Long-term follow-up of patients with an isolated ovarian recurrence after conservative treatment of epithelial ovarian cancer: review of the results of an international multicenter study comprising 545 patients

OBJECTIVE

To determine the long-term outcomes of patients with an isolated ovarian recurrence after fertility sparing surgery (FSS) for epithelial ovarian cancer (EOC) and to evaluate the recurrence rates (and location) according to the new 2014 International Federation of Gynecology and Obstetrics (FIGO) staging system.

DESIGN

Retrospective multicenter study.

SETTING

Teams having reported recurrence after FSS for EOC.

PATIENT(S)

Four series comprising 545 patients undergoing FSS and 63 (12%) recurrences.

INTERVENTION(S)

FSS (salpingo-oophorectomy for a majority of cases) for EOC.

MAIN OUTCOMES MEASURE(S)

Recurrences rates and characteristics of recurrent disease.

RESULT(S)

Among 63 recurrent patients, 24 (38%) recurrences were isolated on the spared ovary, and 39 (62%) arose at an extraovarian site. Among the patients with an isolated ovarian recurrence, three patients died after a median follow-up period of 186 months (range: 28-294 months). Among the patients with recurrent extraovarian disease, 24 died and 7 were alive with persistent disease after a median follow-up period of 34 months (range: 3-231 months). The overall rate of isolated ovarian and extrapelvic recurrences was higher for grade 3 tumors (compared with grades 1/2).

CONCLUSION(S)

The long-term survival of patients with an isolated ovarian recurrence after FSS for EOC remains favorable. The prognosis of patients with an extraovarian recurrence is poor compared with those who have an isolated recurrent ovarian tumor. Grade 3 tumors (compared to grades 1/2) give rise to a higher rate of extraovarian recurrences.

Abstract P2-01-11: Prospective evaluation of the reliability of the combined use of two models to predict non-sentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: The MSKCC nomogram and the Tenon score – PHRC-NOTEGS study

Background: Several mathematical models have been developed to predict non-SN status in patients with breast cancer with SN metastasis. The Memorial Sloan-Kettering Cancer Center nomogram and Tenon score outperform other methods in academic studies but their exportability at multiple geographic locations and practice settings has never been reported. The purpose of this study was to prospectively evaluate the combined use of the MSKCC nomogram (Memorial Sloan-Kettering Cancer Center) and Tenon score to select, in patients with metastatic sentinel lymph node (SN), those at low risk of metastatic non-SN in whom additional axillary lymph node dissection (ALND) could be avoided.

Material and methods: From January 2011 to July 2012, data on 3157 patients with breast cancer from 65 institutions (university affiliated, general, regional hospital, nonprofit private hospital and private practice) were prospectively recorded (NCT01509963). Selection criteria were patients aged over 18 years old with untreated invasive T1-2 breast cancer with an indication of SN procedure. The primary outcome measure was the false negative rate in patients with both a ≤10% probability of metastatic non-SN with the MSKCC nomogram and a Tenon score ≤3.5 (i.e. low risk): proportion of patients with metastatic non-SN at additional ALND. The hypothesis was a 5%±5% rate in this group of patients. Other patients were considered at high risk. Because of the results of the Z011 and IBCSG 23-01 trials, additional ALND was not mandatory.in case of metastatic SN.

Results: Among the 2936 patients, at least one SN was metastatic (isolated tumor cells, micro- or macrometastasis) in 696 patients (23.7%). Among them, 178 did not have completion ALND. Among patients with completion ALND (n=518, 74.4%), 67 (13%), 437 (84%) and 14 (3%) patients were at low, high and undetermined combined risk while 47.5% were at low risk in patients without completion ALND (p<.001). This study did not meet its primary objective as the false negative rate in patients with low risk was 16.4% (11/67) [95% confidence interval: 8.5%-27.5%]. The false negative rate was significantly higher in patients in the high risk group: 33.9% (148/437) [95% confidence interval: 29.6%-38.4%] had non-SN metastasis (p=.004). Analyzed individually, Tenon score and MSKCC nomogram had complementary performances (number of patients at low risk: 35.3% and 18.5%, false negative rates: 21.9% and 17%, concordance index: 0.63 and 0.65, respectively).

Conclusion: In this controlled prospective trial, metastatic SN patients with both a ≤ 10% probability of metastatic non-SN with the MSKCC nomogram and a Tenon score ≤ 3.5 had completion axillary dissection in 47% of cases: in these patients, the false negative rate was statistically over 5% and did not reach the primary endpoint. Further evaluation is warranted to determine the outcome of patients with and without axillary dissection.

Citation Format: Roman Rouzier, Catherine Uzan, Alexandra Rousseau, Eugenie Guillot, Sonia Zilberman, Charles Meyer, Pablo Estevez, Pierre-François Dupre, David Kere, Virginie Doridot, Gauthier D'halluin, Xavier Fritel, Nicolas Pouget, Chafika Mazouni, Tabassome Simon, Charles Coutant. Prospective evaluation of the reliability of the combined use of two models to predict non-sentinel lymph node status in breast cancer patients with metastatic sentinel lymph nodes: The MSKCC nomogram and the Tenon score – PHRC-NOTEGS study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-11.

Impact of radical surgery on outcome in locally advanced breast cancer patients without metastasis at the time of diagnosis

BACKGROUND/AIM

In the era of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography ((18)FDG-PET/CT), more patients are being diagnosed with N3M0 disease. The objective of this study was to assess the prognostic impact of radical lymph node surgery (RLNS) in patients with locally advanced breast cancer classified as lymph node N3 disease according to the American Joint Committee on Cancer (AJCC) 2002 in whom there is no known distant metastasis and in the context of multimodal therapy.

PATIENTS AND METHODS

This was a two-Center retrospective study that included patients with breast cancer classified as N3M0 after (18)FDG-PET/CT assessment. We reviewed the clinical characteristics, surgical treatment and oncological outcomes of those patients.

RESULTS

Thirty-nine patients fulfilled the inclusion criteria. Multimodal treatment included neo-adjuvant chemotherapy (n=34), adjuvant radiotherapy (n=33), adjuvant chemotherapy (n=18) or neo- or adjuvant hormone therapy (n=17). Surgical treatment was not homogeneous. Eight patients had undergone RLNS and 31 conventional axillary lymph node dissection (CD). There was no significant difference in median overall survival between the RLNS group and the CD group (32 months (28-36) vs. 49 months (42-56) respectively (p=0.25)). The overall recurrence rate was 23%. Out of the 8 patients who had under gone RLNS, three had relapsed (two with distant metastases and one local).

CONCLUSION

RLNS was not proven to be beneficial in our study. In order to guide surgical management for these patients, PET/CT and magnetic resonance imaging (MRI) could be of interest, therefore a pilot study to improve reproducible surgical management would be of interest.

Gliomatosis Peritonei: A Particular Entity With Specific Outcomes Within the Growing Teratoma Syndrome

Objectives

Ovarian immature teratoma may be associated with peritoneal spread that could, after adjuvant chemotherapy, develop into disease exclusively composed of mature implants (growing teratoma syndrome) and/or gliomatosis peritonei (GP), defined as the presence of pure mature glial tissue. However, very few specific series are devoted to the outcomes of pure GP. This was the aim of the present study.

Patients

From 1997 to 2013, data concerning patients treated for stage II/III immature teratoma were reviewed. All slides were reviewed by an expert pathologist. Patients with ovarian cancer associated with peritoneal spread in the form of pure GP (initially if patients were treated without adjuvant treatment or after adjuvant chemotherapy if done) were analyzed.

Results

Ten patients fulfilled the inclusion criteria. The median age of patients at diagnosis was 36 years (range, 14–41 years). Six patients had undergone a conservative treatment. Five patients had macroscopic residual disease at the end of surgery.

The median duration of follow-up from the diagnosis of GP was 39 months (range, 6–114 months). Six patients had undergone secondary surgery. Among them, 5 had incompletely resected macroscopic GP. No patients had died of their disease. All patients were asymptomatic at the time of the last consultation (1 of them with abnormal radiologic imaging).

Conclusions

Gliomatosis peritonei is a particular entity of the condition described as growing teratoma syndrome because residual peritoneal disease can be asymptomatic totally stable over a long period which raises the question of a more conservative surgical approach in patients with massive peritoneal spread.

Nomogram to predict recurrence in patients with early- and advanced-stage mucinous and serous borderline ovarian tumors

OBJECTIVE

Recurrence prediction is a cornerstone of patient management for borderline ovarian tumors. This study aimed to develop a nomogram predicting the recurrence probability in individual patients who had received primary surgical treatment.

STUDY DESIGN

This retrospective multicenter study included 186 patients with borderline ovarian tumor diagnosed from January 1980 through December 2008. A multivariate logistic regression analysis of selected prognostic features was performed and a nomogram to predict recurrence was constructed. The nomogram was internally validated.

RESULTS

The overall recurrence rate was 34.4% (64/186), with noninvasive and invasive forms in 29% (54/186) and 5.4% (10/186) of cases, respectively. International Federation of Gynecology and Obstetrics stage, age at diagnosis, histologic subtype, completeness of surgery, and type of surgery (radical vs fertility sparing) were associated with an increased risk of recurrence and were included in the nomogram. The predictive model had a concordance index of 0.78 (95% confidence interval, 0.76-0.80) and 0.77 (95% confidence interval, 0.75-0.79) before and after the 200 repetitions of bootstrap sample corrections, respectively, and showed good calibration.

CONCLUSION

Our results support the use of the present nomogram based on 5 clinical and pathological characteristics to predict recurrence probability with a high concordance, hence to inform patients on surgical management. External validation is required to recommend this nomogram in routine practice.

Feasibility and performance of lymphoscintigraphy in sentinel lymph node biopsy for early cervical cancer: results of the prospective multicenter SENTICOL study

Objective

To evaluate feasibility, SLN detection rate, and SLN location of lymphoscintigraphy in sentinel lymph node (SLN) biopsy for early cervical cancer.

Methods

Ancillary analysis of data from the multicenter prospective SENTICOL study (January 2005–June 2007) of patients with early cervical cancer (FIGO stage IA with emboli to IB1) was conducted. Preoperative lymphoscintigraphy was performed after intracervical administration of 60 or 120 MBq of ^99mTc-labeled radiocolloid on the day before (long protocol) or morning of (short protocol) surgery. SLNs were identified intraoperatively using combined radioactivity/patent blue detection. SLNs were sampled electively and routine bilateral pelvic lymphadenectomy was performed by laparoscopy. A centralized review of lymphoscintigraphies was performed to assess feasibility, detection rates, and anatomic SLN location.

Results

Of 139 patients included in the SENTICOL study, 133 received radiocolloid injection, and 131 (98.5 %) underwent preoperative lymphoscintigraphy, with the long protocol in three-fourths of cases. The lymphoscintigraphic detection rate was 87.8 %, with a median of 2 (1–4) SLNs per patient. By multivariate analysis, factors independently associated with lymphoscintigraphic SLN detection were age [odds ratio (OR) 0.91, 95 % confidence interval (95 % CI) 0.87–0.96; P < 0.001], and protocol (long vs. short; OR 8.23, 95 % CI 1.87–36.25; P = 0.005). Bilateral SLN identification by lymphoscintigraphy occurred in 67 % of cases and was independently influenced by age (OR 0.95, 95 % CI 0.92–0.98, P < 0.001) and protocol (OR 5.42, 95 % CI 2.21–13.27; P < 0.001). Although 60.5 % of preoperative SLNs were in the external iliac territory, unusual drainage patterns included the common iliac (19.6 %), para-aortic (10.8 %), and parametrial (6 %) basins.

Conclusions

Our study demonstrates the feasibility and good detection rate of preoperative lymphoscintigraphy, with better detection in younger patients and with the long protocol. The high proportion of SLN basins in unexpected territories is of interest to guide intraoperative detection. Further studies are needed to better evaluate preoperative detection and to assess the contribution of lymphoscintigraphy to intraoperative detection.

Influence of histological subtypes on the risk of an invasive recurrence in a large series of stage I borderline ovarian tumor including 191 conservative treatments

BACKGROUND

The overall prognosis of stage I borderline ovarian tumors (BOT) is excellent but a small percentage of patients die to their disease. The prognostic factors for such a rare event are still not clearly defined. The aim of this study was to determine these factors for recurrence per se and recurrence in the form of invasive carcinoma in a large series of stage I tumors.

METHODS

A retrospective review of patients with BOT. Three inclusion criteria were defined: (i) a centralized histological review; (ii) macroscopic stage I tumors; (iii) exclusion of metastatic disease to the ovaries.

RESULTS

From 2000 to 2010, 254 patients fulfilled inclusion criteria [140 had mucinous BOT (MBOT) and 114 a serous BOT (SBOT)], and 191 had undergone conservative management. After a median follow-up of 45 months, 43 patients had developed recurrences (31 borderline and 12 invasive). The risks of recurrences were statistically increased after conservative treatment, particularly after a cystectomy, in patients with stage IB and among patients with incompletely staged tumors. In the subgroup of conservatively treated patients (representing 75% of our population), the risks of recurrences were statistically increased in patients affected by a SBOT, in patients who had undergone a cystectomy, in patients with stage IB disease and in patients with a micropapillary pattern (MPP). MBOT and the presence of a MPP were identified as prognostic factors for invasive disease.

CONCLUSIONS

In the present series of BOT with the largest number of patients treated conservatively to date, the presence of a MPP and the mucinous subtype were associated with a higher rate of progression to carcinoma after conservative management. These important results suggest that MBOT belong to a 'high-risk' group likely to develop an invasive recurrence after fertility-sparing surgery in stage I BOT.

Isolated pelvic perfusion in irradiated unresectable recurrence of pelvic tumor: preliminary outcome and ongoing study

The technique of isolated pelvic perfusion (IPP) using extracorporeal circulation is capable of delivering high dose chemotherapy in the pelvic cavity. This technique has improved over time, notably with the use of a G-suit placed and inflated above the iliac bifurcation to impede flow through percutaneous vascular routes. This approach is of potential value in patients with previously irradiated, locally advanced recurrences of cancer originating from the gynecological or gastrointestinal organs. Administration of tumor necrosis factor alpha (TNF-α) in combination with melphalan seems to provide response rates similar to those obtained in the technique of isolated extremity perfusion. A preliminary phase I study has shown promising results in terms of feasibility and response rates. A randomized study is currently underway to compare IPP to standard treatment in patients with unresectable recurrent pelvic tumors of gynecological or gastrointestinal origin.

Prognostic factors for recurrence after conservative treatment in a series of 119 patients with stage I serous borderline tumors of the ovary

BACKGROUND

The aim of this study was to evaluate prognostic factors for recurrence after conservative treatment of a large series of 'apparent' stage I serous borderline ovarian tumors (SBOTs).

PATIENTS AND METHODS

A review of 119 patients treated conservatively between 2000 and 2009 with follow-up data. All pathological slides were reviewed by the same expert pathologist. Prognostic factors for recurrence were studied (age, histological subtypes and surgical procedure).

RESULTS

Conservative surgical procedures were: unilateral cystectomy (n = 43, 36%); unilateral adnexectomy (UA; n = 50, 42%); bilateral cystectomies (n = 11, 9%) and UA + contralateral cystectomy (n = 15, 13%). Stromal microinvasion and/or a micropapillary pattern was present in 21 (18%) and 13 (11%) patients, respectively. With a median follow-up of 45 months, 38 (32%) patients relapsed (10 also had peritoneal disease in the form of noninvasive implants at the first recurrence). In 2 of these 38 patients, progression-to-invasive disease occurred at the second and third relapse (one patient died to the recurrence). Three prognostic factors for recurrence were identified in the univariate analysis: a young age (< or >30 years old), the type of conservative treatment (adnexectomy versus cystectomy) and tumor bilaterality. In the multivariate analysis, only age remained statistically significant.

CONCLUSION

In this series (the largest reported, to date, on recurrences after the conservative management of stage I SBOT), the risk of relapse was not related to tumor histological subtypes (micropapillary and stromal microinvasion) nor to the use of complete staging surgery. Invasive recurrences were very rare in stage I SBOT, but did occur. A young age, tumor bilaterality and the use of a cystectomy were identified as risk factors for recurrence, suggesting that management of fertility preservation (particularly in very young patients) should be associated with a meticulously conducted follow-up.

Adjuvant platinum-based chemotherapy for borderline serous ovarian tumors with invasive implants

BACKGROUND

Most borderline ovarian tumors (BOTs) are cured with surgery. However BOTs with invasive implants have a poor prognosis with a mortality of 20-40%. The benefit of adjuvant chemotherapy (CT) in this setting remains poorly defined.

METHODS

Retrospective study of serous BOT+invasive implants treated with adjuvant CT.

RESULTS

36 patients were referred with serous BOTs+invasive implants and treated with surgery and platinum-based CT between 06/1982 and 02/2011. 83% were stage III/IV. Tumors demonstrated microinvasion, micropapillary pattern or desmoplastic implants in 53%, 47% and 67% of cases, respectively. 8% had fertility-sparing surgery. Taking into account initial and completion surgeries, R0 was achieved in 84% (27/32) (NA, N=4). The majority (72%) received a combination of platinum+taxane. 11% of patients experienced a G3/G4 toxicity. 13 of 36 (36%) patients relapsed at a median of 27.3 months after diagnosis of invasive implants. Among 12 patients with histologically confirmed relapse, 8 patients progressed with invasive disease in the form of carcinoma or invasive implants. 5 year PFS/OS were 67%/96%. Neither microinvasion, micropapillary pattern, nor desmoplastic implants predicted relapse. In cases with evaluable disease, an objective response to chemotherapy was observed in 4 of 6 patients.

CONCLUSION

This is the largest study of BOT with invasive implants treated with surgery and adjuvant platinum-based CT. Treatment was well tolerated and the invasive relapse rate was 22% (8/36). Although numbers are small, the objective responses suggest a possible role for adjuvant CT in BOTs with invasive implants.

External multicentre validation of a nomogram predicting the risk of relapse in patients with borderline ovarian tumours

Background:

The Obermair nomogram was recently developed to predict the risk of relapse in patients with borderline ovarian tumours (BOTs) based on five readily available clinical, biological, and pathological characteristics. We set out to externally validate and assess its robustness using a multi-institutional BOT database.

Methods:

All consecutive patients treated for BOTs in the two participating centres between January 1980 and December 2008 and who had all the nomogram variables documented were identified for analysis.

Results:

Three hundred and fourteen eligible patients were identified and used for external validation analysis. The median follow-up and initial relapse time were 46.43 (range: 0.1–360) and 66.64 (range: 8–77) months, respectively. The nomogram concordance index was 0.54 (95% CI, 0.52–0.56). The correspondence between the actual relapse and the nomogram predictions suggests a limited calibration of the nomogram in the validation cohort.

Conclusion:

This external validation study of the Obermair nomogram showed limitations in its generalisability to a new and independent patient population.

Breast lesion excision sample (BLES biopsy) combining stereotactic biopsy and radiofrequency: is it a safe and accurate procedure in case of BIRADS 4 and 5 breast lesions?

The aim of this study was to evaluate the accuracy and safety of breast lesion excision system (BLES) procedure with an Intact system device, under stereotactic and ultrasound guidance. Retrospective data review of 32 breast lesions BI-RADS 4 or 5 underwent Intact procedures, from March 2010 to January 2012. Underestimation rates of atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were evaluated; percentage of complete radiologic and histologic removal of the breast lesion were analyzed, as were the complications due to procedure. Complete radiologic excision of the target lesion was achieved in all masses and 58.6% of calcifications. Lesion size was less than 11 mm (mean size 5.6 mm). Underestimation of ADH and DCIS was 0% and 10%, respectively. Low complication rate was noted: only one hematoma. BLES appears an accurate and safe biopsy system for sampling nonpalpable breast lesions, especially in case of microcalcifications clusters categorized as BI-RADS 4 and 5.

Prospective Multicenter Study Evaluating the Survival of Patients With Locally Advanced Cervical Cancer Undergoing Laparoscopic Para-Aortic Lymphadenectomy Before Chemoradiotherapy in the Era of Positron Emission Tomography Imaging

Purpose

The aim of this prospective study conducted in three French comprehensive cancer centers was to evaluate the therapeutic impact on survival of laparoscopic para-aortic (PA) staging surgery in locally advanced cervical cancer (LACC) before chemoradiotherapy.

Patients and Methods

We conducted a prospective multicenter study of 237 patients treated from 2004 to 2011 for LACC with negative positron emission tomography (PET) imaging of the PA area and undergoing laparoscopic PA lymphadenectomy. Radiation fields were extended to the PA area when PA nodes were involved. Chemoradiotherapy modalities were homogeneous across institutions. Patients with a poor prognosis histologic subtype or peritoneal carcinosis were excluded.

Results

Patients had clinical International Federation of Gynecology and Obstetrics stages IB2 (n = 79), IIA (n = 10), IIB (n = 121), III (n = 22), or IVA (n = 5). One hundred ninety-nine patients had squamous carcinoma, and 38 had adenocarcinoma/adenosquamous lesions. Twenty-nine patients (12%) had nodal involvement (false-negative PET–computed tomography [CT] results)—16 with a PA nodal metastasis measuring more than 5 mm and 13 with a nodal metastasis measuring ≤ 5 mm. Event-free survival rates at 3 years in patients without PA involvement or with PA metastasis measuring ≤ or more than 5 mm were 74% (SE, 4%), 69% (SE, 21%), and 17% (SE, 14%; P < .001).

Conclusion

To our knowledge, this is the largest series of patients reported undergoing such a strategy. We obtained the same survival rate for patients with PA nodal metastasis ≤ 5 mm and patients without PA lymph node involvement, suggesting that this strategy is highly efficient in such patients. Conversely, the survival of patients with PA nodal involvement greater than 5 mm remained poor, despite the absence of extrapelvic disease on PET-CT imaging in this subgroup.