Intraperitoneal Dissemination Research Articles

Abstract 4044: R-ketorolac targets Cdc42 and Rac1 GTPases and alters ovarian tumor cell behaviors critical for invasion and metastasis

Abstract Ovarian cancer (OvCa) is the 5th leading cause of cancer death in women in the US with a 5-year survival rate of 44.6%. About 70% patients are diagnosed at advanced stages with intraperitoneal dissemination, therefore identifying intracellular targets and developing effective molecules to reduce tumor metastasis have great significance for ovarian cancer therapy. Cdc42 and Rac1 are small Rho GTPase and function as molecular switches of actin reorganization which are crucial to tumor cell adhesion, migration and invasion. In previous work, our group found Cdc42 and the constitutively active Rac1b are overexpressed in primary ovarian tumor tissues and ovarian cancer cell lines. Lead identification through a high-throughput screen combined with a computational shape homology approach, identified R-ketorolac as a Cdc42 and Rac1 regulator, an activity that is distinct from the anti-inflammatory, cyclooxygenase inhibitory activity of S-ketorolac. RhoA was unaffected by R-ketorolac. A bead-based flow cytometry assay identified R-ketorolac reduced Cdc42 and Rac1 GTPase nucleotide binding in vitro and inhibition was an allosteric mechanism of action. In cell-based assays, using Skov3ip cells, and in ascites-derived ovarian tumor cells, R-ketorolac was found to inhibit the activities of Cdc42 and Rac1 and their direct downstream effectors, the phosphorylation of p21-activated kinases (PAKs). R-ketorolac, but not S-ketorolac impeded Cdc42 mediated filopodia formation, measured based on both the length and numbers of filopodia in Skov3ip and primary OvCa cells. Cell behavior assays showed that R-ketorolac but not S-ketorolac strikingly inhibited cell adhesion, migration and invasion. In a xenograft mouse model a 50% reduction in tumor cell number and decreased total tumor burden was observed with R-ketorolac as compared to S-ketorolac treatment. Finally, in a ‘phase 0′ clinical study we found Cdc42 and Rac1 activities were reduced in a time-dependent manner after a single IV dose of racemic ketorolac treatment. In sum, we established R-ketorolac inhibition on Cdc42 and Rac1 activities and subsequent physiological consequences which are critical to tumor metastasis. Our findings provide the first demonstration of selective inhibition of Cdc42 and Rac1 GTPases by an FDA approved drug in humans. Citation Format: Yuna Guo, S. Ray Kenney, Larry A. Sklar, Tione Buranda, Tudor I. Oprea, Oleg Ursu, Sarah F. Adams, Teresa Rutledge, Carolyn Muller, Lesley Lomo, Laurie G. Hudson, Angela Wandinger-Ness. R-ketorolac targets Cdc42 and Rac1 GTPases and alters ovarian tumor cell behaviors critical for invasion and metastasis. [abstract]. In: Proceedings of the 106th Annual Meeting of the American Association for Cancer Research; 2015 Apr 18-22; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Res 2015;75(15 Suppl):Abstract nr 4044. doi:10.1158/1538-7445.AM2015-4044

Primary Fallopian Tube Carcinoma with the Classical Clinical Features: A Case Report

Abstract Background: Malignant neoplasm of fallopian tube is one of the rarest female genital cancers. The resemblance to epithelial ovarian carcinoma leads to difficulty in diagnosing the condition clinically as well as histopathologically. Case: We present a case of a 50-year-old postmenopausal woman with a history of watery vaginal discharge and lower abdominal pain. Clinical examination revealed a solid adnexal mass, which was confirmed upon pelvic ultrasonography with an additional feature of increased vascularity. Her CA-125 was 8.5 IU/mL. The decision for laparotomy was taken when abdominopelvic CECT (Contract Enhanced Computer Tomography) failed to confirm the nature of the mass. Results: An intraoperative solid mass of 6×5×5 cm size was present at the fimbria with a distended left fallopian tube. Uterus, bilateral ovaries, and the contralateral fallopian tube appeared normal. No evidence of intraperitoneal dissemination, and ascites was seen. A staging laparotomy comprising a total abdominal hyst...

Abridged republication of FIGO's staging classification for cancer of the ovary, fallopian tube, and peritoneum.

Ovarian, fallopian tube, and peritoneal cancers have a similar clinical presentation and are treated similarly, and current evidence supports staging all 3 cancers in a single system. The primary site (i.e. ovary, fallopian tube, or peritoneum) should be designated where possible. The histologic type should be recorded. Intraoperative rupture ("surgical spill") is IC1; capsule ruptured before surgery or tumor on ovarian or fallopian tube surface is IC2; and positive peritoneal cytology with or without rupture is IC3. The new staging includes a revision of stage III patients; assignment to stage IIIA1 is based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination. Extension of tumor from omentum to spleen or liver (stage IIIC) should be differentiated from isolated parenchymal metastases (stage IVB).

CD47 is an adverse prognostic factor and a therapeutic target in gastric cancer.

CD47 is an antiphagocytic molecule that acts via ligation to signal regulatory protein alpha on phagocytes; its enhanced expression and therapeutic targeting have recently been reported for several malignancies. However, CD47 expression in gastric cancer is not well documented. Immunohistochemical expression of CD47 in surgical specimens was investigated. Expression of CD47 and CD44, a known gastric cancer stem cell marker, were investigated in gastric cancer cell lines by flow cytometry. MKN45 and MKN74 gastric cancer cells were sorted by fluorescence-activated cell sorting according to CD44 and CD47 expression levels, and their in vitro proliferation, spheroid-forming capacity, and in vivo tumorigenicity were studied. In vitro phagocytosis of cancer cells by human macrophages in the presence of a CD47 blocking monoclonal antibody (B6H12) and the survival of immunodeficient mice intraperitoneally engrafted with MKN45 cells and B6H12 were compared to experiments using control antibodies. Immunohistochemistry of the clinical specimens indicated that CD47 was positive in 57 out of 115 cases, and its positivity was an independent adverse prognostic factor. Approximately 90% of the MKN45 and MKN74 cells expressed CD47 and CD44. CD47hi gastric cancer cells showed significantly higher proliferation and spheroid colony formation than CD47lo, and CD44hiCD47hi cells showed the highest proliferation in vitro and tumorigenicity in vivo. B6H12 significantly enhanced in vitro phagocytosis of cancer cells by human macrophages and prolonged the survival of intraperitoneal cancer dissemination in mice compared to control antibodies. In conclusion, CD47 is an adverse prognostic factor and promising therapeutic target in gastric cancer.

Pseudo-pseudomyxoma peritonei from peritoneal sarcomatosis

Background: Pseudomyxoma peritonei (PMP) is a rare clinical entity of mucinous ascites, most commonly associated with appendiceal mucinous neoplasms. Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) remains the current standard of care for PMP. Peritoneal sarcomatosis (PS) is an exceptionally rare disease with a poor prognosis. PMP associated with PS has not been previously described. The role of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for PS with or without PMP is not well-defined. PS manifesting like PMP has not been previously described. Case presentation: A 74-year-old patient with several weeks history of vague abdominal pain and increased abdominal girth was referred to our facility after incidental finding of PMP during laparoscopic inguinal hernia repair. After complete work-up, he was advised to undergo CRS/HIPEC. Intra-operatively, he was noted to have extensive mucinous ascites and underwent aggressive CRS and HIPEC Result: Final pathology revealed myxoid liposarcoma with associated intraperitoneal mucin dissemination, which was confirmed with cytogenetic analysis. Conclusion: We describe a rare case of pseudomyxoma peritonei originating from an intra-abdominal sarcoma. We propose the term of “pseudo-pseudomyxoma peritonei” to appropriately describe this unusual clinical event.

Co-targeting EGFR and Autophagy Impairs Ovarian Cancer Cell Survival during Detachment from the ECM.

Ovarian cancer (OC) remains the most aggressive and lethal gynecological tumor characterized by massive intraperitoneal dissemination and malignant ascites. The carcinoma cells exfoliated from the primary tumor and were further transformed in the ascites microenvironment. During this suspension process, multi-cellular spheroids are formed and these aggregates represent an invasive and chemoresistant cellular population fundamental to metastatic dissemination. Activation of EGFR signaling is involved in increased cell metastasis and decreased apoptosis of ovarian cancer. The application of EGFR Inhibition in ovarian cancer was hampered for its limited benefit as a solitary therapy. In this work, our results primarily indicated that autophagy was induced in response to EGFR specific inhibitor AG1478 in OC cell lines generated spheres and ascites primary spheroids, characterized by the elevation of LC3-II, Beclin1 and Atg5. Blockage of autophagy with 3MA notably promoted spheroid death in suspension as well as AG1478-induced cell apoptosis, suggesting a protective autophagy contribution during tumor cells in suspension or under EGFR inhibition. Consequently, inhibiting autophagy with 3MA significantly enhanced the inhibitory effect of AG1478 on tumor cell peritoneal propagation in SKOV3 i.p. xenografts model. In addition, elevated EGFR, Beclin1, and Atg5 mRNA levels were associated with decreased ovarian cancer patient survival. Together, our findings suggested that targeting autophagy held the potential to improve EGFR inhibition benefit in the treatment of ovarian cancer cells during detachment from the extra-cellular matrix (ECM), and that this combination strategy might provide a new treatment option in controlling peritoneal metastasis of ovarian cancer.

Visfatin derived from ascites promotes ovarian cancer cell migration through Rho/ROCK signaling-mediated actin polymerization.

Ovarian cancer is characterized by a rapid intraperitoneal spread combination with ascites accumulation. However, the exact mechanisms for ovarian cancer intraperitoneal dissemination remain unknown. Visfatin has recently been established as a novel adipokine and its serum level is increased in various cancers. Here, we identified that the elevated level of visfatin in ascites was associated with ovarian cancer intraperitoneal dissemination. Using the transwell cell migration assay and the wound-healing assay, we found that ascites-derived visfatin could promote migration of Caov-3 cells. Meanwhile, visfatin could induce the aggregation of actin stress fibers and the formation of lamellipodia and filopodia in Caov-3 cells, concomitant with a shift of G-actin to F-actin. Inhibition of actin polymerization with cytochalasin D obviously abolished the effects of visfatin on the migration of Caov-3 cells. Further results showed that visfatin triggered Rho activation and its downstream cofilin phosphorylation in a time-dependent manner, which led to actin polymerization. More importantly, visfatin-induced Caov-3 cell migration was effectively blocked by C3 exoenzyme and Y27632, Rho, and ROCK inhibitor, respectively. Thus, our study showed that ascites-derived visfatin promoted migration of ovarian cancer cells through Rho/ROCK signaling-mediated actin polymerization, which was required for ovarian cancer intraperitoneal dissemination. These findings offered a novel molecular mechanism responsible for ovarian cancer intraperitoneal dissemination, which might be a potential target for ovarian cancer management.

Bile ascites after T-tube removal in liver transplantation: A hepatobiliary scintigraphy finding

Background: Peritoneal spread of tumour cells is a major source of morbidity and mortality in patients with colorectal cancer. In order to develop strategies to prevent intraperitoneal dissemination and to treat peritoneal carcinomatosis, the spread of tumour cells in the peritoneal cavity was studied. Methods: Two million CC531 colon carcinoma cells were administered intraperitoneally in five groups of eight rats. The rats were killed after 1, 2, 4 and 8 hours and 3, 7, 14 and 21 days. After inspection of the abdominal cavity, samples of blood and ascites were taken. Liver, spleen, omentum, mesentery, diaphragm, parathymic lymph nodes and lungs were removed for histology and immunohistochemistry.Results: No abnormalities were seen in the abdominal cavity until day 3. Subsequently the peritoneum and omentum became thickened and after 21 days all rats had haemorrhagic ascites and peritoneal carcinomatosis. The abdominal fluid contained tumour cells at all stages. The number of tumour cells decreased in the first 8 hours, and increased thereafter. At microscopy the peritoneum was completely covered by tumour cells after 3 days. Tumour cells concentrated in the milky spots (MS) of the omentum within 4 hours. The size of the MS increased as a result of an increase in number of tumour cells and macrophages. After 7–21 days the MS were completely replaced by tumour cells and new MS were formed. In the diaphragm tumour cells invaded the lymphatic lacunae after 8 h, and obliterated these after 3–7 days. Also invasion of the muscle fibres was seen after 3 days. Microscopically no tumour cells were found in blood, liver, spleen, parathymic nodes and lung. Conclusion: After intraperitoneal administration of CC531 colon carcinoma cells, tumour cells spread throughout the abdominal cavity, and concentrate in the milky spots of the greater omentum, the paracolic gutters, the subhepatic and subphrenic spaces and in the lymphatic lacunae of the diaphragm.

The Dilemma of Myomectomy, Morcellation, and the Demand for Reliable Metrics on Surgical Quality.

In late 2013, a public awareness campaign was initiated after electromechanical morcellation (EMM) of a uterus with presumed benign leiomyoma, which in fact was leiomyosarcoma (LMS). Over the past year, the focus of the medical community has been on the incidence of occult LMS, specifically related to EMM. The risk of intracorporeal tissue dissemination by EMM resulted in some manufacturers halting sales of the EMM device, various hospitals banning the procedure, and ultimately a black box warning from the US Food and Drug Administration (FDA) for electromechanical morcellators.1 This type of issue is not new inmedicine. In the 1950s and early 1960s, laparoscopic surgery was banned in Germany owing to electrosurgical complications during laparoscopic sterilization.2This led togreaterunderstandingof sparking, capacitation, and coupling related to electrosurgery during laparoscopy; subsequent technological improvements and surgeoneducationresulted inelectrosurgerybeingan integralpart ofminimally invasivesurgery today.AlbertEinsteindefined insanity as doing the same thingover andover again andexpecting different results. As with electrosurgery, EMMneeds reassessment and improvement in techniqueand instrumentation for proper use. Systematic literature reviews,3 reports frommultispecialty centers,4 and largegroupstudies5havemainly focusedonhysterectomypatientswithestimationsofuterinesarcomarelating primarily to symptomaticwomenrequiringhysterectomy.This methodologyoverlooks a large data set of patients undergoing myomectomy to restore anatomy and preserve and enhance fertility.6Worldwide,thousandsofmyomectomiesareperformed vaginallyorbyminilaparotomy,conventional laparotomy, laparoscopy, or hysteroscopy, primarily in women of reproductive ageforsubfertility.WhileEMMisusedmostlyduringlaparoscopic myomectomies,withorwithout robotic assistance, the impact andoutcomeof tissuedisruptionat thetimeofmyomectomyby anymethod, including laparotomy, carries a small riskof intraperitoneal dissemination of occultmalignant tissue. In this issue of JAMA Oncology, Wright and colleagues7 report their analysis concerning the prevalence of undetected cancer and precancerous changes in women who underwent myomectomy with and without EMM. In light of the limited data regarding safety and risks in women undergoing myomectomy with EMM, this report broadens the focus on this matter. Owing to lack of information regarding the risk of occult uterine malignant neoplasms in reproductive-age women and possible tumor dissemination during myomectomy, with or withoutmorcellation, themagnitude of harm is unknown. Consequently, not only morcellation, but the prevalence of malignant and premalignant uterine lesions in younger patients, calls for investigation.8 Enbloc removal of allmyomas translates to total hysterectomy,which is inappropriate;myomectomyremains the surgical treatmentof choice in reproductive-agewomenwithsymptomatic uterine fibroids. Patients prefer minimally invasive surgerybecausethebenefitsoutweightheriskswhenperformed appropriately. TheFDAblackboxwarningonpowermorcellatorsmust not cause a reversal to laparotomyor increase in the number of hysterectomies for uterine tumors. Thedemand for reliablemetrics of surgical quality is at an all-time high, calling for a more systematic and rigorous approach toquality improvement. Since there arenoclinical registries formeasuring surgical qualityduringmyomectomy, the report by Wright et al7 opens the door to the use of administrative data. However, there are significant differences between administrative data and clinical registries to measure outcome and surgical quality. Administrative data are pulled fromclaimsprovided to insurers,while clinical registries containdata collected frommedical records,whichquestions the completenessandreliabilityofadministrativedata. Inananalysis of clinical-based data, Graebe et al4 found that morcellation was associated with substantially higher risk of abdominopelvic recurrence and lower disease-free survival, placing a greater emphasis on the magnitude of the problem, not merely the incidence. Comparisonbetweenadministrativedata andclinical registries conducted for predicting surgical results revealed significant differences in both recording and outcomes.9 Creatingandmaintainingaprospectiveregistry isprohibitivelycostly and time consuming compared with gathering administrativedata,which is inexpensive and readily available electronically.However, clinicaldata suchas finalpathology reportsand long-term results supplemented with reliable administrative data is ideal for surgical quality improvement. Improved and individualizedpatient care is dependent on accurate data collection (both clinical and administrative), research, and innovation. “Although data are being collected to quantify and understand these risksmore clearly, aminimally invasivealternative tounenclosed intracorporealmorcellation is favoredwhen available. It is incumbent on surgeons to communicate the risks of practices anddevices and to advocate for continued improvement in surgical instrumentation and techniques.”8(p790) This dilemma requires retrospective analysisandresearchtowardsafersolutions, includingalternatives to unprotected intracorporealmorcellation. Inaddition,developingstrategies tooptimizedatacollectionandgatheringaccurate andreliable informationwill allowclinicians tocounselpatients basedon scientific research tomakeeducateddecisions rather than on fear of the unknown. Related article page 69 Research Original Investigation Underlying Cancer and Precancer in Myomectomy

Ovarian, fallopian tube and peritoneal cancer staging: Rationale and explanation of new FIGO staging 2013

Ovarian, fallopian tube, and peritoneal cancers have a similar clinical presentation and are treated similarly, and current evidence supports staging all three cancers in a single system. The primary site (i.e., ovary, fallopian tube, or peritoneum) should be designated where possible. The histologic type should be recorded. Intraoperative rupture ("surgical spill") is IC1; capsule ruptured before surgery or tumor on ovarian or fallopian tube surface is IC2; and positive peritoneal cytology with or without rupture is IC3. The new staging includes a revision of stage III patients; assignment to stage IIIA1 is based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination. Extension of the tumor from the omentum to the spleen or liver (stage IIIC) should be differentiated from isolated parenchymal metastases (stage IVB).

Complete plastic lining of the abdominal cavity during laparoscopic electromechanical morcellation—a promising technique

The risk of intraperitoneal fragment dissemination of uterine tissue, especially the dissemination of unexpected leiomyosarcoma during electromechanical morcellation, has been increasingly debated during the last year. An improved technique for contained morcellation of uterine tissue inside an insufflated plastic bag during laparoscopy is presented. Twenty-one consecutive contained morcellations were carried out during the summer of 2014, at one institution. Five laparoscopic myomectomies and 16 hysterectomies were performed. Standard laparoscopic equipment was used and a transparent plastic bag was introduced into the abdominal cavity through the umbilical incision mounted on two curved blunt metal probes, which facilitated the placement of the uterine tissue into the bag. Morcellation was carried out inside the plastic bag through the opening in the umbilicus. All 21 morcellations during the study period were successfully performed. The median operative time was 105 min (range 45–180 min) and applying plastic bag and trocar median 10 min (range 4–30 min). Median specimen weight was 560 g (range 80–1265 g). No complications occurred, and no unintended bag perforation was identified. The presented improved contained morcellation technique is feasible in laparoscopic hysterectomy and myomectomy. Larger studies will however be required before the general introduction of the method. Level of evidence: II-3

A medical-legal review of power morcellation in the face of the recent FDA warning and litigation.

Minimally invasive gynecologic surgeons who perform laparoscopic intraperitoneal morcellation should be aware of the recent US Food and Drug Administration (FDA) warning and litigation arising from use of morcellation devices with claims of intraperitoneal dissemination of cancerous cells. On November 24, 2014, the FDA issued a statement warning against using laparoscopic power morcellators in the majority of women undergoing hysterectomy or myomectomy for uterine fibroids. Despite the best intentions in regards to their patients, gynecologists who continue to use power morcellation devices expose themselves to liability. This article is not meant to further deter gynecologists from using laparoscopic power morcellators, but rather to provide an interpretation of the FDA statement as to the patients for whom the use of power morcellation may still be permitted under the FDA guidelines. This article also offers protective measures from a legal perspective for those who choose to continue to use power morcellation in the face of the recent FDA warning and litigation.

Surgical Cytoreduction for Disseminated Benign Disease After Open Power Uterine Morcellation

Uterine morcellation is a technique used in gynecologic surgery to facilitate a laparoscopic approach to the removal of an enlarged uterus. The safety of this technique has been a source of recent debate, as uterine morcellation can result in the intraperitoneal dissemination of undiagnosed uterine malignancies. We report on three women who previously underwent minimally invasive hysterectomy and open power morcellation for benign disease, who subsequently presented with peritoneal implants highly suspicious for malignancy. Each woman required a laparotomy and extensive, multiorgan resection to clear the disease. Benign pathology was diagnosed in all cases. Even in the setting of benign conditions, open power morcellation of the uterus may be associated with clinically significant dissemination of uterine disease.

Ovarian cancer: imaging in treatment selection and planning with FIGO update

The International Federation of Gynecologists and Obstetricians (FIGO) has recently revised the staging of ovarian cancer [1]. It includes a revision of the stage III patients and allotment to stage IIIA1 is based on spread to the retroperitoneal lymph nodes without intraperitoneal dissemination, because an analysis of these patients indicates that their survival is significantly better than those who have intraperitoneal dissemination [1]. The FIGO staging system for ovarian cancer is surgically based. It does not formally include imaging but the FIGO committee encourages the use of imaging techniques if available to assess the important prognostic factors such as disease resectability and lymph node status. The standard of care for patients with newly diagnosed advanced ovarian cancer has been comprehensive staging laparotomy and primary optimal surgical cytoreduction followed by adjuvant chemotherapy. However, the use of neoadjuvant chemotherapy followed by interval debulking surgery (IDS) as a suitable alternative is supported by multicenter randomized controlled trials [2]. Imaging is therefore of paramount importance in helping triage patients for appropriate management by accurately evaluating the extent and anatomical location of peritoneal spread, which in turn dictates the feasibility of cytoreductive surgery and predicts the likelihood of optimal primary cytoreduction. Optimal cytoreductive surgery (residual disease <1 cm) is a very strong predictor of survival, and even after the threshold for optimal cytoreduction has been reached, it is important to remove as much of the residual tumor as possible. CT is the primary imaging modality used to stage ovarian cancer. It is complimentary to surgical staging identifying possible sites of unsuspected disease such as pelvic peritoneum, paraaortic nodes, diaphragm and chest [3,4]. The thorax frequently harbors undiagnosed pleural disease at the time of the initial diagnosis which is likely to affect survival even in cases of optimal debulking [5,6]. Accurate imaging helps guide the surgeon to areas of disease that may be difficult to identify surgically. Relative criteria for non-optimally resectable disease have been developed [7]. They include lymph node enlargement above the renal hilum, presence of abdominal wall invasion, parenchymal liver and subcapsular liver metastases, peritoneal implants of >2 cm along the diaphragm, lesser sac, porta hepatis, intersegmental fissure, gall bladder fossa, gastrosplenic, gastrohepatic ligament and small bowel mesentery. However, it is important to realize that these criteria may vary and will depend on the aggressiveness of the surgical procedure and on the performance status of the patient. Therefore, they should only be used as a basis for a multidisciplinary consensus. It is important to note that upper abdominal disease and pleural metastases can be surgically resected, but this requires careful planning as it involves a team of surgeons (e.g. liver surgeons for hepatic resection). There has been a growing awareness of the potential of diffusion weighted magnetic resonance imaging (DW-MRI) in improving the mapping of the extent of ovarian cancer [8,9]. There is also growing evidence that FDG-PET/CT may play a role in pre-operative staging of patients with advance ovarian cancer [10].

Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma.

Uterine leiomyosarcoma (ULMS) is identified in 0.1% to 0.2% of hysterectomy specimens of presumed leiomyoma. To date, there is no preoperative technique that reliably differentiates ULMS from uterine leiomyoma. Increasing use of minimally invasive approaches for the management of leiomyomas may result in inadvertently morcellated ULMS with resultant intraperitoneal dissemination of tumor. The objective of this study was to assess the impact of intraperitoneal morcellation on the outcomes of patients with ULMS. In this retrospective cohort study, all patients with ULMS who attended the authors' institutions from 2007 to 2012 were reviewed. Demographics and outcomes were compared between those who underwent morcellation or total abdominal hysterectomy (TAH) as their first surgery for uterus-limited ULMS. In total, 58 patients were identified, including 39 who underwent TAH and 19 who underwent intraperitoneal morcellation. Intraperitoneal morcellation was associated with a significantly increased risk of abdominal/pelvic recurrences (P = .001) and with significantly shorter median recurrence-free survival (10.8 months vs 39.6 months; P = .002). A multivariate adjusted model demonstrated a > 3 times increased risk of recurrence associated with morcellation (hazard ratio, 3.18; 95% confidence interval, 1.5-6.8; P = .003). Intraperitoneal morcellation of presumed leiomyoma worsens the outcomes of women with ULMS. Because there are no reliable preoperative techniques to distinguish ULMS from benign leiomyoma, all efforts to minimize intraperitoneal uterine morcellation should be considered. [See editorial on pages 000-000, this issue.]

P-Cadherin Promotes Ovarian Cancer Dissemination Through Tumor Cell Aggregation and Tumor–Peritoneum Interactions

More than 60% of patients who are diagnosed with epithelial ovarian cancer (EOC) present with extensive peritoneal carcinomatosis. EOC cells typically disseminate by shedding into the peritoneal fluid in which they survive as multicellular aggregates and then implant onto peritoneal surfaces. However, the mechanism that facilitates aggregation and implantation of EOC cells is poorly understood. The cell adhesion molecule P-cadherin has been reported to be induced during early progression of EOC and to promote tumor cell migration. In this study, P-cadherin not only promoted migration of EOC cells, but also facilitated the assembly of floating EOC cells into multicellular aggregates and inhibited anoikis in vitro. Furthermore, inhibiting P-cadherin by short hairpin RNAs (shRNA) or a neutralizing antibody prevented EOC cells from attaching to peritoneal mesothelial cells in vitro. In mouse intraperitoneal xenograft models of EOC, inhibition of P-cadherin decreased the aggregation and survival of floating tumor cells in ascites and reduced the number of tumor implants on peritoneal surfaces. These findings indicate that P-cadherin promotes intraperitoneal dissemination of EOC by facilitating tumor cell aggregation and tumor-peritoneum interactions in addition to promoting tumor cell migration. Inhibiting P-cadherin blocks multiple key steps of EOC progression and has therapeutic potential.

HOXA9 promotes homotypic and heterotypic cell interactions that facilitate ovarian cancer dissemination via its induction of P-cadherin.

BackgroundEpithelial ovarian cancer (EOC) is a lethal disease that frequently involves the peritoneal cavity. Dissemination of EOC is a multi-step process in which exfoliated tumor cells survive in the peritoneal fluid as multi-cellular aggregates and then form invasive implants on peritoneal surfaces. The mechanisms that control this process are poorly understood. We previously identified that high expression of the developmental patterning gene HOXA9 is associated with poor survival in EOC patients. In this study, we investigated the significance and mechanisms of HOXA9 in controlling aggregation and implantation of floating EOC cells.MethodsHOXA9 was inhibited by shRNAs or expressed in EOC cells that were propagated in suspension cultures and in the peritoneal cavity of mice. Cell death was assayed by flow cytometry and ELISA. Cell aggregation, attachment and migration were evaluated by microscopy, transwell chamber assays and histopathologic analysis. DNA-binding of HOXA9 and its effect on expression of the cell adhesion molecule P-cadherin were assayed by chromatin immunoprecipitation, quantitative RT-PCR and Western blot. HOXA9 and P-cadherin expression was evaluated in publicly available datasets of EOC clinical specimens.ResultsWe identified that HOXA9 promotes aggregation and inhibits anoikis in floating EOC cells in vitro and in xenograft models. HOXA9 also stimulated the ability of EOC cells to attach to peritoneal cells and to migrate. HOXA9 bound the promoter of the CDH3 gene that encodes P-cadherin, induced CDH3 expression in EOC cells, and was associated with increased CDH3 expression in clinical specimens of EOC. Inhibiting P-cadherin in EOC cells that expressed HOXA9 abrogated the stimulatory effects of HOXA9 on cell aggregation, implantation and migration. Conversely, these stimulatory effects of HOXA9 were restored when P-cadherin was reconstituted in EOC cells in which HOXA9 was inhibited.ConclusionThese findings indicate that HOXA9 contributes to poor outcomes in EOC in part by promoting intraperitoneal dissemination via its induction of P-cadherin.

Relapse as Advanced Carcinosarcoma Following Uterus-Preserving Therapy in a Patient with Early-Staged and Grade 1 Endometrioid Adenocarcinoma: A Case Report and Review of the Literature

Fertility-sparing treatment with high-dose progestin is now used in many young patients with early stage, grade 1 endometrioid adenocarcinoma. The response rate of this therapy is quite good, but the relapse rate is relatively high. If the site of recurrence is limited to the uterus, this may be treated with additional hormone therapy or hysterectomy. We recently experienced a case of a 30-year-old primigravida patient in whom intraperitoneal dissemination of carcinosarcoma occurred during follow-up after apparent complete remission of early-stage grade 1 endometrioid adenocarcinoma. We report the case as an example of a rare high-grade histology tumor that relapsed in an extrauterine site after primary remission had been achieved with high-dose progestin therapy. In a review of the literature through a MEDLINE search, we found 13 articles describing relapse in an extrauterine site, including 6 ovarian metastases, 4 retroperitoneal lymph node metastases, and 3 metastases to organs other than the ovary. Early stage, well-differentiated endometrioid adenocarcinoma of the uterine corpus is generally considered to have a good prognosis, but counseling of patients regarding life decisions is important, with provision of sufficient information on the possibility of extrauterine progression or disseminated recurrence.

Oncolytic viral therapy with a combination of HF10, a herpes simplex virus type 1 variant and granulocyte–macrophage colony‐stimulating factor for murine ovarian cancer

Ovarian cancer is the most frequent cause of gynecological cancer-related mortality as a majority of patients are diagnosed at an advanced stage with intraperitoneal dissemination because of the absence of initial symptoms. Granulocyte-macrophage colony-stimulating factor (GM-CSF) plays an important role in the maturation of specialized antigen-presenting cells. In this study, we utilized a herpes simplex virus (HSV) amplicon expressing murine GM-CSF combined with HF10 (mGM-CSF amplicon), a highly attenuated HSV type 1 strain functioning as a helper virus to strengthen anti-tumor immune response, for the treatment of ovarian cancer with intraperitoneal dissemination. A mouse ovarian cancer cell line, OV2944-HM-1 (HM-1), was intraperitoneally injected, following which HF10 only or the mGM-CSF amplicon was injected intraperitoneally three times. HF10 injection prolonged survival and decreased intraperitoneal dissemination, but to a lesser extent than the mGM-CSF amplicon. Although HF10 replication was not observed in HM-1 cells, expression of VP5, a late gene coding the major capsid protein of HSV, was detected. Moreover, mGM-CSF production was detected in transfected HM-1 cells. Immunohistochemical staining revealed the infiltration of CD4- and CD8-positive cells into the peritoneal tumor(s). A significantly increased CD4+ T cell concentration was observed in the spleen. Murine splenic cells after each treatment were stimulated with HM-1 cells, and the strongest immune response was observed in the mice that received mGM-CSF amplicon injections. These results suggested that the mGM-CSF amplicon is a promising agent for the treatment of advanced ovarian cancer with intraperitoneal dissemination.

Tissue Extraction and Morcellation: The Menace of Unexpected Malignancy

ABSTRACT Uterine fibroids are a common indication for hysterectomy or myomectomy. Even with optimal preoperative imaging, unexpected uterine sarcoma can be detected in histopathology after uterine fibroid surgery. In case of inadvertent morcellation of an unexpected uterine sarcoma the clinical outcomes, due to the rapid intraperitoneal dissemination of malignant tissue during the procedure can be negatively influenced. The purpose of this study was to determine the prevalence of uterine sarcoma in women undergoing hysterectomy or myomectomy for benign uterine fibroids. We performed retrospective study (2003-2014 years). The total number of women operated for uterine fibroids was 2297. Of this, 938 (42.5%) women had myomectomies and 1269 (57.5%) women had hysterectomies. In myomectomies the most frequently used surgical method was laparoscopic myomectomy in 591(63%) cases, followed by hysteroscopy myomectomy in 306 (32.62%) cases, and laparotomic myomectomy only in 41 (4.37%) cases. In hysterectomies, laparoscopic approaches significantly dominated in 1163 (61.1%) cases, showing laparotomic approaches in 491(25.82%) cases and vaginal approaches in 247 (12.99) cases. Only one patient with endometrial stromal sarcoma (ESS) was not preoperatively diagnosed and treated as symptomatic uterine fibroid; this patient underwent laparoscopic supracervical hysterectomy. In the post-operative histopathological examination ESS was detected. Thus, our incidence of sarcomas among women who underwent benign uterine fibroid surgery is 1/2297 (0,043%). Laparoscopic power morcellation should be performed only in cases with no suspicion of malignancy Patients, who undergo laparoscopic surgery with power morcellation should be informed about the possible risks of morcellation in cases of rare not suspected malignant disease. How to cite this article Mettler L, Abdusattarova K. Tissue Extraction and Morcellation: The Menace of Unexpected Malignancy. Int J Gynecol Endsc 2017;1(1):1-4.