Outcomes after conservative treatment of advanced-stage serous borderline tumors of the ovary

BACKGROUND

The aim of this study was to assess the outcomes of the largest series of patients treated conservatively for a stage II or III serous borderline ovarian tumor.

MATERIALS AND METHODS

From 1969 to 2006, 41 patients were treated conservatively for an advanced-stage serous borderline ovarian tumor. Patient outcomes were reviewed.

RESULTS

Twenty patients had undergone a unilateral salpingo-oophorectomy, 18 a unilateral cystectomy and two bilateral cystectomy (unknown for one patient). Three patients had invasive implants. The median duration of follow-up was 57 months (range 4-235). The recurrence rate was high (56%), but overall survival remained excellent (100% at 5 years, 92% at 10 years). One death had occurred due to an invasive ovarian recurrence. Eighteen pregnancies (nine spontaneous) were observed in 14 patients.

CONCLUSIONS

This study demonstrates that spontaneous pregnancies can be achieved after conservative treatment of advanced-stage borderline ovarian tumors (with noninvasive implants) but the recurrence rate is high. Nevertheless, this high rate has no impact on survival. Conservative surgery can be proposed to patients with a borderline tumor of the ovary and noninvasive peritoneal implants. Should infertility persist following treatment of the borderline tumor, an in vitro fertilization procedure can be cautiously proposed.

Final results of a FNCLCC French Sarcoma Group multicenter randomized phase II study of gemcitabine (G) versus gemcitabine and docetaxel (G+D) in patients with metastatic or relapsed leiomyosarcoma (LMS)

10527

Background: An objective response rate (RR) of 8% and 17% with G and G+D were respectively reported in metastatic soft tissue sarcomas (Maki, J Clin Oncol. 2007). We previously reported a 5% RR in 41 evaluable patients (pts) with ‘non uterus‘ LMS randomized to each arm of this randomized phase II study (Duffaud, ASCO. 2008). We present here the results of G vs G+D in uterine and all LMS. Methods: Patients had histologically proven metastatic or unresectable LMS, one prior anthracycline- based regimen, age ≥18, measurable disease (RECIST), PS ≤ 2. Treatment was G 1,000 mg/m2(over 100 minutes, d1+d8+d15) q28 days (d) or G 900 mg/m2(over 90 min, d1+d8) and docetaxel 100 mg/m2 (over 60 min, d8) q21 days; in the G+D arm, pts received lenograstim d9–15, 25% dose reductions were employed for prior pelvic radiation. The primary endpoint was the objective RR (CR+PR), evaluated every 2 cycles. Stratification was by primary tumor location (uterus vs. non-uterus). The Simon method was used: for “uterus” study, 20 pts per arm for a 74% probability of selecting the arm with a real RR of 50%, expected baseline RR was 40%; for the “non-uterus” study, 20 pts per arm for a 92% probability of selecting the arm with a real RR of 40%, expected baseline RR was 20%. Results: From 02/06 to 12/08, 44 pts were enrolled in the “non-uterus” study, 40 pts in the “uterus” study. Currently 76/82 pts are evaluable for response (41/44 in the “non uterus” and 35/38 in the “uterus” study) and 80/84 for toxicity. In the uterus group the median age is 57 (range 41–80), 24 pts received prior pelvic radiotherapy, the median number of cycles was 5 (range 0–8) and dose received/dose planned (%) were 69% in G arm, 88% of G and 86% of D in G+D arm. No differences in toxicity were observed between both LMS locations: in the G arm, toxicity was moderate except for one pulmonary gr4; in the G+D arm one toxic death was related to gr5 thrombocytopenia and there were 2 non-haemathologic gr4 toxicities; 11 pts stopped for intolerable toxicity (3 in G and 8 in G+D arm) and 1 pt for hypersensitivity (G+D arm). Conclusions: Final tumor response for uterine LMS and updated toxicity and PFS data for all the LMS will be presented during the meeting.

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Postoperative morbidity after completion surgery in patients undergoing chemoradiotherapy for locally advanced cervical carcinoma

5595

Background: The aim of this study was to evaluate the morbidity rate in patients undergoing completion surgery after homogeneous chemoradiation therapy (CRT) for locally advanced stage cervical cancer. Methods: Patients fulfilling following inclusion criteria were studied: 1. Stage IB2-IVA cervical carcinoma; 2. Tumor confined radiologically initially to the pelvic cavity; 3. Pelvic external radiation therapy with delivery of 45 Gy in pelvic cavity with concomitant chemotherapy (cisplatin 40 mg/m2/week) followed by utero-vaginal brachytherapy; 4. Completion surgery after the end of radiation therapy including at least a hysterectomy. Modalities of this completion surgery depended on the presence, location and size of residual disease. Results: One-hundred and fifty patients treated between 1998 and 2007 fulfilled inclusion criteria. Modalities of hysterectomy performed were: extrafascial hysterectomy in 106 (71%) patients and radical hysterectomy in 44 (29%). Para-aortic lymphadenectomy was performed in 131 (87%) patients and pelvic lymphadenectomy in 34 (23%) patients. Thirty-four (23%) patients had macroscopic (> 1 cm) residual disease on pathologic examination. Twenty-five (23%) patients had post-operative complications (in whom 17 severe morbidity requiring surgical or radiological treatment). Presence of residual disease was the only factor associated with overall morbidity rate in univariate and multivariate analysis. The use of radical hysterectomy and pelvic lymphadenectomy increased significantly the rate of severe morbidity (particularly bowel and urinary tract morbidity). Conclusions: In the present study involving a large number of patients undergoing completion surgery after homogeneous CRT in locally advanced cervical carcinoma the morbidity rate is important. Radical hysterectomy and pelvic lymphadenectomy increase the rate of severe morbidity. The interest on the survival of this completion surgery should be evaluated in prospective trial.

No significant financial relationships to disclose.

Prognostic factors of patients with advanced stage serous borderline tumors of the ovary

5573

Background: The aim of this study was to determine prognostic factors in a large series of patients with stage II or III serous low malignant potential ovarian tumor (LMPOT) and peritoneal implants. Methods: A retrospective review of patients with a serous LMPOT and peritoneal implants treated or referred in our institution. The slides of ovarian tumors and peritoneal implants were reviewed by the same pathologist. Prognostic factors were studied. Results: From 1969 to 2006, 168 patients were reviewed, 21 of whom had invasive implants. Tumors exhibited a micropapillary pattern in 56 patients. Adjuvant treatment had been administered to 61 patients. The median duration of follow-up was 57 (range, 1–437) months. Forty-four patients had relapsed and 10 patients had died. 5-year overall survival of patients was 98%. Among patients with noninvasive and invasive implants, 8% and 10%, respectively, relapsed at 5 years in the form of invasive disease (p = 0.08). Prognostic factors for recurrence in the univariate analysis were: a laparoscopic approach, conservative treatment and positive second-look surgery. In the multivariate analysis the use of conservative treatment was the only prognostic factors for recurrence. Conclusions: The prognosis of serous LMPOT with peritoneal implants remains good. The strongest prognostic factor in patients with an advanced-stage borderline tumor is the use of conservative surgery. In this series, a micropapillary pattern and implant subtypes (invasive vs. noninvasive) were not prognostic factors.

No significant financial relationships to disclose.

Massive low gastrointestinal bleeding due to a Dieulafoy rectal lesion

Massive low gastrointestinal bleedings are often difficult diagnostically and in terms of management. Sometimes, it is not possible to identify the bleeding point after performing diverse diagnostic tests and the patient undergoes a blind subtotal colectomy. With rectal bleeding, this form of surgery is completely useless, as it will not solve the cause of the haemorrhage. The Dieulafoy lesion has been widely described in the stomach, but in the rectum is a very rare entity that can cause massive lower gastrointestinal bleeding. In the literature, there are only 25 described cases of rectal Dieulafoy lesion.

Combination of bleomycin, etoposide, and cisplatin for the treatment of advanced ovarian granulosa cell tumors

The objective is to investigate the activity and toxicity of bleomycin, etoposide, and cisplatin (BEP) regimen in ovarian granulosa cell tumors (OGCTs). Twenty consecutive patients with initial metastatic (5 patients) or recurrent (15 patients) OGCT were treated; BEP regimen: B: 30 mg intravenously or intramurally on days 1, 8, and 15; E: 100 mg/m2/day on days 1–5; and P: 20 mg/m2/day on days 1–5. Median age: 42 years (range: 17–60); median follow-up: 45 months (range: 3–112). The overall response rate is 90% (nine clinical complete response [CR], nine clinical partial response) with a median duration of 24 months (range: 4–77). A second-look laparotomy performed in 11 patients showed a pathologic CR in 7 cases and microscopic disease in 1 case. Seven patients remain free of disease (at 4–84 months); 11 patients relapsed (median: 24 months, range: 13–58), 12 patients are still alive, and 9 patients are without disease (2 patients in second CR). At 4 years, overall survival and event-free survival are respectively 58% and 30%. Toxicity is evaluable for 19 patients (48 cycles). A grade 4 neutropenia occurred in 15% of cycles (in seven patients) with a febrile neutropenia in four patients. Five patients experienced a low bleomycin pulmonary toxicity. BEP regimen appears to be an active regimen for OGCT in first-line chemotherapy.

Survival and reproductive function of 52 women treated with surgery and bleomycin, etoposide, cisplatin (BEP) chemotherapy for ovarian yolk sac tumor

BACKGROUND

Ovarian yolk sac tumor (YST) is a very rare malignancy arising in young women. Chemotherapy has dramatically improved the prognosis. Current treatment consists of surgery followed by bleomycin, etoposide, and cisplatin (BEP) chemotherapy. However, given the rarity of this tumor, ovarian YST-specific survival and outcome after such treatment are not precisely known.

PATIENTS AND METHODS

This report concerns prospectively recorded cases that were either treated at Institut Gustave Roussy (Villejuif, France) or referred there for advice about therapy. From 1990 to 2006, 52 patients underwent surgery followed by BEP chemotherapy. Data on patient characteristics, treatment, survival, and fertility outcome were analyzed to assess treatment efficacy and gonadal toxicity after achieving a complete remission.

RESULTS

Thirty-five patients had stage I/II tumors while 17 patients presented with stage III/IV disease. With a median follow-up of 68 months, the overall 5-year survival and disease-free survival rates were 94% and 90%, respectively. Forty-one women underwent fertility-sparing surgery. Pregnancy was achieved in 12 of 16 (75%) women who attempted conception. Overall, 19 pregnancies have been recorded.

CONCLUSIONS

BEP chemotherapy following fertility-sparing surgery is a very effective treatment of ovarian YSTs. Most of the patients who attempt conception after complete remission will have children.

Results of a prospective dose-intensive regimen in 27 patients with small cell carcinoma of the ovary of the hypercalcemic type

BACKGROUND

The evaluation of first-line intensive combination therapy in small cell carcinoma of the ovary (SCCO).

PATIENTS AND METHODS

Debulking surgery; four to six cycles of chemotherapy with cisplatin (P) 80 mg/m(2) day 1, adriamycin (A) 40 mg/m(2) day 1, vepeside (V) 75 mg/m(2)/day days 1-3, cyclophosphamide (EP) 300 mg/m(2)/day days 1-3, every 3 weeks and granulocyte colony-stimulating factor with, in case of a complete remission, high-dose chemotherapy with carboplatin, vepeside, cyclophosphamide and stem-cell support.

RESULTS

Twenty-seven patients (median age 25 years); International Federation of Gynecology and Obstetrics stage: five I, four IIC, 17 IIIC-IV and one unknown. Twenty patients underwent complete surgery. Eight patients progressed under chemotherapy. Among 18 patients in complete response (CR), 10 received high-dose chemotherapy (CT) (three stem-cell collection failures, two protocol violations, two disease progression and one refusal). The main grade 3-4 toxic effects were hematologic. There were eight relapses among the 18 CR, four of which were pelvic alone. Among the 27 patients, 13 died and 10 patients are in CR1, three in CR2. The median follow-up is 37 months (8-166) and the median duration of the 18 CR is 30 months (5-111). Overall survival at 1 and 3 years is 58% [confidence interval (CI) 40% to 75%] and 49% (CI 30% to 67%).

CONCLUSIONS

Initial dose-intensive therapy achieves interesting overall survival in SCCO.

Evidences for a role of p38 MAP kinase in the stimulation of alkaline phosphatase and matrix mineralization induced by parathyroid hormone in osteoblastic cells

Increased bone formation by PTH mainly results from activation of osteoblasts, an effect largely mediated by the cAMP-PKA pathway. Other pathways, however, are likely to be involved in this process. In this study we investigated whether PTH can activate p38 MAPK and the role of this kinase in osteoblastic cells. Bovine PTH(1-34) and forskolin markedly increased alkaline phosphatase (ALP) activity and doubled osteocalcin (Oc) expression in early differentiating MC3T3-E1 cells. These effects were associated with increase in cellular cAMP and activation of the MAP kinases ERK and p38. Activation of these MAP kinases was detectable after 1 h incubation with 10(-7) M PTH and lasted 1-2 h. Activation of p38 was mimicked by 10 microM forskolin and prevented by H89 suggesting a cAMP-PKA-dependent mechanism of p38 activation. Interestingly, PTH-induced ALP stimulation was dose-dependently inhibited by a specific p38 inhibitor with no change in the generation of cAMP and the production of osteocalcin. Similar inhibitory effect was obtained in cells stably expressing a dominant-negative p38 molecule. Finally, treatment of MC3T3-E1 cells with PTH for 3 weeks significantly enhanced matrix mineralization and this effect was markedly reduced by a selective p38 but not a specific MEK inhibitor. In conclusion, data presented in this study indicate that PTH can activate p38 in early differentiating osteoblastic cells. Activation of p38 is cAMP-PKA-dependent and mediates PTH-induced stimulation of ALP which plays a critical role for the calcification of the bone matrix.

Implant auditif du tronc cérébral: indications et résultats

OBJECTIVES

To summarize the indications and evaluate the Auditory Brainstem Implant (ABI) performances in neurofibromatosis type 2 (NF2) and other otologics indications, as postmeningitis ossified cochlea.

MATERIAL AND METHODS

Main and first indication of ABI is NF2. Emergent indications are bilateral total ossified cochlea, vestibular schwannoma with controlateral lesions, cochlear nerve aplasia or inner ear's malformations. The pre-operative evaluation includes clinical, radiological, lipreading, and psychological status. A translabyrinthine or retrosigmoid approach is performed, depending on tumoral or not tumoral status. The auditory perception with the ABI is evaluated by testing, the words recognition in open-set lists, and the speech understanding with usual sentences.

RESULTS

In NF2 patients, best results are obtained in cases of smaller vestibular schwannoma and none, or short term, auditory deprivation. Negative prognostic factors are duration of total hearing loss (>10 years), tumor size (>30 mm), difficulties in electrode array placement, complications during post-operative course and number of active electrodes (<10). In cases of postmeningitis total deafness with totally ossified cochlea, results demonstrate a good benefit reaching these obtained with cochlear implant in post-meningitis deafness.

CONCLUSION

These results show a clear benefit of ABI in NF2 patients, with or without previous tumor removal, in case of small tumor with a short duration of hearing loss. In case of postmeningitis ossified cochlea, results potentially reach those of cochlear implants.

Long-term evaluation of ifosfamide-related nephrotoxicity in children: The French experience

9551

Background: Ifosfamide-induced nephrotoxicity is a significant issue in patients treated for tumours during childhood. This study aimed at documenting incidence of late renal toxicity of ifosfamide and its risk factors. Methods: 183 patients have been investigated. 100 were male. Median age at treatment was 9.3 years (0.4–18 years). Median dose of ifosfamide was 54 g/m2 (18–77 g/m2). No patients received cisplatin and/or carboplatinum. Diagnoses included rhabdomyosarcoma (77), other soft tissue sarcoma (39), Ewing (39), and osteosarcoma (28). Investigations were performed at a median interval of 10.3 years (5–20.7) after the end of the treatment, at a median age of 21.6 years (7.1–44.2). No patient had electrolyte or vitamine supplementation. Glomerular and tubular functions were graded according to the Skinner's system. Results: After 5 year minimal follow-up 55% had normal tubular and 79% had normal glomerular functions. Natraemia, kalaemia, serum HCO3 and calcaemia were normal in all patients. Hypomagnesaemia was observed in 4, hypophosphaetemia in 8 %. The tubular threshold for phosphate was reduced in 44% of the patients (grade 2 or 3 in 15%, grade 3 in 1 pt). Significant glycosuria (> 0.5 g/24h) was detected in 5 % of the patients but it was clearly abnormal only in 5 patients. 34% of the patients had beta2 microglobulinuria, however, proteinuria was observed in only 12%. Cumulative dose of ifosfamide, older age at treatment and follow-up since treatment were predictor for tubulopathy in univariate and multivariate analyse. The glomerular filtration rate was normal in 79% of the patients. 21% had a grade 1 toxicity and 1 patient a grade 2. Univariate analysis did not find any prognostic factor for glomerular toxicity apart from the association with tubular toxicity. Conclusions: Since ifosfamide-induced renal toxicity can be severe, long term evaluation is important and this risk should be balanced carefully against efficacy.

No significant financial relationships to disclose.

Prognostic impact of histological response after neoadjuvant chemotherapy in patients with stage IIIC/IV ovarian cancer undergoing complete cytoreductive surgery at the time of interval debulking surgery

16032

Background: The aim of this study was to evaluate the prognostic impact of histological response at the time of interval debulking surgery (IDS) in patients treated with neoadjuvant chemotherapy (NACT) for unresectable advanced-stage ovarian cancer (ASOC). Methods: A retrospective study was conducted in our institution to select cases fulfilling 3 following inclusion criteria: 1. Patients with unresectable (evaluated in most of them with initial surgery + biopsies) ASOC. All patients had residual disease > 2 cm after such initial surgery; 2. At least 3 courses of platinum + paclitaxel NACT; 3. Patients undergoing after NACT an IDS with absence of macroscopic residual disease at the end of the debulking surgery. IDS was followed by post-operative chemotherapy. Patients were classified into 3 groups according to the histological response (in the peritoneum & nodes) after NACT: group 1: no residual disease in peritoneum; group 2: persistent residual disease but with histological signs of chemoactivity (marked histological changes) and group 3: persistence of at least 1 site with no changes in the tumor (persistence of very active cells). Survival was compared between these 3 groups. Results: Fifty-eight patients treated between 1997 and 2004 fulfilled inclusion criteria (49 had stage IIIC and 9 stage IV disease). Respectively 47 & 11 patients received 3–4 or 5–6 courses of chemotherapy before IDS. Respectively 11, 11 and 36 patients were in groups 1, 2 & 3. The median time of follow-up was 41 months. Three-year overall survival in groups 1, 2 & 3 was respectively: 81%, 39% and 62% (no statistical difference). Three- year event-free survival in groups 1, 2 & 3 was respectively: 46%, 18% and 19% (p=.04 between group 1 versus 2+3). Conclusions: These results suggest that the degree of histological response have a limited impact on the survival of patients when complete debulking surgery is achieved at IDS. The degree of tumor cell viability after initial chemotherapy is not a reliable marker for modifying chemotherapy after debulking surgery in such patients.

No significant financial relationships to disclose.

Prognostic factors in metastatic rhabdomyosarcoma (RMS): The results of a pooled analyze from U.S. and European cooperative groups

9542

Background: Prognosis factors on outcome for metastatic RMS are still matter of discussion. The analysis of a large cohort of patients can give arguments for development of risk-based therapy. Methods: We studied data from SIOP 84, SIOP 98, European Intergroup MMT89–91, Italian RMS4.99, IRS-III, -IV Pilot, -IV, -V, -D9501 to look at the influence of age, histology, sites of primary and metastatic disease, and number of sites of metastatic disease at the 3 year event-free survival. Results: 788 patients were included in the analyze and 776 in the multivariate analyse. The 3 year overall survival and EFS were 34% (se 1.7) and 27 % (se 1.6) respectively. By univariate analysis, 3-year EFS was significantly influenced by age 10 years or more (15% vs 36%), alveolar histology (28% vs 40%), location of primary tumor in unfavorable site -parameningeal, extremity and “other” sites- (31% vs 48%) the presence of three or more metastatic (17% vs 38%), the presence of bone or bone marrow involvement (24% vs 45%). By multivariate analysis, histology had no more impact on EFS. The EFS was strongly correlated to the number of the 4 other unfavorable prognostic factors: age, site of the primary, number of metastis sites, bone/bone marrow involvement relative risks were 1.6 for age (p<0.0001), 1.4 for site of primary tumor (p=0.002), 1.3 for bone/bone marrow involvement (p=0.005), 1.4 for number of metastatic sites (p=0.002). EFS was 58% for the 46 patients without any factors and was respectively 40%, 22%, 14% and 4% in patients with 1 factor (250 patients), 2 factors (233 patients), 3 factors (177 patients) or 4 factors (70 patients) (p<0.01). Conclusions: This analysis identified subsets of patients with very different outcomes. Patients with EFS less than 50% might be appropriate candidates for experimental approaches.

No significant financial relationships to disclose.