myc proto-oncogene in genomic instability is just becoming more fully understood. However, its role in endometrial cancer is essentially unknown. The objective of this study was to determine the relationship among cytoplasmic and nuclear myc staining, DNA index, and survival in patients with endometrial carcinoma. Methods. One hundred twentyone patients with endometrial carcinoma were studied. Image analysis was used to determine DNA index. In addition to cytoplasmic and nuclear myc staining and DNA index, histologic type, stage, grade, depth of invasion, lymphovascular space invasion, and peritoneal cytology were evaluated as prognostic indicators. Univariate and multivariate analysis were performed. Results. One hundred twenty-one patients were followed for over 5 years. Myc cytoplasmic staining was present in 75.2% of the patients’ tumors and nuclear staining was present in 66.9% (P ⫽ 0.99). DNA index was significantly higher in patients with nuclear myc staining and no cytoplasmic staining (DNA index 1.38) compared to those patients whose tumors displayed cytoplasmic myc staining but no nuclear myc staining (1.18) (P ⫽ 0.016). Seventeen patients died during the follow-up period of this study. By multivariate analysis, myc cytoplasmic staining (P ⫽ 0.0076), nuclear staining (P ⫽ 0.011), and FIGO stage (P ⬍ 0.0001) were shown to be independent prognostic indicators predictive of survival. Conclusion. Nuclear and cytoplasmic myc staining, as well as FIGO stage, when assessed by multivariate analysis, was demonstrated to be an important factor in predicting survival in the 121 patients in this study. Nuclear myc staining and increasing FIGO stage were predictive of decreased survival while cytoplasmic myc staining was predictive of increased survival. 177. Adjuvant Chemotherapy and Radiation Therapy Do Not Improve Survival in Most Patients with Leiomyosarcoma of the Uterus. Robert L. Giuntoli II, Daniel S. Metzinger, Connie S. Dimarco, Stephen S. Cha, Jeff A. Sloan, Gary L. Keeney, and Bobbie S. Gostout. Mayo Clinic, Rochester, Minnesota; and University of Louisville, Louisville, Kentucky. Objective. The aim of this study was to evaluate the impact of standard surgical and adjuvant therapy and clinicopathologic characteristics on outcome in patients with leiomyosarcoma (LMS) of the uterus. Methods. Using the ICD 9 codes for LMS and malignant neoplasm of the uterus, a medical record search of the years 1976 to 1999 identified 285 potential study subjects. Charts were retrospectively reviewed and relevant clinical and pathologic data were extracted. A total of 208 patients met study inclusion criteria including confirmation of the diagnosis of LMS of the uterus by our department of pathology. Stage was assigned using the 1988 FIGO criteria for endometrial adenocarcinoma. Survival curves were generated using the methods of Kaplan and Meier and compared using the log-rank test. Multivariate analysis was performed using the Cox proportional model. P values ⬍0.05 were considered significant. Results. Median age of diagnosis was 50.9 years. Median follow-up of survivors was 7.6 years. Adjuvant radiation therapy (RT) and chemotherapy (CT) were given to 17 and 18% of patients, respectively. Bilateral salpingo-oophorectomy was documented in 82% of patients. Median disease-specific survival was 4.9 years. Univariate analysis demonstrated lower stage, lower grade, patient age ⱕ51, primary tumor diameter ⱕ5 cm, and ovarian preservation to be associated with significantly improved diseasespecific survival. However, neither RT nor CT improved disease-specific survival. Multivariate analysis revealed high grade and size ⬎5 cm to have a significant adverse effect on recurrence. In addition, high grade, advanced stage, and removal of the ovaries were associated with significantly worsened disease-specific survival. Conclusions. This is the largest clinicopathologic review of LMS of the uterus. Tumor grade and stage (using standard staging criteria for endometrial cancer) appear to be valid prognostic indicators for LMS of the uterus. Although LMS is a hormonally responsive tumor, ovarian

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preservation in selected cases does not appear to adversely impact prognosis. As adjuvant treatment does not appear to be beneficial to survival, the development of novel therapeutic options is critical for patients with high-risk LMS. 178. Outcome of Fertility-Sparing Treatment with Progestins in Young Patients with Endometrial Cancer. Walter H. Gotlieb, Mario Beiner, Yaacov Segal, Nissim Zmira, Yaacov Korach, and Gilad Ben-Baruch. Tel Aviv University, Tel Hashomer, Israel. Objective: The aim of this study was to evaluate the safety of fertilitysparing hormonal therapy as treatment for endometrial cancer in young patients. Methods. The clinical and pathological records of 71 patients diagnosed with endometrial adenocarcinoma prior to the age of 40, treated, and followed over a 30-year period in the division of gynecologic oncology were reviewed. Eleven patients who underwent conservative management with progestins were identified and are the subjects of this study. Results. Follow-up was available for all patients. Age at presentation ranged from 23 to 40 years, with a mean age of 31 years. All patients were nulliparous. In 6 patients the diagnosis was made during infertility workup and 4 patients had a history of anovulation. All patients responded to treatment within a mean period of 3.5 months, with normal pathology on follow-up endometrial samplings. Three patients had no residual disease after 2 months of treatment, another 5 patients had no residual disease after 3 months of treatment, and the remaining 3 patients required a longer period to achieve complete response (4, 5 and 8 months). Five patients had a recurrence within a mean period of 33 months (range 19 – 44). Four patients were treated with a second course of progestins, and all had a histologic complete response. Three patients ultimately underwent hysterectomy and staging. Seven healthy babies were born, and all patients remain without evidence of disease, with a mean follow-up of 85 months. Conclusions. Conservative management of well-differentiated endometrial carcinoma in young patients, combined with assisted reproductive technologies if needed, does not seem to worsen the prognosis and provides the chance of conceiving and carrying a normal pregnancy. 179. Immunohistochemical Evaluation of the c-Kit Proto-Oncogene in Sarcomas of the Uterus. Warner K. Huh, Michael G. Conner, J. Michael Straughn Jr., Charles A. Leath III, Mack N. Barnes III, Ronald D. Alvarez, and Edward E Partridge. University of Alabama at Birmingham, Birmingham, Alabama. Objectives. C-kit, a growth factor receptor with tyrosine kinase activity, is expressed in gastrointestinal stromal tumors (GIST), and an inhibitor of c-kit, STI-571, has recently been shown to have significant anti-tumor activity in GIST. The aim of this study was to evaluate the incidence of c-kit expression in sarcomas of the uterus. Methods. Immunohistochemical evaluation for the expression of c-kit was performed in specimens from 11 patients with pathologically documented uterine sarcomas. Histologic subtypes included 5 carcinosarcomas, 3 leiomyosarcomas, and 3 endometrial stromal sarcomas. Histologic sections of formalin-fixed, paraffin-embedded hysterectomy specimens from patients with uterine sarcomas were immunostained with c-kit (CD117) antibody (Santa Cruz Biotechnology, Santa Cruz, CA). A GIST sample was used as a positive control and standard negative controls were used in this study. Staining intensity was broken down into the following three categories: strong, intermediate, and weak. Immunostaining results in both the epithelial and the mesenchymal elements in the carcinosarcomas were also evaluated. Results. In all 11 patients with uterine sarcomas, c-kit (CD117) immunostaining was positive. Four specimens demonstrated a stronger staining intensity than the GIST control. Five specimens demonstrated intermediate staining intensity, and 2 specimens demonstrated weak staining intensity. Furthermore, in the carcinosarcoma specimens, the epithelial and sarcomatous elements were both positive for c-kit staining. Conclusions. In this pilot study, c-kit expression was demonstrated in all sarcomas of the uterus, irrespective of histologic type. These results suggest that drugs that inhibit the c-kit tyrosine kinase, such as STI-571, should be investigated in these mesenchymal neo-

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plasms. As such, a clinical trial with STI-571 has been proposed for patients with advanced or recurrent uterine sarcomas. 180. p53 and p21 Genetic Polymorphisms and Endometrial Cancer Risk among Koreans. Kim Jae-Weon, Roh Ju-Won, Seo Sang-Soo, Kim Moon-Hong, Park Noh-Hyun, Song Yong-Sang, Park Sang-Yoon, Kang Soon-Beom, and Lee Hyo-Pyo. Center for Uterine Cancer, National Cancer Center, Goyang, Gyeonggi, South Korea; Department of Ob/Gyn, Seoul National University; Cancer Research Institute, Seoul, South Korea; and Seoul National University Hospital, Seoul, South Korea. Objective. Genetic polymorphism at codon 72 (CCC/proline to CGC/ arginine [Pro 72Arg]) of the p53 gene is one of the most frequently studied subjects in the pursuit of the association of specific cancers with single nucleotide polymorphisms. An association between endometrial cancer and polymorphism at codon 31 (AGC/serine to AGA/arginine [Ser 31Arg]) of the p21 gene, known as a downstream mediator of p53, has been reported. Methods. To investigate the association between polymorphisms in the p53 and p21 genes and endometrial cancer risk among Koreans, we designed a case– control study of 95 endometrial cancer patients and 101 noncancer controls. Results. We found statistically significant differences in the frequency of p53 and p21 genotypes between the two groups, respectively. The p53 Pro allele, collapsing the homozygous and heterozygous categories, was significantly associated with endometrial cancer with an odds ratio (OR) of 2.415 (95% confidence interval [CI], 1.345– 4.338, P ⫽ 0.003). Patients with endometrial cancer had an OR of 0.375 (95% CI ⫽ 0.158 – 0.889, P ⬍ 0.001) for heterozygosity relative to the control group when homozygosity of the Arg allele of p21 was assumed as a baseline. On the other hand, homozygous carriers of the p21 Ser allele showed a substantially increased risk (OR ⫽ 2.415, 95% CI ⫽ 1.345– 4.338, P ⫽ 0.003) of endometrial cancer compared to homozygous and heterozygous carriers of the Arg allele. Moreover, there was a statistically significant multiplicative interaction between p53 and p21 genotype for the risk of endometrial cancer (P ⬍ 0.001). Conclusions. These data suggest a significant association between the genetic polymorphisms of p53 and p21 and endometrial cancer risk among Koreans. 181. Microarray Analysis Reveals Differential Gene Expression between Endometrial Cancer and Normal Endometrium. Lisa M. Dauffenbach and Patricia L. Judson. University of Minnesota, Minneapolis, Minnesota. Objective. Little is known about gene expression and tumorigenesis in endometrial cancer. Although endometrial cancer is generally a curable cancer, when advanced or recurrent disease is encountered the treatment results are often disappointing. Microarray technology allows us to look at the expression of thousands of genes at one time. Analysis of these microarrays is a powerful approach for gaining insight into the molecular mechanisms involved in the development and progression of endometrial cancer, helping us to identify anticancer genes and disease-specific targets for cancer therapy. The aim of this study was to compare the gene expression in endometrial cancer with that in normal endometrium to distinguish differentially expressed genes that play a role in the tumorigenesis of the endometrium. Methods. Affymetrix U95A human gene chips were used to analyze the expression of 12,000 genes in 10 specimens of endometrioid adenocarcinoma of the endometrium (varying stages and grades) compared to 10 specimens of normal endometrium. cDNA was synthesized from 10 –15 ␮g of purified total RNA. The cDNA was used as a template to prepare biotin-labeled cRNA by in vitro transcription. cRNA was hybridized to the oligonucleotide array. Detection of bound probe was achieved by confocal microscopy. Gene expression profiles were subject to analysis algorithms using Affymetrix Genechip software to identify novel, differentially expressed genes specific to endometrial cancer. Results. A differential pattern of expression was observed in 1147 genes: 531were up regulated and 616 were down regulated. Analyzing genes with a fivefold or greater change, 59 genes were up regulated and 49 were down regulated. The differentially expressed genes include those associated with angiogenesis, apoptosis, transcription, cell-cycle regulation, signaling, and hormone re-

sponse. Many of the genes have previously been implicated in tumor progression and poor prognosis. Conclusion. Based on our analysis of differentially expressed genes, it may be possible to identify cell signaling pathways altered by the specific gene expression of endometrial cancer. A better understanding of the molecular circuitry in endometrial cancer compared to normal endometrium will likely provide new targets for treatment. The characterization of these differentially expressed genes is an important step in the understanding of endometrial tumorigenesis. 182. Expression of Cyclooxygenase-2 in Endometrial Adenocarcinoma. Gokhan Kilic, Josef Blankstein, Jack Garon, Banu K. Arun, and Raheela Ashfaq. Chicago Medical School–Mount Sinai Hospital, Oak Park, Illinois; M. D. Anderson Cancer Center, Houston, Texas; and University of Texas Southwestern Medical Center, Dallas, Texas. Objective. Studies have shown that COX-2 is upregulated in several epithelial carcinomas. In this study, we aim to elucidate whether endometrial cyclooxygenase-2 (COX-2) expression in endometrial adenocarcinoma is greater than its expression in normal endometrium. Methods. Deparaffinized tissue sections from patients with endometrial adenocarcinoma were analyzed by immunohistochemistry for the presence of COX-2. A control group was developed from 13 age-matched patients without malignancy who had undergone surgery for uterine prolapse. Statistical analysis was performed by the Kruskal–Wallis test, and differences between groups were evaluated using Fisher’s exact test. Results. COX-2 was markedly increased in 13 of 36 (36.1%) endometrial adenocarcinomas; in contrast, only 1 of 13 (7.7%) control specimens demonstrated increased COX-2 expression (P ⫽ 0.05). Eight of 13 COX-2-positive patients in the study had well-differentiated adenocarcinoma; the remaining 5 COX-2-positive patients had moderately and poorly differentiated adenocarcinoma (4 and 1, respectively). Conclusion. Our results imply that COX-2 expression in the endometrium is associated with endometrial adenocarcinoma. This may provide a complimentary target for chemoprevention for endometrial adenocarcinoma. In addition, with new selective inhibitory molecules emerging, inhibition of COX-2 may play a role as an alternative approach, especially in well-differentiated endometrial carcinoma. Further studies are required to investigate the role of COX-2 in carcinogenesis. 183. When Is Paraaortic Lymphadenectomy Useful? Andrea Mariani, Maurice J. Webb, Gary L. Keeney, Giacomo Aletti, and Karl C. Podratz. Mayo Clinic, Rochester, Minnesota; and University of Milano, Milan, Italy. Introduction. It has been recently suggested that paraaortic (PA) lymphadenectomy (LND) may be therapeutic in patients with positive lymph nodes (LNs) (Mariani et al., Gynecol Oncol 2000) and that patients with positive LNs portend a risk for PA failure. The objective of this study was to determine when PA LND may be useful (from both a diagnostic and a therapeutic point of view) in patients with endometrial carcinoma. Methods. We studied 612 consecutive epithelial endometrial cancer patients who had a hysterectomy over a period of 10 years. We reasoned that PA LND may have been useful, for diagnostic and/or therapeutic purposes, in those patients who had positive PA LNs or who subsequently experienced a PA failure or both (n ⫽ 41; subgroup hereafter identified as PA⫹). We excluded from the analysis patients who had no information about the status of PA LNs but received adjuvant irradiation to the PA area and those patients without information about sites of recurrent disease. ␹ 2 and logistic regression methods were used for statistical analyses. Results. Based on univariate analysis, stage IV disease, cervical stromal invasion, adnexal involvement, myometrial invasion ⱖ66%, tumor diameter ⬎2 cm, tumor invading the whole uterine cavity, positive peritoneal cytology, positive pelvic LNs, histologic grade 3, nonendometrioid histology, and lymph–vascular invasion (LVI) were significantly (P ⱕ 0.01) associated with PA⫹. However, logistic regression analysis identified only two independent factors predictive of PA⫹: positive pelvic LNs (P ⬍ 0.001; OR ⫽ 36.60) and LVI (P ⫽ 0.03; OR ⫽ 5.93). Notably, only 2% of patients with negative pelvic LNs were PA⫹, compared to 47% of those with positive pelvic LNs; moreover, only 2% of patients without LVI were PA⫹, compared to 33% of

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS those with LVI (P ⬍ 0.001). When both variables were negative only 0.8% of the patients were PA⫹, compared to 33% among those patients with at least one of these two variables being positive. Patients with positive pelvic LNs and/or LVI represented 19% of the overall population of endometrial cancers. Conclusion. Positive pelvic LNs and LVI identify a subgroup of endometrial cancer patients (19% of the overall population) that may benefit from PA LND and/or adjuvant therapy. 184. A Phase II Trial of LY353381-HCl, a Selective Estrogen Response Modulator, in Patients with Recurrent or Advanced Endometrial Cancer. D. Scott McMeekin, Alan Gordon, Jeffrey M. Fowler, Allen S. Melemed, Richard E. Buller, Thomas W. Burke, Jeffrey Bloss, and Paul J. Sabbatini. Eli Lily & Co., Indianapolis, Indiana; Ellis Fishel Cancer Center, Columbia, Missouri; Memorial Sloan-Kettering Cancer Center, New York, New York; Ohio State University, Columbus, Ohio; Texas Oncology, Dallas, Texas; University of Iowa Hospitals and Clinics, Iowa City, Iowa; University of Texas, Houston Health Science Center, Houston, Texas; and University of Oklahoma, Health Sciences Center, Oklahoma City, Oklahoma. Objective. The aim of this study was to determine the response rate and evaluate the toxicity of LY353381-HCl (arzoxifene) in patients with recurrent or advanced endometrial cancer (EC). Methods. A phase II, open labeled study with LY353381-HCl was performed at 13 centers. Patients with measurable recurrent/advanced EC, not amenable to curative therapies, were eligible if either the primary tumor or the recurrent tumor was ER⫹ and/or PR ⫹. If receptor status could not be determined, patients with well or moderately well differentiated EC were also permitted. Prior use of salvage chemotherapy was not allowed; however, prior use of progestins was permitted and patients were stratified by prior exposure to progestin. Patients received 20 mg/ day PO and were to be treated for at least 8 weeks in the absence of disease progression or unacceptable toxicity. Efficacy was based on the frequency of complete and partial responses (CR, PR), and a 95% confidence interval (CI) was calculated. The Kaplan–Meier method was used to analyze time to progression and duration of response. Results. From February 1999 through April 2001, 37 patients were entered, of whom 34 received treatment. Efficacy was evaluated for the 29 patients who received at least 4 weeks of therapy, and safety was assessed in all 34 patients who received any drug. Thirty patients were considered progestin sensitive (no prior progestin use or no use in the past 6 months), and 4 had previously progressed while on progestins. Twenty-six patients were ER⫹, and 22 were PR⫹. Nine (1 CR ⫹ 8 PR) of 29 patients responded (31%, CI 25–51%), with a median duration of response of 13.9 months. All 9 responses occurred in progestin-sensitive patients. Two additional patients (1 from each progestin cohort) had stable disease for ⱖ6 months. The median time to progressive disease was 3.7 months (CI 1.9 – 6.6 months) and the median time to treatment failure among all 29 patients was 3.5 months (CI 1.8 – 6 months). Toxicity was minimal with no grade 3– 4 toxicities, and 9 patients had only grade 1–2 toxicities (7 grade 1, 2 grade 2). Hot flashes were the most common toxicity, and in all 3 reported cases they were grade 1. Conclusions. Arzoxifene has demonstrated a high response rate with the longest median duration of response reported in a phase II trial of this patient population. The ease of administration and extremely favorable toxicity profile make this an agent warranting further evaluation. 185. Urokinase Plasminogen Activator Receptor. Correlation with Pathologic and Clinical Outcome in Endometrial Cancer. Sanaz Memarzadeh, Sathima Natarajan, Lisbeth H. Chang, Peter Shintaku, and Robin FariasEisner. Department of Obstetrics and Gynecology and Department of Pathology, University of California Los Angeles, School of Medicine, Los Angeles, California. Objective. Urokinase plasminogen activator receptor (UPAR) is a glycosylphosphotidylinositol-linked membrane protein. Activation of this receptor can enhance degradation of the extracellular matrix resulting in invasion and metastasis. UPAR overexpression has been demonstrated in epithelial carci-

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nomas such as breast, lung, liver, ovary, and bladder. The objective was to examine the expression of UPAR protein in endometrial cancer and correlate it with grade, stage, recurrence-free interval, and overall survival. Methods. Seventy formalin-fixed surgically excised endometrial tissue specimens were accessioned through the Department of Pathology registry. Immunohistochemical analysis was performed using UPAR goat anti-human polyclonal antibody. UPAR protein expression was examined in 7 normal tissues, 5 with endometrial hyperplasia, and 58 specimens with endometrial cancers (endometrioid n ⫽ 40, uterine papillary serous carcinoma n ⫽ 12, mixed malignant mesodermal tumors n ⫽ 6). Staining intensity was graded 0 to 3⫹. A retrospective review was performed to determine stage, recurrence-free interval, and overall survival. Results. There was no UPAR expression in 7 benign endometrium samples. UPAR protein expression was positively correlated with grade of disease (0.71, P ⬍ 0.0001). The highest levels of UPAR expression were noted in 29% of grade 1 specimens, 57% of grade 2 specimens, and 91% of specimens with grade 3 disease. UPAR protein expression was highly correlated with stage (0.625, P ⬍ 0.0001): 40% of patients with stage I, 66% of patients with stage II, 100% of patients with stage III, and 85% with stage IV demonstrated the highest level of UPAR expression. The median follow-up was 12 months. There was no recurrence when tumors had low levels of UPAR protein, an 11% recurrence when moderate levels of UPAR were expressed, and a 42% recurrence when high levels of UPAR protein were expressed (P ⬍ 0.003). Conclusions. UPAR protein expression: (i) positively correlated with grade in endometrial cancer, (ii) was high in aggressive subtypes of endometrial cancer (i.e., UPSC and MMMT), (iii) correlated with stage of disease, (iv) positively correlated with rate of recurrence and death, and (v) demonstrated inverse association with disease-free survival. UPAR is a useful marker for biologically aggressive forms of endometrial cancer and may be a potential target in the treatment of this disease.

186. MSI in Endometrial Carcinoma: Absence of MLH1 Promoter Methylation Is Associated with Increased Familial Risk for Cancers. David G. Mutch, Sheri Babb, Janet S. Rader, Thomas J. Herzog, Christina Todd, Jennifer L. Ivanovich, Paul J. Goodfellow, and Alison J. Whelan. Washington University School of Medicine, St. Louis, Missouri. Objectives. Loss of DNA mismatch repair occurs in a variety of malignancies and is associated with genome-wide instability of microsatellite repeats, a molecular phenotype referred to as microsatellite instability (MSI). MSI is a consistent feature of colorectal and endometrial tumors from patients with hereditary nonpolyposis colorectal cancer (HNPCC). Sporadic colorectal and endometrial cancers that exhibit MSI frequently have methylation of the MLH1 promoter. Methods. We undertook a detailed family and medical history study to compare family cancer risk for women with MSI-positive and -negative endometrial cancers. MLH1 promoter methylation was assessed for MSI-positive cancers. Family histories were developed for 80 probands (40 with MSI-positive and 40 with MSI-negative tumors). The number of reported cancers in the first- and second-degree relatives of the two groups was similar. Results. There was a modest increase in familial cancer clustering for MSIpositive probands. When MSI-positive tumors were subclassified according to MLH1 promoter methylation, an association between methylation status and familial cancer risk was evident. Women with MSI-positive endometrial cancers in which the MLH1 promoter was unmethylated had a threefold relative risk of demonstrating familial clustering of cancers (P ⫽ 0.003, Fisher’s two-sided test). When only those malignancies for which medical records could be obtained to confirm the diagnosis were considered, the relative risk increased to 7.07 (95% confidence interval 2.29 –21.81). Furthermore, women with MSI-positive, MLH 1 unmethylated tumors were significantly younger than the rest of the study population (56.1 years vs 65.4 years, P ⫽ 0.01). Conclusion. Age of onset and family history of cancers are associated with tumor MSI in the absence of MLH1 promoter methylation. Therefore, women with MSI-positive tumors without methylation of the MLH1 promoter may have increased genetic susceptibility to malignancies.

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187. Adjuvant Therapy in Uterine Papillary Serous Carcinoma. Monica Prasad, Brian M. Slomovitz, Robert M. Allbright, Xiaolin Liu-Jarin, and Thomas A. Caputo. New York Presbyterian Hospital–Weill Medical College of Cornell University, New York, New York. Objective. The aim of this study was to examine the various adjuvant therapy regimens administered to patients with uterine papillary serous carcinoma (UPSC) at a single institution and to compare survival rates between treatment regimens within each stage. Methods. Fifty-seven patients with histologically diagnosed UPSC underwent surgical resection and staging of disease from 1/1987 to 2/2001. A retrospective review of clinicopathologic features was performed for each patient with emphasis on adjuvant therapy regimen. Four groups were compared within each stage: chemotherapy alone (CT), chemotherapy and radiation therapy (CT ⫹ RT), radiation therapy alone (RT), or no adjuvant therapy. Analysis of survival was performed using the Kaplan–Meier method and comparisons of survival were made with the log-rank test. Results. The mean age for all 57 patients was 66.9 years, with 89.7% postmenopausal and 86.2% parous. The distribution of patients was FIGO stage I (n ⫽ 21), stage II (n ⫽ 4), stage III (n ⫽ 20), and stage IV (n ⫽ 12). Chemotherapy regimens consisted of cyclophosphamide/doxorubicin/cisplatin (n ⫽ 19) or paclitaxel/cis- or carboplatin (n ⫽ 21). Radiation therapy was external beam whole-pelvic radiation therapy (n ⫽ 30). All eight patients in stage I who received CT ⫹ RT were alive at time of last follow-up (7/8 no evidence of disease and 1/8 alive with disease) with a median of 19.25 months. Median survival (MS) for the six patients who did not receive adjuvant therapy with stage I disease was 13.70 months. The CT ⫹ RT group showed improved survival versus those with no adjuvant therapy in stages I (P ⫽ 0.044) and III (P ⫽ 0.001). All four patients with stage II disease received CT ⫹ RT and were alive without evidence of disease at time of last follow-up with a median of 26.32 months. In stage III, patients with CT ⫹ RT had MS ⫽ 33.40 months and those with no therapy had MS ⫽ 7.20 months. A trend toward improved survival was found in stage III for CT alone or RT alone versus no therapy with P values of 0.064 and 0.074, respectively. For stage IV disease, those who received CT ⫹ RT (MS ⫽ 34.70 months) survived significantly longer than those with CT alone (MS ⫽ 26.87 months, P ⫽ 0.039). Conclusions. Adjuvant therapy for patients with UPSC utilizing a combination of platinum-based chemotherapy and whole-pelvic radiation therapy is associated with significantly longer survival versus no therapy for stages I and III and may be superior to chemotherapy alone for stage IV disease. 188. Promoter Hypermethylation and Lack of Expression of the Adenomatous Polyposis Coli Tumor Suppressor Gene in Endometrial Cancers. John I. Risinger, G. Larry Maxwell, Tricia Patterson, Barbara J. Davis, Andrew Berchuck, and J. Carl Barrett. Duke University Medical Center, Durham, North Carolina; National Cancer Institute, Bethesda, Maryland; National Institute of Environmental Health Sciences, Research Triangle Park, North Carolina; and Walter Reed Army Medical Center, Washington, DC. Objective. Increased nuclear accumulation of the ␤-catenin transcription factor is present in about one-third of endometrial adenocarcinomas and is believed to play a role in malignant transformation. Our group and others have shown that mutations in exon 3 of ␤-catenin that stabilize the protein product occur in some, but not all, of these cancers. Since the adenomatous polyposis coli (APC) tumor suppressor gene product is involved in degradation of ␤-catenin, we sought to determine whether inactivation of APC underlies increased nuclear ␤-catenin levels which are characteristic of many endometrial adenocarcinomas. Methods. We examined APC expression in 7 immortalized endometrial cancer cell lines, 25 primary endometrial adenocarcinomas, and 7 normal endometrial samples using RT-PCR and immunohistochemistry. Mutation screening was performed using protein truncation testing and DNA sequencing in a subset of 17 cancers. Methylation-specific PCR was used to assess whether the APC promoter was hypermethylated in the cancer cell lines and primary tumors. Results. A complete lack of APC transcript was found in 5 of 7 (71%) immortalized endometrial cancer cell lines (AN3CA, HHUA, Rl95-2, HEC-1-A, and HEC-59) and APC protein was

absent in 7 of 25 (28%) primary endometrial cancers. We did not find mutations in any of the primary endometrial cancers screened, including those with decreased APC expression. APC promoter hypermethylation was detected in the 5 endometrial cancer cell lines and in 5 of 7 (71%) primary endometrial cancers lacking APC expression using methylation-specific PCR. Cell lines, primary cancers, and normal endometria that expressed APC were found to contain unmethylated APC promoter alleles. Treatment of APC-negative immortalized endometrial cancer cell lines (AN3CA and HHUA) with the DNA methylation inhibitor 5 Aza Dc restored expression of APC suggesting a role for promoter methylation in silencing of the APC gene. Conclusions. These data suggest that increased nuclear accumulation of the ␤-catenin transcription factor in some endometrial adenocarcinomas is attributable to loss of expression of the APC tumor suppressor gene due to promoter hypermethylation. Restoration of APC tumor suppressor gene expression represents a potential molecular therapeutic strategy for treatment of endometrial cancers. 189. Whole-Pelvis Radiotherapy Is Not Necessary in High-Risk Surgical Stage 1 Endometrial Cancer. Paula V. Rittenberg, Robert J. Lotocki, Mark S. Heywood, Keith D. Jones, and Garry V. Krepart. University of Manitoba, Winnipeg, MB, Canada. Objective. Prior to 1995, surgically staged endometrial cancers with greater than 50% myoinvasion (FIGO 1C) were treated with vault brachytherapy and whole-pelvis (WP) radiotherapy despite negative nodes. After October 1, 1995, these patients were treated with vault brachytherapy alone. The aim of this study was to ensure that the survival and recurrence rate has not changed. Methods. A review of Cancer Care Manitoba charts was undertaken in a retrospective fashion. All patients diagnosed with endometrioid adenocarcinoma between October 1, 1995, and January 2000 were reviewed. Data for all FIGO stage 1 patients, and a subset of stage 1C patients, were analyzed and compared with those of a historical control group, composed of patient data previously collected in our center (1978 –1990). Results. A total of 160 patients had pelvic lymph node sampling for endometrioid-type endometrial cancer where no extrauterine disease was present, and 134 (83.8%) proved to be FIGO stage 1. Distribution by FIGO stage was 7.5% 1A (10 patients), 56.0% 1B (75 patients), and 35.8% 1C (48 patients). Forty-four patients were spared WP radiotherapy on the basis of negative nodes. Four patients had inadequate node sampling (0 or 1 node) and were therefore treated with WP radiotherapy. All patients with greater than one-third myoinvasion received vault brachytherapy. Two recurrences occurred (one pelvic and one extrapelvic) and both subsequently died. Four patients were lost to follow-up and three died of intercurrent disease. Mean and median follow-ups were 26.9 and 24 months, respectively. Recurrence rate in FIGO stage 1 disease was 1.5% (2/134) and for the subset 1C was 4.5% (2/44). The recurrence rate was not statistically and significantly different from the historical control group, 3.6% for stage 1 (P ⫽ 0.33) and 6.6% for stage 1C (P ⫽ 1.0). Two-year and 5-year survivals for stage 1 patients in this study were 97 and 92%, respectively. In the historical group, 2-year and 5-year survivals were 97 and 94%, respectively. Survival did not change significantly with omission of whole-pelvis radiotherapy in this group of patients. Conclusion. Whole-pelvis radiotherapy can be safely omitted in patients with FIGO stage 1C endometrial cancer if nodal status is known. As WP radiotherapy has potential morbidities, this knowledge greatly improves the care of our patients. 190. HER2/neu Overexpression in Uterine Serous Papillary Carcinoma. Alessandro D. Santin, Stefania Bellone, Michela Palmieri, Gokden Murat, Juan Roman, Sergio Pecorelli, Martin Cannon, and Groesbeck P. Parham. University of Arkansas for Medical Sciences, Little Rock, Arkansas; and University of Brescia, Brescia, Italy. Objective. To evaluate the expression of HER-2/neu, the transmembrane receptor encoded by the c-erbB2 gene, in fresh, established, and paraffinembedded fixed uterine serous papillary carcinoma cells (USPC). To evaluate the sensitivity of USPC cells to Herceptin treatment. Methods. Ten USPC specimens were assessed by immunohistochemistry for the intensity of ex-

SOCIETY OF GYNECOLOGIC ONCOLOGISTS—ABSTRACTS pression of HER-2/neu. In addition, USPC cell lines were analyzed at different time points of in vitro growth for expression of HER-2/neu by flow cytometry as well as for sensitivity to Herceptin treatment. Results. Eight of 10 (80%) USPC assessed immunohistochemically for the intensity of expression of HER-2/neu stained heavily for HER-2/neu (2⫹ to 3⫹). Fresh and established primary USPC cell lines were found to express significantly more HER-2/neu receptor by flow cytometry (on the average 10-fold greater) when compared to HER-2/neu positive primary or established breast and ovarian cancer cell lines (P ⬍ 0.001). Importantly, while these USPC cell lines were resistant to chemotherapy in vivo and to natural killer cytotoxicity in vitro, they were found to be highly sensitive to Herceptin-mediated antibody-dependent cellular cytotoxicity (ADCC). USPC cell proliferation was also inhibited by Herceptin. A significant enhancement of ADCC was demonstrated when effector cells were exposed to low doses of IL-2 in vitro. Physiologic concentrations of human serum IgG did not inhibit Herceptin-mediated cytotoxicity against USPC. Conclusions. On the basis of these findings and previous reports showing a positive in vivo correlation between efficacy of Herceptin therapy and the level of HER-2/neu overexpression by tumor cells, we propose that Herceptin might be a novel and attractive therapeutic strategy in patients harboring chemotherapy-resistant, recurrent, or metastatic USPC. 191. Incidence and Survival Rates for Gestational Trophoblastic Disease (GTD) in the U.S.A.: A SEER (1973–1997) Population-Based Study. Harriet O. Smith, Beth A. Prairie, Luis A. Padilla, Clifford R. Qualls, and Charles R. Key. University of New Mexico Health Sciences Center, Albuquerque, New Mexico. Objective. To compare incidence and survival rates for malignant GTD in the U.S.A. using population-based data. Methods. The Surveillance, Epidemiology, and End-Results Public-Use Database [SEER STAT 4.0, 9 original registries, 1973–1998] was used to compute, by 5-year sequential intervals (1973–1997), age-adjusted incidence rates (AAIRs) and age-adjusted relative survivals (AARSs) per 100,000 women-years, by histology, race, region, stage, and age. Statistics included Fisher’s exact and Mantel–Haenszel common odds ratio estimates (COR) with 95% confidence intervals (CI). Results. A total of 433 cases— 422 choriocarcinomas and 11 placental site tumors—were identified. The AAIR overall was 0.136 and declined by 46% [from 0.180 (1973– 1977) to 0.098 (1993–1997)] over 25 years. By race (AAIRs), 292 whites (0.114), 82 blacks (0.228), 58 others (0.209), and 1 unknown were affected. Per 5-year interval, AAIRs were significantly higher for blacks vs whites (COR 2.19, 95% CI 1.71–2.79, P ⬍ 0.001), whites vs others (COR 2.14, 95% CI 1.61–2.84, P ⬍ 0.001), but not for blacks vs others (COR 0.99, 95% CI 0.70 –1.38, P ⫽ 0.96). There were also significant differences (all P ⬍ 0.001) in AAIRs by geographic region, age at diagnosis, and stage of disease. By stage (localized, regional, distant, respectively), AAIRs declined by 49.1% [from 0.057 (1973–1977) to 0.029 (1993––1997)], 18.2% [from 0.011 (1973– 1977) to 0.009 (1993–1997)], and 41.4% [from 0.085 (1973–1977) to 0.050 (1993–1997)]. By race, AAIRs decreased 39.5% for whites [from 0.114 (1973–1977) to 0.089 (1993–1997)], 47.2% for blacks [from 0.339 (1973– 1977) to 0.179 (1993–1997)], and 46.5% for others [from 0.357 (1973–1977) to 0.191 (1993–1997)]. The 5-year AASR overall was 0.8927 and was significantly influenced (all P ⬍ 0.001) by stage (localized 0.9554, regional 0.9157, distant 0.8142, unknown 0.9694, P ⬍ 0.001), race (blacks 0.8126, others 0.8726, whites 0.9174, P ⫽ 0.01), and age (P ⬍ 0.001). By race, post-hoc testing determined that only blacks had poorer AASRs [blacks vs whites COR 2.60 (95% CI 1.28, 5.267), P ⫽ 0.008]. Conclusions. Malignant GTD AAIRs declined by 46% over 25 years and were influenced by age at diagnosis, stage of disease, race, and geographic region. While survivals overall were excellent and improved over calendar time, survival rates were significantly influenced by stage of disease, age at diagnosis, and race, with blacks alone at increased risk. 192. Whole-Abdominal Radiotherapy in Stage I and II Papillary Serous (PS) or Clear-Cell (CC) Cancers of the Uterus (A GOG Study). Gregory

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Sutton, Brian Bundy, Janice Axelrod, T. Roy, Howard Homesley, John Malfetano, B. Mychalczak, and M. King. Gynecologic Oncology Group, Buffalo, New York. Objectives. To evaluate toxicity and outcome among patients with stage I and II PS or CC treated with whole-abdominal radiotherapy. Methods. After TAH–BSO, pelvic/para-aortic lymph node sampling, peritoneal washings, and central pathology review, eligible patients (adequate hematologic, renal, hepatic function, and signed informed consent) were treated with radiotherapy utilizing anterior/posterior parallel opposed fields to the abdomen (3000 cGy @ 150 cGy/day) and pelvis (1980 cGy @ 180 cGy/day). Posterior kidney but no liver shielding was used. Doses were decreased by 25 cGy/day for severe gastrointestinal symptoms or granulocytopenia. Results. Between 1986 and 1994, forty-nine patients with stage I and II PS (31) or CC (18) cancers of the uterus were treated. There were 4 grade IV and 1 grade III GI toxicities, 1 grade IV and 4 grade III hematologic toxicities, and grade III toxicities of GU (2), CV (1), hepatic (1), and cutaneous (2) origin. Thirty-one patients with PS had a median age of 68 (48 – 83) years. One refused therapy and died of disease (DOD) at 38 months. A second patient received a protocol-violating vaginal boost and was alive with no disease (NED) at 97 months. Thirteen patients were DOD at 4.4 to 60.4 months. One death was attributed to protocol toxicity, one was caused by toxicity of subsequent chemotherapy, and three were from intercurrent disease (DOC) or unknown cause. Ten patients were NED at 60 –114 months. PFS was 35% at 5 years. Sites of recurrence (2.8 – 40.1 mos) were lung (3), lung ⫹ vagina (1), abdomen/pelvis (7), vagina (1), and unknown site (1). Eighteen patients with CC had a median age of 66 (46 – 86). One patient who received pelvic radiotherapy only was DOD at 9 months. Four additional patients were DOD, 1 was DOC, and 1 died of unknown cause. Eleven patients (61%) were NED at 60 – 83 months. PFS was 61% at 5 years. Sites of recurrence (6.4 – 67.5 mos) were lung (1), vagina (1), abdomen (1), and unknown (1). Conclusions. In this small series, whole-abdominal radiotherapy was of limited value in patients with stage I/II PS. Patients with CC fared better (not significantly). Since at least 62% of PS recurrences (8/13) and 50% (2/4) of CC recurrences were within treatment fields, consideration should be given to radiosensitizing chemotherapy in future adjuvant radiotherapy trials involving these patients.

193. Laparoscopic-Assisted Vaginal Hysterectomy (LAVH) in Stage I Endometrial Cancer Does Not Increase the Incidence of Positive Peritoneal Cytology. Ignace Vergote, Isabel De Smet, Frederic Amant, and Patrick Berteloot. University Hospitals Leuven, Leuven, Belgium. Objective. Recently Sonada et al. (Gynecol Oncol 2001;80:378) reported an increased incidence of positive peritoneal cytology in low-risk endometrial cancer treated at the Memorial Sloan Kettering Cancer Center with LAVH compared with a contemporarily treated group of patients treated with total abdominal hysterectomy (TAH). Methods. Between September 1993 and March 2001, 156 hysterectomies with bilateral salpingo-oophorectomy were performed at the University Hospitals Leuven in patients with clinical FIGO stage I endometrial carcinoma. Patients with a body mass index of less than 34, uterine size on ultrasonography of less than 10 cm, and good descensus of the uterus were selected for LAVH. For the vaginal manipulation of the uterus we used only a Pozzi tenaculum on the cervix. A pelvic lymphadenectomy was performed in patients with a grade 3 endometrioid carcinoma, a grade 2 lesion with myometrial infiltration (based on frozen section), a grade 1 lesion with deep myometrial infiltration (⬎1/2), or a clear-cell or serous histology. Results. Ninety-eight patients were treated with TAH and 58 with LAVH. Four of 98 patients (4.1%) treated with TAH and 1 of 58 (1.7%) patients treated LAVH had positive peritoneal cytology. The incidence of positive peritoneal cytology after LAVH in this series is similar to the 2.8% incidence observed after TAH in the Sonada series, but much lower than their incidence of 10.7% after LAVH. In the Memorial Sloan Kettering Cancer Center series, an intrauterine manipulator was used in the patients treated with LAVH, while we did not use this approach. Conclusion. The current series suggests that LAVH

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without the use of an intrauterine manipulator in patients with endometrial carcinoma does not increase the incidence of positive peritoneal cytology. 194. Gene Expression Profiling of Endometrial Carcinomas: Identification of Molecular Biomarkers. Oi Wah S. Yap, Shirley Zhu, Matt Van de Rijn, Teri A. Longacre, Nelson Teng, and Amreen Husain. Stanford University Medical Center, Stanford, California. Objective. The goal of this project is to generate gene expression profiles of endometrial tumors. We used DNA microarrays to elucidate the molecular events involved in the malignant transformation of endometrial cells. Methods. Endometrial surgical specimens were obtained from patients at Stanford University Medical Center with Institutional Review Board approval. Tissues were homogenized in Trizol reagent (Gibco-BRL) and mRNA was purified with a FastTrack 2.0 kit (Invitrogen) according to the manufacturer’s protocol. The reference standard is a mixture of 11 human cell lines derived from a group of human malignancies chosen for their contribution of a most diverse mixture of cell types. Results. A set of 26 specimens was examined, including 8 endometrial adenocarcinomas (with 1 corresponding myometrium), 5 endometrial papillary serous carcinomas, 6 atypical hyperplasias, 1 malignant mixed Mullerian tumor, 1 normal endometrium, 3 uterine leiomyomas, and 1 endometrial adenomyosis. The inherent underlying molecular diversity among the 3 surveyed tumor types (adenocarcinoma, endometrial papillary serous carcinoma, and atypical hyperplasia) was captured as gene expression patterns with a simple hierarchical clustering diagram. The samples were classified correctly into their respective tumor types, with few exceptions. Benign conditions of the uterus, such as adenomyosis and leiomyomas, clustered separately from atypical hyperplasia and malignant diseases of the uterus. Within the endometrial cancer cluster, the endometrial papillary serous carcinomas (with the exception of one sample) and the endometrial atypical hyperplasias formed distinct subgroups. Expression of a subset of genes, including GRB14, an adaptor protein, was found to be upregulated in cancer specimens. Genes belonging to the IGFI, IGFII, MAP kinase, and TCF4 families were found to be downregulated. Conclusion. This preliminary study shows that gene expression profiling can distinguish subtypes of endometrial tumors and may prove to be an important adjunct to standard histopathological tumor classification. The above analysis has yielded results implicating gene families with known function in cell growth and differentiation as differentially expressed in cancer versus benign endometrial tumors, thus identifying targets for potential novel biologic therapy.

195. Clinical and Pathologic Characterization in Hereditary Polyposis Colorectal Cancer (HNPCC)-Associated Endometrial Cancer. Kristine M. Zanotti, James Church, Carol Burke, Michael Geither, Susan Fay, Sherrie Vidmar, and Brian Clark. The Cleveland Clinic Foundation, Cleveland, Ohio. Objective. HNPCC is an autosomal dominant cancer predisposition characterized by the early occurrence of colorectal cancer and selected extracolonic cancers, including EC. Although the incidence and age of onset of HNPCCassociated EC have been well-described, there is almost no information on the clinical and pathological features of these carcinomas as they compare to sporadic EC. Methods. Pedigrees of 16 HNPCC families (defined by the Amsterdam Criteria) with ECs were abstracted from the Jagelman Colorectal Cancer Registry at the Cleveland Clinic Foundation. Clinical records of patients (pts) with ECs were reviewed for presenting symptoms, pathologic features, and clinical outcome. Results. Thirty-nine patients were identified among 16 families as having EC. Clinicopathologic information was unavailable or unreliable in 21 pts due to purged medical records (10 pts), inability to identify the treating facility (8 pts), the use of preoperative radiation therapy (2 pts), and refusal to participate (1 pt). Complete clinical and pathologic information with follow-up was available in 18 pts. The median follow-up in these patients is 8 years (range 1–52). Two ECs were clarified to be complex atypical hyperplasia on review. Twelve stage I and II tumors (FIGO grade I, II, and III, in 5, 5, and 2 pts, respectively) and 4 stage III tumors [FIGO grade II and III and uterine papillary serous carcinoma (UPSC) in 2, 1, and 1 pt, respectively] were identified. Median age among the 6 pts with poor pathologic features due to high-grade or stage III disease was 39 (range 35– 49). By contrast, the median age among the 12 pts with more favorable pathologic features was 55 (range 37–73; P ⬍ 0.05). There has been one documented EC recurrence among the 18 pts thus far. This stage IIIc patient with UPSC died of her disease. Median follow-up of the remaining patients with poor prognostic features is 2 years. Conclusions. A wide range of clinical and pathologic features was noted among the HNPCC-associated ECs. In contrast to sporadic EC, patients with adverse pathologic features of high-grade or stage III disease are younger than patients with more favorable pathologic features. Microsatellite instability analysis and testing for the mismatch repair genes are currently underway to determine if there is an underlying molecular difference in these two patient groups.