Association Between Tumor Hypoxia and Malignant Progression in Advanced Cancer of the Uterine Cervix1

(CANCER RHSl-AKCH 56. 45(Â»-45l5. Octnbcr I. 1996] Association between Tumor Hypoxia and Malignant Progression in Advanced Cancer of the Uterine Cervix1

Michael HÃ¶ckel,2Karlheinz Schienger, Billur Aral, Margarete Milze, Uwe SchÃ¤ffer, and Peter Vaupel

Department iif Ohsieirics anil Ã¼yneciiltiuy /M. H., K. S.. B. A.. U. S.] unti lile Institutes Â¡ifPiilholiifty Â¡M.M./ und Ph\\inli>K\ ami Paihuiihysii>li>KyÂ¡P-V.]. University

ABSTRACT ture is evident ( I ). As a consequence, tissue hypoxia results from either insufficient O-, diffusion (chronic hypoxia) or insufficient Experimental tumors contain a significant fraction of microregions that perfusion (acute hypoxia. transient hypoxia. or ischemie hypoxia). are chronically or transiently hvpoxic. Experimental evidence showing Moreover, in vitro and experimental tumor studies showed that that hypoxia (und suhsequent reoxygenation) muy huve a profound impact hypoxia (and subsequent reoxygenation) may have a dramatic on malignant progression and on responsiveness to therapy is growing. I lie clinical relevance of tumor oxygÃ©nationin Immun solid malignancies impact on malignant progression in terms of tumor spread and is under Â¡mesticatimi. resistance to therapy (2-13). Despite these striking observations in \\ e huve developed and validuted a clinically applicable method for tumor models, the clinical relevance of tumor oxygÃ©nation is still measurement of tumor oxygÃ©nation in locully udvunced cancer of the unclear. After Thomlinson and Gray (14) presented evidence for uterine cervix using a computerized polarographic electrode system. Ap hypoxic microregions within human tumors from a detailed his- plying this procedure in patients with cervical cancers S3 cm in diameter, topathological study of lung cancers. Urbach (15) was the first to who gave informed consent. \ve have been studying the clinicul relevance measure low oxygen tensions in malignant skin tumors directly of tumor oxygÃ©nationprospective!)' since 1989. with pO2 polarography. Gatenby et al. (16) reported in 1988 the As of June 1995, 103 patients with advanced cancers of the uterine results from polarographic oxygen tension measurements in lymph cervix [Federation Internationale des Gynaecologistes et Obstetristes (FICO) stages Ih. bulky di = 13). Ha and Uh (H = 51), IIIu and IHh node mÃ©tastasesof head and neck cancers showing a significant (n = 34). and IVa und I\ h (n = 5)| hud entered the study. Fifty "i of the relationship between low mean intratumoral pO-, values and failure patients had carcinomas with median pO, readings <10 mm Hg. referred to respond to fractionated radiotherapy thus supporting older stud to as hypoxic tumors. ies, such as that of Kolstad (17). with cancer of the uterine cervix. Tumor oxygÃ©nation was found to be independent of various patient These investigations, however, did not receive widespread atten demographics and also of pretreutment tumor churucteristics, such as tion because of the low number of patients involved, methodolog clinical tumor stage and size, histolÃ³gica! type, and differentiation. How ical limitations of pO, determinations, and both short and/or in ever, histopatbological examination of the surgical specimens following complete patient follow-up. radical tumor resection in 47 patients showed that lm\-p<>, tumors ex In 1989. a computerized histography system was introduced, al hibited larger tumor extensions and more frequent (occult) parumetrial spread, as well as lymph-vusculur space involvement, compared to well- lowing quick and reliable polarographic tissue pO, readings in the clinical setting (18-21 ). Applying this device in patients with locally oxygenated tumors of similar clinicul stuge und size. Forty-two putients completing primary radiatimi therapy and 47 patients who underwent advanced cancer of the uterine cervix, we initiated a controlled pro radical surgery were analyzed for treatment outcome after u median spective trial to evaluate the clinical relevance of tumor oxygÃ©nation. observation period of 28 months (range. 3-76 months). Patients with The measurements were performed according to the principles of hypoxic tumors had significantly worse disease-free und overall survival systematic random sampling (22, 23) to take into account intratumorul probabilities compared to patients with nonhypoxic tumors. Cox regres heterogeneity. After having presented preliminary data from the first sion analysis identified tumor oxygÃ©nationand FICO stage as the most analysis in 1992 demonstrating the powerful predictive value of tumor important independent prognostic factors. The poorer outcome of the oxygÃ©nation on recurrence-free and overall survival for patients patients with hypoxic tumors was mainly due to locoregionul failures with treated with radiation (24. 25). we now report the results from a larger and without distunt metustuses. irrespective of whether surgery or radi patient cohort and longer follow-up, including a subgroup of patients ation was applied as primary treatment. Tumor oxygÃ©nation as measured with a standardized polarographic who underwent primary surgery. We show that the adverse out method proved to be a powerful new pretherapeutic prognostic parameter come of patients with hypoxic cervical tumors is independent of the providing important information on malignant progression in terms of standard treatment and apparently represents a tumor biological extracervical tumor spread and rudioresistunce in advanced cervical phenomenon. cancers. MATERIALS AND METHODS

INTRODUCTION Study Protocol. All patients with cervical cancers of at least 3 cm in largest In normal tissue, oxygÃ©nation is a spatially and temporally diameter as estimated by clinical investigation who had been admitted to the heterogenous homeostatic flow equilibrium determined by micro- Department of Obstetrics and Gynecology at the University of Mainz Medical School for treatment were eligible for the open prospective trial initiated in regional oxygen delivery and oxygen consumption. In fast-growing June 1989. The study was approved by a medical ethics committee. All experimental tumors, a Multhusian principle characteri/ed by a patients needed to give informed consent to be enrolled in the study. Clinical more rapid increase of oxygen-consuming tumor cell populations staging according to FIGO1 and si/ing were performed by experienced than expansion of the oxygen-supplying functional microvascula- gynecological oncologists. Histopathology. HistolÃ³gica! type and grade according to the modified Broders' system were obtained from routine H&E-stained sections of defined Rcccivcd 4/5/96; accepted X/I6M6. The costs ot publication of this article were defrayed in part by the payment of page tumor biopsies. The specimens from radical surgery were processed in giant charges. This article must therefore he hereby marked aihvriisement in accordance wilh sections for histolÃ³gica! examination to verify tumor extension, depth of 18 U.S.C. Section 1734 solely to indicate this laci. 1Supported by Deulsehe Krehshille Grani M4(V9]/Va I. To whom requests tor reprints should be addressed, at UniversitÃ¤tsfrauenklinik. 1The abbreviation used is: FIGO. Federation Internationale des (Â¡ynaecologisles et Langcnhcckstrassc I. D-55IOI Main/. Cicrmany. Ohslclrisles. 4509

Downloaded from cancerres.aacrjournals.org on September 28, 2021. © 1996 American Association for Cancer Research. IIYPOXIA IS O-:RVICAI CANCI-.K cervical invasion, and bladder or rectal involvement. Paramctriul tumor infil Follow-Up. Regular follow-up investigations were performed either in the tration was investigated in the axial sections of the lateral parts of the surgical Department of Obstetrics and Gynecology at the University of Main/ Medical specimens. The presence of tumor cell clusters within an endothelial-lined School or in other clinical institutions at 3-month intervals during the first 2 space was regarded as lymph-vascular space involvement. This feature was years following treatment and twice yearly thereafter. The patients were classified as pronounced if it could he detected in nearly all of the high-power interviewed and examined clinically. In case of symptoms or suspicious or fields at the invading tumor front. The demonstration of a tumor cell embolus pathological clinical findings, further diagnostic procedures were ordered, within a blood vessel identified by the tunica media was interpreted as including interventional biopsies for definitive diagnosis. Further information evidence of vascular invasion. Four sections from each removed lymph node regarding the posttreatment disease course of the patients was obtained by were scrutinized for tumor mÃ©tastases. telephone interviews or correspondence with the patients, their relatives, or Treatments. Primary treatments with curative intent were performed uni their primary care physicians. formly during the study period by either surgery or radiation. Treatment Statistical Analysis. Statistical analyses were performed with the SAS decisions for the individual patients were made at a tumor conference with Sottware. Version 6.04. For comparison, the determination of correlation coefficients. Fisher's exact test, and the Mann-Whitney-Wilcoxon test (U test) participation of the radiation oncologists and gynecological oncologists based on the clinical judgment of tumor rescctability and on the age and nutritional were applied. Survival and recurrence-free survival probabilities were calcu and performance status of the patients. The results of the tumor oxygÃ©nation lated with the Kaplan-Meier method. Differences between survival probabili measurements were not contributed and did not influence any decision on ties were analyzed with the log-rank test. Variables influencing survival and treatment. disease-free survival probabilities were evaluated with the univariate and Surgical treatment consisted of radical hysterectomy or primary pelvic multivariate Cox proportional hazards model. A P value ^0.05 was considered exenteration with pelvic lymph node dissection. Definitive radiation was to indicate statistical significance. administered as combined teletherapy and brachytherapy. External beam irradiation was applied with 10-MV photons produced by a linear acceler RESULTS ator at the Department of Radiology. For the brachytherapy. a high-dose- rate Ir 192 afterloading machine at the Department of Obstetrics and Gyn- From June 1989 until June 1995. 134 patients with advanced ecology was used. The patients usually received 45 Gy whole-pelvis (i.e.. >3 cm in clinical diameter) cancers of the uterine cervix were external-beam radiation with the standard four-field box technique at admitted to the Department of Obstetrics and Gynecology. During 2-Gy/day fractions five times per week, followed by three to four endo- that period, 23 eligible patients could not be accrued to the con cavitary brachytherapy insertions with a Hentschke applicator delivering a total dose of 24-28 Gy at a dose rate of 0.5-1 Gy/min to point A at weekly trolled prospective study because either the principal investigator intervals. Lateral tumor spread was treated with additional parametrial or the pO, histograph was not available. Three patients could not teletherapy boosts of up to 15 Gy. be involved due to missing informed consent. In the remaining 108 In contrast to the primary treatment, adjunctive therapies varied during patients, pO-, measurements have been performed. The measure the course of this study. From 1989 to 1992 a series of patients received ments were tolerated by all patients; 13 patients complained about "induction chemotherapy" with cisplatin. vincristine. and bleomycin fol minor discomfort. No complications occurred as a consequence of lowed by definitive radiation. During that time, surgically treated patients the pO2 determinations. Bleeding caused by the hypodermic needle with parametrial and nodal involvement underwent adjuvant chemotherapy probe insertion was minimal, and bleeding from the needle core with carboplatin and ifosfamide. From 1993 on. chemotherapy was given biopsies did not exceed 20 ml in the majority of cases. Two concomitantly with radiation using cisplatin or carboplatin instead of the patients had to be treated with temporary intravaginal packings. No sequential mode. Adjuvant treatment for surgical risk factors was changed to external-beam radiation of the pelvis with 50 Gy with the four-field box patient required blood transfusions for any blood loss due to the technique at 2-Gy/day fractions. study protocol. The following treatments for recurrent disease have been applied: percuta On the basis of the histolÃ³gica! investigation of the core biopsies, neous pelvic radiation up to 60 Gy for postsurgical locoregional recurrences, intratumorul measurements were made in 103 of the 108 patients. pelvic exenteration for central pelvic disease, and the CORT procedure for Eight patients had more than two intrutumorul measurement tracks. 83 side-wall disease in cases with previous pelvic radiation (26). patients had two, and 12 patients had only one. Tumor OxygÃ©nation Measurements. Tumor oxygÃ©nationwas measured To validate the procedure, we determined interobserver. intratu- pretherapeutically with the Eppendorf histography system (Eppendorf. Ham burg. Germany) adhering to the standard procedure as developed and validated earlier (21. 24. 25). pOs readings were performed in the conscious patient Tahlc I MclÃ¬Ã¬iHÃŒDÃŒiÃ¬^Ã¬i'itÃ¬f\'ÃititÃitii>nofÃ¬titnitiiiiitinilÂ¡tO^mt'tÂ¡\urt'iiu'nt\ in i along linear tracks, first in the s.c. fat of the mons pubis followed by cervical cancer nf ihr uterine cenÃ¯x measurements at the 12 and 6 o'clock sites of the macroscopically vital tumor Hg)Range0-9.90.3-8.80.1-9.30-170-160-200.1-3.4O.l^tO.6 tissue. Prior to 1993. pO2 measurements in the normal tissue were not carried out. Within the tumor tissue, up to 35 pO, measurements were taken in each oftumors1699302091g103DeviationMean2.31.82.73.55.04.50.98.9(mm tumor track (70 readings in total) starting at a tissue depth of 5 mm. The Intcrohservcrvariation"Standard measuring points were placed 0.7 mm apart from each other, resulting in an twoinvestigators,procedure, overall measurement track length of approximately 2.5 cm. samehistographStandard After the pO, measurements, needle core biopsies of approximately 2 mm twoinvestigators,procedure, in diameter and 20 mm in length were taken from those tumor areas where the twohistographsStandard pOs determination had been made and processed for histology. Both the pO, readings and the taking of the needle core biopsies were done without anes procedure.measurement twolimes at thesia in all patients. Intravaginal temperature, blood pressure, heart rate, days)tnlralumnral(At. 1-5 hemoglobin concentration, hematocrit. and arterial oxyhemoglobin saturation '12 variation were monitored concomitantly with the pO, determinations. The pretherapeu- o'clock6o'clock v.v. 12 tic pO, measurements were usually performed 1-5 days prior to the oncolog o'clock12o'clock i'.v.6 o'clockStandardo'clock vs. 6 ical treatment. For validation of the standard procedure, a series of pO2 extendedIntertumoralv.v. measurements has been performed in the same patients (Â¡i)at two different variation'No. times, (ft) with two different histographs. and (c) by two different investigators. " The reference values for calculatinÂ«!the deviations were the median p()2 from the In another series, in addition to the measurements at the standard 12 and 6 pooled measurements of the individual tumors. o'clock locations, up to eight further measurements at different sites were done 'The reference values were the median pO-, lor each measuring track. in the same tumor. ' The reference value was the median pO-, of all tumors. 4510

Table 2 Preireatinent iunior characteristics and tumor oxygÃ©nation

No. of patients

VariablesClinical tumors725l'I125274663220Nonhypoxictumors62615425264293714InfluenceP(FIGOoxygÃ©nation= stageClinicaltumor Ib(bulky)FIGO Ila.hFIGO Illa,hFIGO 1.000II IVa.bmaximum I+PPPonI.V.Ill= IV) si/.eHistolÃ³gica!tumor cmmaximumdiameter ^5 cmSquamousdiameter >5 1.000= typeDifferentiationFIGO carcinomaAdcnocarcinoma.cell carcinomaG adenosquamous 0.416= 1/2G 3Hypoxie 0.296+

moral, and intertumoral variations. The results are compiled in Table hysterectomy (/? = 43) or exenteration (n = 4) along with pelvic 1. If the standard two-track procedure was performed, the interob lymph node dissection. In this subgroup, again, no correlation be server variation of the median pO, with respect to histograph, oper tween tumor oxygÃ©nationand the clinical tumor data (FIGO stage and ator, and time of measurement was of the magnitude of only 2-3 mm size) or histological type and differentiation was found. However, the Hg. Intratumoral variation between measuring positions located just a histopathological investigation of the surgical specimens identified few millimeters apart from each other was of the same order as the significantly larger maximum tumor extensions, higher pT categories variation between measuring positions, which spanned some centime due to occult parametrial spread, and more frequent lymph-vascular ters. However, although intratumoral heterogeneity in microregional space involvement in the hypoxic tumors as compared to their non pO, values was pronounced, intertumoral heterogeneity was signifi hypoxic counterparts (Table 3). cantly higher if compared with the U test, thus allowing the use of the Thirteen patients in whom tumor oxygÃ©nationmeasurements had median pO, as determined with the standard procedure for character been performed were not treated for cure by standard therapy or ization of individual cervical cancers. refused or abridged treatment. Table 4 presents a breakdown of the For the 103 patients in the trial, the mean oxygÃ©nation(i.e.. the pretreatment tumor characteristics, treatment modalities, and tumor mean of the medians of the pooled histograms) was 12.5 mm Hg. oxygÃ©nation status of the remaining 90 patients treated for cure Fifty-two patients had tumors with median pCh <10 mm Hg. desig according to accepted standards. No significant differences were nated "hypoxic tumors," whereas the remaining 51 patients had tu detected between the hypoxic and nonhypoxic tumors in the whole mors with median pO-, values >10, termed "nonhypoxic." Median group, the radiation subgroup, or the surgery subgroup with respect to pO3 values correlated significantly with the relative frequencies of the FIGO stage, clinical tumor size, and adjuvant treatment. One patient two lowest pOi classes of the pooled histograms (median pO,, relative was lost to follow-up. After a median follow-up time of 28 months frequency of measurements up to 2.5 mm Hg: r = â€”¿0.7361, (range, 3-76 months) 35 of the 89 patients progressed or relapsed. P = 0.0001: median pO2, relative frequency of measurements up to 5 Five of the relapsing patients received another treatment for cure. mm Hg: /â€¢=-0.6071. P = 0.0001). Thirty patients died of cervical cancer, and the death of one patient Tumor oxygÃ©nationwas independent of patient demographics such was due to intercurrent disease (Table 5). as age. menopausal status, parity, smoking, and hemoglobin levels. The overall and disease-free survival probabilities calculated with Likewise, as shown in Table 2. tumor oxygÃ©nationwas independent of the Kaplan-Meier method were significantly lower for the patients the pretreatment tumor characteristics, such as clinical tumor stage with hypoxic cervical cancers compared to those with nonhypoxic according to the FIGO, clinical tumor size, and histological type and tumors (Fig. 1). The results of the regression analysis with the Cox differentiation (grading). proportional hazards model are given in Table 6. Tumor oxygÃ©nation, In 47 of the 103 patients, the tumors had been resected by radical expressed as median pO,. was the strongest independent predictor of

Table 3 HÃ¬stopalhaÃ¬oxiuillunwr chanicterixlic\ and Junior oxygÃ©nationof 47 patients treated with primary surgery As shown in Table 4. no difference in clinical stages and si/es with respect to tumor oxygÃ©nationwas found for this subgroup of patients.

patientsVariablePathological No. of

tumors tumors (n =25)222012141114111414118170Nonhvpoxicdi =22)7681913175175IS411101Influence onoxygÃ©nationP (pT)(Occult) tumor stage (bulky)2a2h3a. =0.026>'â€¢'â€¢ bYesNo^4 tumorextensionMaximumparametrial =4cmNegative/moderatePronouncedNegativePositiveNegativePositiveUnknownHypoxic =P spaceinvolvementVascular =P invasionNodal =P statusIb =0.0627Â».

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Table 4 Treatment modalities. FICO stages, and tumor o.iyxenaliun conscious patient without significant discomfort. Extending the num ber of measuring tracks from two (in the standard protocol) to up to subgroupPrimaryTreatment tumors256917Ih21872352o914716Nonhypoxictumors2266251611371Â»5319991010 did not significantly influence the results, but it prolonged the surgeryAdjuvant CT"Adjuvant procedure and is therefore not warranted. Similar experiences have RTAdjuvant been reported for head and neck lymph node mÃ©tastasesand soft- RTFIGO CT + tissue sarcomas by others (28, 29). We restricted our investigation to Ib(bulky)FIGO cervical cancers of at least 3 cm (as estimated clinically) to enable Ila.hFIGO IllaMaximum valid intratumoral measurements under clinical conditions. The po cmMaximumdiameter s5 tential to accurately determine tumor oxygÃ©nationin smaller tumors cmPrimary diameter >5 with the Eppendorf histograph is currently being investigated in our RTInduction CTConcomitant institution. CTFIGO We used the median pO2 of all investigated cervical cancers, IbFIGO which was 10 mm Hg, as the cutoff level to discriminate hypoxic Ila.bFIGO 1MbMaximum from nonhypoxic tumors. Interestingly, Vaupel el til. (30), in an cmMaximumdiameter ^5 animal tumor model, have identified significantly different meta diameter >5 cmTotal471215312323331442II)S118231626Hypoxie " CT, chemotherapy; RT. radiation therapy. bolic energy status in tumors with median pO2 <10 mm Hg compared to those with median pO2 >10 mm Hg. Singer et al. (31) demonstrated with breast cancer cell lines that diminished mito overall and disease-free survival in the study population of patients chondria! energy generation was related to malignant progression. with advanced cancer of the uterine cervix. Analyzing both subgroups Whether different metabolic states are also relevant for human of patients treated with primary surgery and primary radiation re cervical cancers with different oxygÃ©nation profiles remains to be vealed significant disadvantages in the outcome for the patients with established. In a preliminary investigation, associations between hypoxic tumors irrespective of the mode of primary treatment (Figs. energy status measured with a bioluminescence technique in ran 2 and 3). As demonstrated in Table 5, the majority of recurrences dom tumor samples and incidence of mÃ©tastases were recently appeared in the pelvis with or without a distant component, indicating found (32). that extracervical pelvic tumor spread and radioresistance were the What determines the oxygÃ©nation status in cervical cancer? It most important reasons for treatment failure. can generally be assumed that the pO-, distribution in solid neo plasms is influenced by host as well as tumor cell factors. In our study cohort, we could not find any relation between tumor oxy DISCUSSION gÃ©nationand patient characteristics such as age, menopausa! status, This prospective study shows that the pretherapeutic determina smoking, hemoglobin concentration, and parameters of systemic tion of the tumor oxygÃ©nation status provides important informa blood circulation, which may affect oxygÃ©nationin normal cervical tion concerning the malignant progression in terms of extracervical stroma (21). spread and radioresistance of locally advanced cancer of the uter This study with more than KM)patients also confirmed our earlier ine cervix. Although knowledge about oxygÃ©nation in human tu findings that tumor oxygÃ©nationin locally advanced cervical cancer is mors in situ may be obtained indirectly through various noninva- independent from clinical stage, clinical tumor size, and histological sive, highly sophisticated methods, such as magnetic resonance type and grading. However, contrary to the pretherapeutic clinical spectroscopy, single photon emission computed tomography, or findings, the histopathological evaluation of the complete surgical positron emission tomography to detect labeled hypoxia markers, specimens from 47 patients who underwent radical surgery revealed we applied the invasive polarographic electrode assay since it significantly larger maximum tumor extensions and more frequent alone allows the direct measurement of tumor tissue pO2 values (occult) parametrial infiltration, as well as pronounced lymph-vascu and has therefore been regarded as the "gold standard" [for a lar space involvement at the tumor front, in hypoxic cervical cancers review, see Stone et al. (27)]. as compared with the nonhypoxic tumors. Clearly, tumor oxygÃ©nation The pO2 measuring protocol applied in this trial allows for the valid measurements identified more aggressive tumor phenotypes, which determination of tumor oxygÃ©nationwithin a few minutes in the were underestimated by the clinical evaluation with respect to size and

Table 5 Patterns of treatment failure and tumor oxygÃ©nati (n = 47)Nonhypoxic 42)Hypoxic radiation (;i =

tumors tumors lumors Nonhypoxic tumors statusNED"RecurrencePelvisDistantPelvisDisease (n =25)12135441TIO10Surgery (n =22)1575111144Primary (n =19)12 23) (n = 15II 49 31 0i +distantTreatment iII relapseExenterationCORTRTDeathFromfor

5II cancerFromcervical 41 intercurrent diseaseHvpoxic ' NED, no evidence of disease; CORT. combined operative and radiotherapeutie treatment: RT, radiation therapy.

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A with low-pO2 and well-oxygenated tumors both for the radiation and surgery treatment group, and therefore the comparison appears not to 1.0- be biased. Why do hypoxic cervical cancers have a poorer outcome? Since the majority of the patients who were not disease-free relapsed in the pO2> 10 mmHg pelvis with or without simultaneous distant mÃ©tastases,radioresis- n = 41 tance and extracervical pelvic tumor spread must be considered as n 0.6, primary causes of failure. Several mechanisms established from in vitro studies and animal tumor models may aid to explain these clinical findings. 0.4 (a) The radiosensitizing effect of molecular oxygen for photon pO,< 10mmHg irradiation should be diminished in low-pO2 tumors, which may n = 48 contain significant levels of radiobiologically hypoxic fractions (33- 0.2- 35). However, direct measures of tumor oxygÃ©nationmay not be representative of the radiobiological hypoxic fraction, if a substantial Log-rank p = 0.0039 proportion of cells within a tumor are nonclonogenic (36). Likewise, 0.0- the impact of pretreatment tumor hypoxia for fractionated radiother 10 20 30 40 50 60 70 80 Time [months] apy with claimed reoxygenation is unknown at present (37). (b) Tumor cells, like normal cells, when starved in a hypoxic microenvironment can respond with the expression of a variety of

â€¢¿i.4!. Surgery*-*

Tt... 0.8, pO,> 10 mmHg !_.Â»-â€¢ n = 41 OverallsurvivalprobabilityA1.0-0.8-0.4-IÂ«.

0.61 pO,>10mmHg Â«* 22!; n = 1 0.4 H pO3 < lOmmHg n = 48 ii ipOj 0.2H b < lOmmHg 0.2-~?I Log-rank p = 0.0085 25Log-rank n = o.o- 070 p = 0.01 10 20 30 40 50 60 70 80 Time [months] 10 20 308Time 40 50 60 70 Fig. I. Overall (A) and disease-free (ÃŸ)survival probabilities calculated with the [months] Kaplan-Meier method for 89 patients treated with curative intent stratified for tumor oxygÃ©nation. stage. We are presently investigating the relation between histopatho- B logical size, vascularity, and oxygÃ©nationin cervical cancers. It ap Surgery pears that a Malthusian principle of neoplastic cell populations out growing their nutritive blood supply with increasing tumor size, which has been observed in experimental tumors (1), may also be relevant in human solid neoplasms.4 pO,> 10 mmHg Five-year overall survival and disease-free survival probabilities rÃ¤ 0.6 H n = 22 calculated for 89 patients who underwent standard primary treatment for cure were significantly lower for hypoxic tumors than for nonhypoxic tumors of similar clinical stages and sizes. Multivariate Cox 0.4- regression analysis revealed tumor oxygÃ©nationas the most powerful 10mmHg n = 25 pretreatment prognosticator in our study cohort. Most interestingly, the disadvantage in outcome for low-pO2 tumors was independent of 0.2- the mode of primary treatment (radiation or radical surgery). Unlike the uniform primary treatment, adjuvant treatments changed during Log-rank p = 0.0804 the trial, and recommendations were not always followed by the O.O-1 patients or their health care providers. As a result, there was no 10 20 30 40 50 60 70 80 Time [months] significant difference between the adjuvant treatments of the patients Fig. 2. Overall (A} and disease-free (ÃŸ)survival probabilities calculated with the Kaplan-Meier method for 47 patients treated with primary surgery stratified for tumor 4 M. HÃ¶ckel.K. Schlenger. B. Aral, and P. Vaupcl. manuscript in preparation. oxygÃ©nation. 4513

Table 6 Cox regression analysis of the pretreattnent tumor characteristics of 89 patients with locally advanced cen'ical cancer treated with curative intent

survivalOdds survivalOdds

VariableUnivariateTumor CD"3.058(1.383-6.757)ratio (95<7r value0.0059 CD2.551ratio (95% value0.0108

oxygÃ©nation,hypoxic v.v. (1.201 -5.236) nonhvpoxic bMultivariateTumorFIGO stage. Ih. Ila, b vs. Illa, 1.945(0.936-4.042)P 0.07480.0039 1.504 (0.748 -3.025)P 0.25250.0084

oxygÃ©nation,hypoxic vs. nonhvpoxic 0.0692" FIGO stage. Ib. Ha. b 1-5.Ilia, bOverall 0.0495Disease-free CI. confidence interval. genes coding for oxygen-regulated proteins (38, 39). Several potential donai evolution of metastatic and intrinsically resistant tumor cell mechanisms have been suggested for how some of these oxygen- variants according to Darwinian principles. regulated proteins, including p53 and VEGF, influence tumor aggres In a recent paper. Brizel et al. (40) showed in high-grade soft tissue siveness in terms of malignant progression and decreased responsive sarcomas a relationship between pretherapeutic tumor hypoxia and the ness to therapy (2-10). development of distant mÃ©tastasesas first site of failure following (f) There is evidence that hypoxia enhances genetic diversity in treatment with irradiation/hyperthermia and surgery. Although locore- addition to exerting a selective pressure (11-13). This may lead to the gional failures were dominant in our investigation of patients with advanced cervical cancer, it is interesting to note that in the surgically treated subgroup of patients. 8 of 13 recurrences of the hypoxic tumors had a distant component, as compared to only 2 of 7 recur rences in the nonhypoxic tumors. Radiation In both cervical cancer and soft tissue sarcoma the hypoxic tumor pO; > 10 mmHg phenotype is strongly associated with advanced malignant progression. 0.8- n = 19 This tumor biology phenomenon must be taken into consideration when evaluating the effect of hypoxia on non-surgical anticancer treatments.

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Downloaded from cancerres.aacrjournals.org on September 28, 2021. © 1996 American Association for Cancer Research. Association between Tumor Hypoxia and Malignant Progression in Advanced Cancer of the Uterine Cervix

Michael Höckel, Karlheinz Schlenger, Billur Aral, et al.

Cancer Res 1996;56:4509-4515.

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