Cis-platin based combination chemotherapy for advanced ovarian cancer. High overall response rate with curative potential only in women with small tumor burdens

Is complete mesocolic excision or total mesorectal excision necessary during cytoreductive surgery in ovarian peritoneal carcinomatosis with colonic involvement?

INTRODUCTION

Cytoreductive surgery (CRS) and intraperitoneal chemotherapy are effective in the treatment of ovarian peritoneal carcinomatosis (OPC). Colon resection is often required to achieve maximal cytoreduction during CRS. The success of complete mesocolic excision (CME) and total mesorectal excision (TME) in the surgical treatment of primary colorectal tumors is well-known. Our study aimed to investigate the factors affecting mesocolic lymph node metastasis (MLNM) and the contribution of CME/TME techniques to maximal cytoreduction in patients diagnosed with ovarian peritoneal carcinomatosis (OPC) with colon metastasis.

PATIENTS AND METHODS

Between 2004-2020, 30 patients who underwent colorectal resection with CME/TME techniques due to OPC-related colon metastasis were retrospectively analyzed.

RESULTS

The median age of patients was 61 (33-86). Six (20%) patients underwent total colectomy, 7 (23%) subtotal colectomy, 6 (20%) right hemicolectomy, 4 (13%) left hemicolectomy, and 7 (23%) rectosigmoid resection. Histopathological diagnosis was high-grade serous carcinoma in 29 (97%) patients, and malignant mixed Mullerian tumor in 1 (3%) patient. MLNM was detected in 17 (56%) of 30 patients. There was a significant relationship between MLNM and pelvic and para-aortic lymph node metastasis (PALNM) (p = 0.009) and lymphovascular invasion in primary ovarian tumors (p = 0.017). There was no significant relationship between MLNM and depth of colonic invasion (p = 0.463), histological grade (p = 0.711), and primary/secondary surgery (p = 0.638). MLNM was seen in 8 (47%) of 17 patients with only serosal invasion.

CONCLUSION

A high rate of MLNM can be seen in OPC-induced colon metastasis regardless of the degree of colon wall invasion. In patients with PALNM, the frequency of MLNM increases. We believe that if colon resection is to be performed in OPC, a colectomy should be performed by CME/TME principles to achieve maximal cytoreduction.

Combination Chemotherapy in Advanced Ovarian Carcinoma

Ovarian carcinoma is the fifth most common cause of death among women in western countries. It is often diagnosed in an advanced stage (FIGO Stage III and IV) and requires effective chemotherapy as first-line treatment. The advent of cisplatin combined with adriamycin and cyclophosphamide has remarkably increased the response rate in advanced disease. The authors report 31 cases of epithelial ovarian neoplasia, without prior chemotherapy, treated with cisplatin, adriamycin and cyclophosphamide (PAC I). Of the 30 evaluable patients, 15 had clinical complete remissions (cCR = 50%), 10 clinical partial remissions (cPR = 33%) and 5 no response (NR = 17%). The total response (cCR + cPR) was equal to 83%. Twelve of the 15 patients in cCR underwent second-look laparotomy; in 8 of these cases, histologic and cytologic confirmation of CR was obtained. PAC I was found to be a highly effective therapeutic regimen with moderate toxicity. The individual toxicity reported was gastroenteric (nausea and vomiting), but transitory. No chronic toxic side-effects from cisplatin or adriamycin were noted. However, more definitive results must be obtained to verify its impact on the prolongation of survival.

Cisplatin (P) versus Cyclophosphamide, Adriamycin and Cisplatin (CAP) for Stage III-IV Epithelial Ovarian Carcinoma: A Prospective Randomized Trial

In 1982 a randomized trial was started to compare a cisplatin-containing polychemotherapy (CAP: cyclophosphamide - CPA 750 mg/m2, adriamycin - ADM 50 mg/m2, cisplatin - P 50 mg/m2 on day 1 every 21 days) with full-dose cisplatin as single agent (P 60 mg/m2/day on days 1 and 2 every 28 days) in 44 patients undergoing exploratory laparotomy or debulking sugery for stage III-IV epithelial ovarian carcinoma with residual disease > 5 cm. The response was evaluated at second-look surgery with random biopsies and peritoneal washing. On the basis of the final results the authors underline some data which, although merely indicative (because of the small number of patients) appear to be worth considering since they are in accordance with the latest reports: a) similar response rate (CR+PR=47%) to first-line treatment in the two groups; b) the CAP treatment may achieve a longer median duration of CRs than the P treatment (20 versus 11 months); c) overall survival seems similar in the two groups of patients (19 versus 18 months), whereas the survival of CRs seems longer in the CAP treated patients (> 32 versus 25 months). The authors also discuss some observations on a possible salvage therapy.

Timing of Surgery and the Role of Cytoreductive Chemotherapy in Patients with Advanced Ovarian Carcinoma

We retrospectively selected 27 consecutive patients with advanced ovarian carcinoma (15 stage III, 11 stage IV and 1 relapse) who had an unresectable intraabdominal tumor at presentation and prospectively evaluated the overall treatment outcome. Patients were initially treated with chemotherapy consisting of cisplatin-containing regimens in 20 cases, adriamycin and cyclophosphamide in 5, and melphalan in 2. Treatment was continued until maximal tumor response or progression. Following a median of 6 cycles of chemotherapy, all patients underwent debulking surgery. Six women were without evidence of disease and 13 had minimal residual disease after surgery, for an overall 70% rate of optimal debulking. Patients with evidence of disease at laparotomy were treated with 5 additional cycles of chemotherapy, and response was then assessed at laparotomy except for patients with progressive disease. Nine (33%) patients were pathologic complete responders at the end of the entire treatment program. Overall median survival time was 26 months, with a median relapse-free survival of 33 months. Tumor responses were not associated with any particular chemotherapy regimen. The results achieved in this series of patients together with the data from the literature suggests that use of a cytoreductive chemotherapy of short duration has the potential of increasing the rate of optimal debulking surgery. Furthermore, it may contribute to a better disease control in women with bulky ovarian carcinoma compared to the present strategy, which consists of surgery followed by chemotherapy.

The Use of “Optimal Cytoreduction” Nomenclature in Ovarian Cancer Literature: Can We Move Toward a More Optimal Classification System?

Objectives

The objective of this study is to explore how cytoreductive surgical outcomes such as residual disease (RD) and use of the term “optimal cytoreduction” (OCR) have changed over time in the ovarian cancer literature.

Methods

We identified all English-language publications referring to ovarian cancer cytoreduction for a 12-year period. Publications were evaluated for how the diameter of RD was categorized and whether OCR was defined. In addition, the use of RD and OCR terminology trends over time and associations between terminology and the region of corresponding author, study type, and journal impact factor were explored.

Results

Of the 772 publications meeting inclusion criteria, the RD stratification points used to demarcate patient groups were as follows: 0 mm (45%), 5 mm (3.6%), 10 mm (65%), and 20 mm (24%). The use of 0-mm RD (odds ratio [OR], 1.1; 95% confidence interval, 1.05–1.15) and 10-mm RD (OR, 1.1; 95% confidence interval, 1.09–1.20) to delineate patient outcomes increased over time. The use of OCR terminology did not change over time but was more commonly used in clinical studies as well as those from North America. Many studies (70%) defined OCR as less than or equal to 10-mm RD, whereas 30% defined OCR differently or not at all.

Conclusions

Optimal cytoreduction terminology remains ambiguous and inconsistently used in the ovarian cancer surgical literature. On the basis of this literature review, we propose a novel classification system to categorize RD without reference to OCR while accurately and succinctly identifying meaningful clinical subgroups and minimizing bias.

Baseline tumour measurements predict survival in advanced non-small cell lung cancer

BACKGROUND

The association between tumour measurements and survival has been studied extensively in early-stage and locally advanced non-small cell lung cancer (NSCLC). We analysed these factors in patients with advanced NSCLC.

METHODS

Data were derived from the E4599 trial of paclitaxel-carboplatin±bevacizumab. Associations between the Response Evaluation Criteria in Solid Tumors (RECIST) baseline sum longest diameter (BSLD), response rate, progression-free survival (PFS) and overall survival (OS) were evaluated using univariate and multivariable Cox regression models.

RESULTS

A total of 759 of the 850 patients (89%) in the E4599 trial had measurable diseases and were included in this analysis. The median BSLD was 7.5 cm. BSLD predicted OS (hazard ratio (HR) 1.41; P<0.001) and had a trend towards association with PFS (HR 1.14; P=0.08). The median OS was 12.6 months for patients with BSLD <7.5 cm compared with 9.5 months for BSLD ≥ 7.5 cm. This association persisted in a multivariable model controlling multiple prognostic factors, including the presence and sites of extrathoracic disease (HR 1.24; P=0.01). There was no association between BSLD and response rate.

CONCLUSION

Tumour measurements are associated with survival in the E4599 trial. If validated in other populations, this parameter may provide important prognostic information to patients and clinicians.

Evolution of surgical treatment paradigms for advanced-stage ovarian cancer: redefining 'optimal' residual disease

Over the past 40 years, the survival of patients with advanced ovarian cancer has greatly improved due to the introduction of combination chemotherapy with platinum and paclitaxel as standard front-line treatment and the progressive incorporation of increasing degrees of maximal cytoreductive surgery. The designation of "optimal" surgical cytoreduction has evolved from residual disease ≤ 1 cm to no gross residual disease. There is a growing body of evidence that patients with no gross residual disease have better survival than those with optimal but visible residual disease. In order to achieve this, more radical cytoreductive procedures such as radical pelvic resection and extensive upper abdominal procedures are increasingly performed. However, some investigators still suggest that tumor biology is a major determinant in survival and that optimal surgery cannot fully compensate for tumor biology. The aim of this review is to outline the theoretical rationale and historical evolution of primary cytoreductive surgery, to re-evaluate the preferred surgical objective and procedures commonly required to achieve optimal cytoreduction in the platinum/taxane era based on contemporary evidence, and to redefine the concept of "optimal" residual disease within the context of future surgical developments and analysis of treatment outcomes.

Outpatient platinum-taxane intraperitoneal chemotherapy regimen for ovarian cancer

INTRODUCTION

Intraperitoneal (IP) chemotherapy is associated with an improved survival at the expense of increased toxicity in optimally debulked ovarian cancer patients. We describe the toxicity profile of an outpatient regimen of an intravenous (IV) and IP taxane-platinum chemotherapy.

METHODS

A chart review of all patients who received IP chemotherapy from December 2005 to May 2008 was performed. Optimally debulked patients after primary surgery for ovarian, primary peritoneal, or fallopian tubal cancer who received IV docetaxel 60 to 70 mg/m and IP cisplatin 80 to 85 mg/m on day 1 and IP paclitaxel 60 to 70 mg/m on day 8 every 21 days were included. Toxicities were recorded using the Common Terminology Criteria for Adverse Events v3.0.

RESULTS

Thirty-three patients have completed chemotherapy. Of these, 19 patients (58%) completed all planned cycles of IP chemotherapy and 23 (70%) completed 75% or greater of the planned cycles. Four patients (12%) did not complete 50% or greater of the cycles. A total of 150.5 IP cycles were delivered, with a median number of 4 IP cycles (range, 0.5-7.5) completed. Grades 3 and 4 hematologic toxicities occurred in 21% of patients (n = 7), and 8 patients (24%) experienced grade 3 or 4 nonhematologic events. The overall response rate was 100% (complete response, 91%; partial response, 9.0%) with a progression-free survival of 19 months.

CONCLUSIONS

This outpatient regimen of IV and IP platinum-taxane chemotherapy is well tolerated with acceptable toxicity. Importantly, most patients were able to complete all planned cycles of chemotherapy. These findings suggest that continued investigation of methods to decrease the toxicity of the treatment seen in the Gynecologic Oncology Group Protocol 172 is needed and should be studied in future phase 2 IP chemotherapy trials.

Surgical management of malignant bowel obstruction: strategies toward palliation of patients with advanced cancer

The management of malignant bowel obstruction is a challenging problem because of the poor definition of malignant bowel obstruction compounded by its myriad clinical presentations. Surgeons are called upon to perform invasive procedures designed to alleviate symptoms or correct the underlying obstruction. Unfortunately, interventions may carry a high rate of morbidity and mortality. Balancing these risks and potential benefits is complicated, and there is a paucity of data to help guide these difficult decisions. The surgeon is further handicapped when he or she is not understanding of the patient's disease status, prognosis, or long-term goals. Diligent discussion with the primary team and frank discussions with the patient and his or her family are essential to formulate an appropriate plan. It is also essential that the surgeon have a thorough understanding of the surgical options to relieve or palliate malignant bowel obstruction as well as effective nonsurgical interventions. The best approach may be appropriate surgical intervention coupled with aggressive medical management.

Cytoreductive surgery for gynecologic malignancies--new standards of care

Studies on cytoreductive surgery for advanced ovarian and primary peritoneal cancer have consistently shown a strong correlation between cytoreduction and survival, with the best survival observed in patients who have no visible residual disease after successful cytoreductive surgery. Recent data that intraperitoneal chemotherapy further improves survival after optimal cytoreduction adds to the potential benefit of such surgery. More recently, significant survival benefit from optimal cytoreduction has also been shown for patients with recurrent disease and for women with advanced endometrial carcinoma. The selection criteria for patients and critical aspects of the operative technique and timing of cytoreductive surgery are discussed.

Role of surgery in ovarian carcinoma

Surgery plays a critical role in the optimal management of all stages of ovarian carcinoma. In apparent early-stage ovarian cancer, a comprehensive surgical evaluation allows stratification of patients into low- and high-risk categories. Low-risk patients may be candidates for fertility-sparing surgery and can safely avoid chemotherapy and be observed. Treatment of patients with high-risk early- or advanced-stage ovarian cancer usually requires a combined modality approach. Although it is well known that epithelial ovarian cancer is moderately chemosensitive, what distinguishes it most from other metastatic solid tumors is that surgical cytoreduction of tumor volume is highly correlated with prolongation of patient survival. Procedures such as radical pelvic surgery, bowel resection, and aggressive upper abdominal surgery are commonly required to achieve optimal cytoreduction. Women who develop recurrent disease may be eligible for a secondary cytoreductive surgery or may require a surgical intervention to palliate disease-related symptoms. For women at high risk of ovarian cancer, prophylactic bilateral salpingo-oophorectomy significantly reduces the incidence of this disease. The purpose of this article is to provide a comprehensive review of the surgical management of ovarian carcinoma. The roles of primary, interval, and secondary cytoreductive surgeries; second-look procedures; and palliative surgery are reviewed. The indications for fertility-sparing and minimally invasive surgery as well as the current guidelines for prophylactic surgery in high-risk mutation carriers are also discussed.

Diagnosis and management of epithelial ovarian cancer

Epithelial ovarian cancer is the leading cause of death from gynecologic cancer in the United States. Although there has been a statistically significant improvement in 5-year survival, in 2005 more than 16,000 women were expected to die of this disease. To date, there is no reliable method to screen for ovarian cancer; therefore, the majority of cases are diagnosed with advanced disease. For early ovarian cancer, appropriate surgical staging and adjuvant chemotherapy for selected cases will result in survival rates of 90-95%. For advanced ovarian cancer, survival depends primarily on the success of the initial surgical procedure. Patients with complete cytoreduction to microscopic disease are often cured with adjuvant chemotherapy. There is growing evidence that these patients with microscopic residual disease are excellent candidates for intraperitoneal chemotherapy, and this mode of chemotherapy delivery may be their best opportunity for cure. Patients with optimal cytoreduction also may benefit from intraperitoneal chemotherapy, but cure is less likely. For patients with suboptimal cytoreduction, intravenous chemotherapy with a combination of carboplatin and paclitaxel is the current standard therapy. Most of these patients will experience recurrence of the cancer, with small chance of cure. Salvage chemotherapy is important in ovarian cancer because many patients respond to several salvage regimens. Because of the high response rate of ovarian cancer, even after relapse, it is probably better to consider 10-year survival as the ideal end point. Finally, new biologic agents, in combination with traditional surgery and chemotherapy, may result in further improvement in survival for patients with ovarian cancer.

Maspin expression in epithelial ovarian cancer and associations with poor prognosis: A Gynecologic Oncology Group study

OBJECTIVE

This study examined MASPIN expression in human ovarian cancer, and explored the association between MASPIN and prognosis in patients with advanced stage disease treated with first-line cisplatin, carboplatin and/or paclitaxel.

METHODS

Frozen primary tumors were obtained from 68 women with previously untreated, advanced stage epithelial ovarian cancer who participated in a specimen banking protocol and a phase III treatment trial conducted by the Gynecologic Oncology Group. Immunoblot analysis was performed in lysates prepared from these tumor specimens to quantify the relative expression of MASPIN/beta-actin.

RESULTS

MASPIN was expressed at detected levels in 49 (72%) cases with relative expression ranging from 0.02 to 7.7 (median = 0.2), and was not detected in 19 (28%) of the primary tumors tested. Non-detectable levels of this class II tumor suppressor gene product and inhibitor of angiogenesis were associated with suboptimally-debulked disease (P = 0.034) but not with patient age, FIGO stage, tumor grade, or histologic subtype. After adjusting for prognostic variables for disease progression or death, non-detectable MASPIN expression predicted an increased risk of disease progression (hazard ratio [HR] = 1.89; 95% confidence interval [CI]: 1.04-3.45; P = 0.038) and death (HR = 1.99; 95% CI: 1.07-3.69; P = 0.030).

CONCLUSIONS

In advanced stage epithelial ovarian cancer, non-detectable MASPIN appears to be associated with suboptimally-debulked disease and be an independent predictor of an increased risk of progression and death. Further studies are needed to validate these exploratory findings, determine the molecular mechanism controlling MASPIN expression as well as down-regulation and loss in ovarian cancer, and determine if MASPIN can prevent progression of this disease.

Secondary cytoreductive surgery for recurrent epithelial ovarian carcinoma: proposal for patients selection

The value of secondary cytoreductive surgery (SCS) for recurrent ovarian cancer is still controversial. The aim of this study was to clarify candidates for SCS. Between January 1987 and September 2000, we performed SCS in 44 patients with recurrent ovarian cancer, according to our selection criteria, disease-free interval (DFI) >6 months, performance status <3, no apparent multiple diseases, age <75years and no progressive disease during preoperative chemotherapy, if undertaken. The variables were investigated by univariate and multivariate analyses. Of 44 patients, 26 (59.1%) achieved complete removal of all visible tumours at SCS. Secondary cytoreductive surgery outcome, complete or incomplete resection, was significantly related to overall survival (P=0.0019). As for variables determined before SCS, DFI >12 months, no liver metastasis, solitary tumour and tumour size <6 cm were independently associated with favourable overall survival after recurrence in the multivariate analysis. Patients with three or all four variables (n=31) had significantly better survival compared with the other patients (n=13) (47 vs 20 months in median survival, P<0.0001). In these patients, fairly good median survival (40 months) was obtained even in patients with incomplete resection. Secondary cytoreductive surgery had a large impact on survival of patients with recurrent ovarian cancer when they had three or all of the above-mentioned four factors at recurrence. These patients should be considered as ideal candidates for SCS.

Predictive factors for irresectability in advanced ovarian cancer

Despite advances in surgical modalities and chemotherapeutic agents, the 5-year survival for patients with advanced ovarian cancer is barely 40-50%. At the moment, optimally cytoreductive primary surgery is the best option for patients with advanced ovarian cancer. Predictive factors of primary optimum reduction surgery have been described based on imaging studies and tumor markers and based on the premise to know a priori the weight and tumor volume, with promising results. A retrospective study was conducted based on the hypothesis that it is feasible to identify those patients not susceptible of undergoing optimum primary cytoreductive surgery. The variables associated with a lesser probability of success in this study are the presence of palpable abdominal tumor on physical examination, the presence of tumor in Douglas' cul-de-sac on vaginal exploration, the presence of ascites in any quantity, elevation of CA-125 above 1000 U/l, and the presence of pulmonary and liver metastases. The success rate for cytoreduction was 62% when none or one of these variables was present and 32% when two or more variables were present.

Prediction of optimal versus suboptimal cytoreduction of advanced-stage serous ovarian cancer with the use of microarrays

OBJECTIVE

The purpose of this study was to define gene expression patterns that are associated with the optimal versus suboptimal debulking of advanced-stage serous ovarian cancers.

STUDY DESIGN

RNA from 44 advanced serous ovarian cancers (19 optimal, 25 suboptimal) was evaluated with microarrays that contain >22,000 genes. Genes were screened on the basis of their association with debulking status to obtain the top 120 differentially expressed genes. These genes were then used to develop a predictive model for debulking status, which was subjected to out-of-sample cross validation.

RESULTS

We found that patterns of expression of 32 genes can distinguish between optimal and suboptimal debulking with 72.7% predictive accuracy. An analysis of the data that were based on clusters of co-ordinately expressed genes resulted in only a marginal improvement in predictive accuracy (75%).

CONCLUSION

These data support the hypothesis that favorable survival that is associated with optimal debulking of advanced ovarian cancers is due to, at least in part, the underlying biologic characteristics of these cancers.

High-dose whole abdominal and pelvic irradiation for treatment of ovarian carcinoma: long-term toxicity and outcomes

PURPOSE

To evaluate the role of high-dose whole abdominal and pelvic irradiation (WART) in the treatment of epithelial ovarian carcinoma.

METHODS AND MATERIALS

A retrospective review was performed on 71 patients with Stage I-III ovarian carcinoma who were treated with WART using an open field technique after total abdominal hysterectomy and bilateral oophorectomy with or without omentectomy. Whole abdominal doses greater than typically recommended were used in a series of patients to enhance local control and to decrease abdominal recurrence. None of the patients had received chemotherapy before RT. Thirty-one patients received Alkeran or cyclophosphamide and two received cisplatin-based chemotherapy after WART. The median whole abdominal dose was 36 Gy (range 9-45.5), delivered in a median of 30 fractions (range 8-46). A pelvic boost was delivered using AP-PA fields during whole abdominal RT to a total midline pelvic dose of 200 cGy/d. The median pelvic dose was 51 Gy (range 16-59). The right lobe and a portion of the left lobe of the liver were shielded with custom blocks at a median dose of 25 Gy (range 9-41). The kidneys were shielded either AP-PA or PA from the first day of RT. The median dose to the kidneys was 19 Gy (range 4-30).

RESULTS

The 5-year overall survival rate was 93%, 48%, and 29% for Stage I, II, and III patients, respectively. On multivariate analysis, stage and the extent of residual disease were independent prognostic factors. The 5- and 10-year overall survival rate for the 46 patients in the intermediate-risk group was 61% and 54%, respectively. For this group, a total abdominal dose of > or /=36 Gy was associated with a longer overall survival independent of stage, grade, and the amount of residual disease. This was most likely due to a significant reduction in the incidence of abdominal recurrence in patients receiving >36 Gy to the whole abdomen (18% vs. 49%, p = 0.006). Multivariate analysis revealed that grade (p = 0.023) and abdominal dose (p = 0.018) were independent factors influencing the rate of abdominal recurrence. Pelvic recurrence was rare as a first site of failure (6%). Twenty-one percent (n = 15) of the patients developed Grade 3 or 4 (Radiation Therapy Oncology Group [RTOG] criteria) chronic small or large bowel toxicity. Eleven percent of all patients had a small bowel obstruction requiring surgery. A whole abdominal dose >30 Gy and a pelvic dose >50 Gy were associated with a significant increase in small bowel obstruction (p = 0.01) independent of other factors. Chronic Grade 3 or 4 (Common Toxicity Criteria) anemia, thrombocytopenia, and leukopenia were seen in 7%, 1%, and 4% of the patients, respectively. Transient liver enzyme elevation was common (62%). Two patients had Grade 3 (RTOG) hepatic toxicity. Grade 3 or 4 renal toxicity (RTOG) was observed in 4%, and 2 patients (3%) were diagnosed with pelvic insufficiency fractures that were managed conservatively.

CONCLUSION

Survival after RT for ovarian carcinoma rivals that achieved with systemic chemotherapy. The results of this study suggest a possible dose-control relationship between the whole abdominal dose and the risk of abdominal recurrence; however, a higher rate of small bowel obstruction was observed when greater abdominal doses and greater pelvic doses were combined. Careful attention to balancing toxicity and efficacy is imperative if RT is to have a future role in the treatment of this disease.

Neoadjuvant chemotherapy for the management of ovarian cancer

Neoadjuvant chemotherapy refers to the administration of chemotherapy before definitive surgery is performed; this approach was introduced into the management of ovarian cancer approximately one decade ago, initially for use in women who were medically unable to tolerate aggressive cytoreductive surgery. Subsequently, neoadjuvant chemotherapy was employed in women who, by diagnostic imaging analysis, were unlikely to undergo successful optimal cytoreductive surgery. Only very limited data are available on the use of neoadjuvant chemotherapy in the management of women with apparent advanced ovarian cancer; these data are derived mainly from single institution experiences and suggest that this approach may increase disease-free survival but does not improve overall survival for the patient. However, it has consistently enhanced the feasibility of optimum surgical cytoreduction once neoadjuvant chemotherapy has been administered. Reduced blood loss, and shorter operations, intensive care unit stays and overall hospitalizations have been well documented. The methods for selecting candidates for neoadjuvant chemotherapy vary among institutions. Non-optimal surgical cytoreducibility has been assessed on the basis of diagnostic imaging studies, laparoscopic assessment and/or laparotomies. Currently, neoadjuvant chemotherapy is most beneficial for women who are medically impaired and unable to tolerate aggressive cytoreductive surgery and for women who are found to have such aggressive cancers that optimal cytoreductive surgery does not appear by diagnostic imaging or direct visualization to be possible.

Surgical management of ovarian cancer

The management of ovarian cancer presents one of the greatest challenges to physicians caring for patients with cancer. The treatment almost always involves a combination of surgery and chemotherapy. Over the past 75 years we have formed a rational system for the surgical management of this disease. Initial surgical therapy should include the following three objectives: (1) staging, (2) cytoreduction, and (3) determining a definitive histologic diagnosis. The importance of meticulous staging cannot be overstated. Fully one third of patients not compulsively staged will be upstaged if surgically restaged. Cytoreductive surgery is the mainstay of initial treatment. Data clearly demonstrate that ovarian cancer is different from other solid tumors in that reduction of the tumor burden is important in the management of this disease. Patients with less than 1 to 2 cm of disease remaining at the conclusion of initial surgery have a survival advantage over those who do not. The benefits of secondary cytoreduction are less clear, and data support the concept of cytoreduction in many circumstances. These surgical issues surrounding ovarian cancer support the concept that physicians trained to treat ovarian cancer be involved in its management. Data are emerging that clearly suggest that gynecologic oncologists should be involved in both the surgical and medical management of patients with ovarian cancer.

A population-based study of patterns of care for ovarian cancer: who is seen by a gynecologic oncologist and who is not?

OBJECTIVES

To determine the fraction of patients diagnosed with ovarian cancer and seen by a gynecologic oncologist and to compare outcomes with those patients and others who are not seen by a gynecologic oncologist.

METHODS

The statewide, population-based Utah Cancer Registry was used to identify 848 patients diagnosed with epithelial ovarian cancer between 1992 and 1998. Differences between selected characteristics of cases seen/not seen by gynecologic oncologists were assessed with chi2 tests, and survival data were analyzed using Kaplan-Meier curves and log-rank testing.

RESULTS

Of 848 incident epithelial ovarian cancer cases diagnosed in Utah residents during the period 1992-1998, 333 (39.3%) were seen by a gynecologic oncologist at some time during their cancer diagnosis and/or treatment. The percentage of ovarian cancer cases seen by a gynecologic oncologist varied with age: 35.6% of cases under 40 years of age at diagnosis were seen by a gynecologic oncologist, as were 54.5% of cases 40-59 years of age, 42.6% of cases 60-69 years, and 23.7% of women 70+ years of age (chi2 test, P < 0.01). The percentage of ovarian cancer cases seen by a gynecologic oncologists increased during the study period, from 33.0% in 1992-1993 to 47.5% in 1997-1998 (chi2 test for trend, P < 0.01). The vast majority of the state's population resides within a contiguous, four-county area near the only major city where gynecologic oncology care is available. Ovarian cancer cases that resided within that geographic area were generally more likely to have been seen by a gynecologic oncologist than those who lived in more rural regions of the state (42.7 and 27.1%, respectively; chi2 test, P < 0.01). For ovarian cancer cases diagnosed with local or regional stages of disease, there were no significant differences in survivorship between those treated or not treated by gynecologic oncologists. Among cases diagnosed with advanced disease, those cases seen by gynecologic oncologists had a significant survival advantage when compared to those that were not (median survival 26 and 15 months, respectively, P < 0.01).

CONCLUSIONS

Gynecologic oncologists see less than half of ovarian cancer patients. Patients under 40 years of age, over 70 years of age, and in rural areas were significantly less likely to be seen by a gynecologic oncologist in their course of treatment. Patients with advanced disease experienced a significant survival advantage when a gynecologic oncologist was involved in their care.

Bowel resection at the time of primary cytoreduction for epithelial ovarian cancer

BACKGROUND

The purpose of this study was to determine the morbidity and survival associated with bowel resection at the time of primary cytoreductive surgery for ovarian cancer.

STUDY DESIGN

We reviewed all patients undergoing bowel resection by gynecologic oncology faculty at the time of primary cytoreduction for advanced epithelial ovarian cancer diagnosed between 1983 and 1995.

RESULTS

There were 105 patients meeting the above criteria. The median age was 65 years (range 34 to 85 years). There were 76 stage III and 25 stage IV cancers. The primary indication for bowel resection was tumor debulking in 92% of the patients. Seventy patients had segmental resection of the colon only, and 22 patients underwent resections that included the large and small bowels. Mean operating time was 260 minutes and mean estimated blood loss was 1,447 mL. Thirty-three (31%) patients were optimally cytoreduced to less than 1 cm residual disease. Ten patients experienced major complications directly related to bowel resection, including bowel fistula (4 patients), early postoperative bowel obstruction (5 patients), and stomal hernia (1 patient). Other morbidity included ileus for more than 10 days (18 patients), cardiac complications (17 patients), pneumonia (8 patients), sepsis (5 patients), and thromboembolism (4 patients). Six patients died and five patients required reexploration within 30 days of operation. Patients with preoperative bowel obstruction and suboptimal residual disease were more likely to have postoperative morbidity. Median survival in the optimally debulked patients was 35 months compared with 18 months in patients suboptimally cytoreduced (p = 0.006). Multivariate analysis demonstrated that optimal debulking (p = 0.009) and platinum chemotherapy (p = 0.00006) were independently associated with improved survival. Age, International Federation of Gynecologia Oncologists stage, American Society of Anesthesiologists class, and paclitaxel chemotherapy did not influence survival.

CONCLUSIONS

In patients undergoing bowel resection at the time of primary cytoreduction for ovarian cancer, optimal cytoreduction to less than 1 cm residual disease results in improved survival. Morbidity is common but is comparable to other published series of ovarian cancer patients undergoing primary cytoreductive surgery without bowel resection. Additionally, patients with preoperative bowel obstruction and suboptimal residual disease are more likely to have serious morbidity.

Cytoreductive surgery for ovarian cancer

Cytoreductive surgery is a crucial component of the management of cancer of the ovary. Surgical cytoreduction of ovarian cancer volume has been associated with an increase in survival in all settings in which it has been studied. This association seems strongest, and the benefits of aggressive surgery are generally greatest, in patients with chemosensitive disease. Effective surgical management of ovarian cancer, therefore, requires competence in surgical anatomy and cytoreductive techniques and a thorough understanding of the patient's disease status and therapeutic goals.

Secondary cytoreductive surgery for localized intra-abdominal recurrences in epithelial ovarian cancer

OBJECTIVE

The aim of this study was to evaluate the role of secondary cytoreductive surgery in patients with recurrent epithelial ovarian cancer with an apparent solitary intra-abdominal focus.

METHODS

We conducted a retrospective review of patients with epithelial ovarian cancer who underwent secondary cytoreduction for recurrence at the University of Texas M. D. Anderson Cancer Center between 1985 and 1994. Eligible patients included those who had a laparotomy to resect a tumor that was apparently solitary. Cytoreductive surgery was defined as optimal if the diameter of the largest residual tumor was < or =2 cm and suboptimal if >2 cm.

RESULTS

Twenty-five patients met our eligibility criteria. Their mean age was 55 years (range, 35-73 years). The median time from primary diagnosis to recurrence was 37.6 months. Tumor was found to be confined to a solitary site in 15 patients (60%), to two sites in 6 (24%), and to three or more sites in 4 (16%). Surgical procedures included cytoreduction in 10 patients, intestinal resection in 8, splenectomy in 3, and limited biopsies in 4. Secondary cytoreduction was optimal in 18 of 25 patients (72%). The median postsecondary cytoreduction survival was 25.1 months for patients who had suboptimal secondary cytoreduction compared with 56.9 months for those who had optimal cytoreduction (P = 0.08).

CONCLUSIONS

Secondary cytoreductive surgery for recurrent ovarian cancer at an apparently solitary intra-abdominal site resulted in optimal residual tumor in a high proportion of patients. Although there was no survival advantage for patients whose tumor was optimally debulked, there was a trend toward improved survival. A large prospective randomized trial of secondary cytoreduction for recurrence is recommended.

Selective irradiation for the treatment of recurrent ovarian carcinoma involving the vagina or rectum

OBJECTIVE

The aim of this study was to evaluate the role of selective irradiation in the management of recurrent or persistent ovarian carcinoma involving the vagina or rectum after initial surgery or surgery and chemotherapy.

METHODS

Twenty-eight patients with recurrent or persistent vaginal and/or perirectal disease from ovarian carcinoma received selective irradiation and were evaluated for local control, survival, and quality of life. Seventy-nine percent had previously received various combinations of chemotherapy after initial surgery. At recurrence, 68% of the 28 patients were treated with external beam irradiation only, 7% with brachytherapy only, and 18% with both external beam irradiation and brachytherapy. In addition, 50% of the patients received various combinations of chemotherapy before or after radiotherapy and 3 patients received additional surgery.

RESULTS

Vaginal bleeding was controlled in all patients and a complete symptomatic response was achieved in 79% of the symptomatic patients. Survival after recurrence at 2 years was 57% for patients who had no liver or extra-abdominal metastasis at the time of radiotherapy (21 patients) and 0% for patients who had liver or extra-abdominal metastases (7 patients). Median survival of 5 patients with abdominal and pelvic disease and 16 patients with no extrapelvic disease at the time of recurrence was 2.16 (0.16-10.67) and 2.08 (0.58-27) years, respectively, after recurrence. Fifty percent of the 16 patients without extrapelvic disease had a complete response to radiotherapy (CR group) and the remaining had a partial response or stable disease (non-CR group). The 1-year survival after salvage irradiation in this same group was 100% in the CR group and 37.5% in the non-CR group (P < 0.0001). There are 4 long-term survivors in the CR group who are still alive in excess of 5 years after salvage radiotherapy. Thirty-five percent (5/14) of the patients with pelvic disease only recurred in the unirradiated upper abdomen.

CONCLUSIONS

Radiation can be considered an effective treatment option for patients with vaginal and/or perirectal recurrences of ovarian carcinoma. It offers excellent palliation to patients with disseminated disease and may result in both local control and long-term survival in patients with nondisseminated disease. This location may represent a sanctuary site from chemotherapy. Pelvic irradiation alone may be effective salvage and the addition of brachytherapy may improve local control, particularly in patients with disease confined to the pelvis who undergo debulking or chemotherapy.

A critique of surgical cytoreduction in advanced ovarian cancer

Due in most part to the abundant retrospective evidence suggesting that surgical cytoreduction is essential to the management of advanced ovarian cancer, most clinicians do not question its application. Irrespective, there are many who still doubt its value, given its unique role in ovarian cancer, in comparison to other solid tumors. While many papers have extolled the virtues of debulking surgery, few have taken the opposing view. This paper attempts to expose the weaknesses in the current available data regarding surgical cytoreduction in advanced ovarian cancer. By reviewing the retrospective data, the theoretical benefits of surgery, cellular kinetics, the fallacies of residual disease, interval debulking surgery, and neoadjuvant chemotherapy, a critique of debulking surgery is made. Issues surrounding perioperative morbidity and its impact on quality of life have not been adequately addressed. Despite the need for randomized trials of surgery in advanced ovarian cancer, they are unlikely to occur. The window of opportunity with respect to studying the questions on the optimal timing, degree of aggressiveness, and patient selection for surgery has likely passed. Biases and ethical issues based upon the data cited in this paper have and will continue to hamper our ability to fully elaborate the benefits of surgery with respect to survival and quality of life.

Primary cytoreductive surgery with rectosigmoid colon resection for patients with advanced epithelial ovarian carcinoma

BACKGROUND

The impact of radical bowel resection with multiple organ resection on the survival if patients with advanced ovarian carcinoma has not been well defined. The authors investigated whether primary cytoreductive surgery including rectosigmoid colon resection would affect the recurrence free interval and survival of these patients.

METHODS

Between April 1990 and April 1997, 66 previously untreated Stage IIIC-IV ovarian carcinoma patients with macroscopic involvement of the rectosigmoid colon were enrolled. All patients underwent cytoreductive surgery with rectosigmoid colon resection to remove residual tumor less than 2 cm in greatest dimension and received 6 cycles of cisplatin-based postoperative chemotherapy.

RESULTS

The median follow-up was 26 months (range, 7-104 months). In multivariate analysis, residual disease and depth of tumor infiltration of the bowel wall were independently associated with overall survival and recurrence free interval. Disease stage was independently associated only with overall survival. Residual tumor was the most strongly predictive factor for recurrence or death. The 2-year estimated survival rates according to the amount of residual tumor were 100% for 24 patients with no macroscopic residual disease and 77.3% for 28 patients with residual disease less than 1 cm. None of the 14 patients with residual disease larger than 1 cm were alive 2-years after operation. Overall, 48 patients (72.7%) developed disease recurrence: 43 (65.1%) in the abdomen, 19 (29.8%) in the liver, and 3 (4.5%) in the pelvis.

CONCLUSIONS

The current findings suggest that cytoreductive surgery with rectosigmoid colon resection should be considered for ovarian carcinoma patients with bulky pelvic disease to help ensure that they are left with no residual disease after debulking surgery.

Surgical management of ovarian cancer

Ovarian cancer affects over 25,000 women each year in the United States. The performance of appropriate surgery for ovarian cancer is critical in directing further therapies and improving survival. Systematic surgical staging must be performed in patients who appear to have early stage ovarian cancer because a significant proportion of these women have occult metastases. A marked improvement in survival has been demonstrated in patients with bulky disease if all masses larger than 2 cm can be surgically removed. Despite the dramatic effect of surgery on the subsequent course of the disease, recent studies show that only a minority of women with ovarian cancer receive appropriate initial surgery. We review the evidence and rationale for systematic surgical treatment of ovarian cancer.

Prognostic factors in ovarian carcinoma in complete histologic remission at second-look surgery

Prognosis of ovarian carcinoma in complete histologic remission (CHR) at second-look surgery is still controversial. In a series of 83 patients in CHR we studied retrospectively several prognostic factors (age, stage, histologic grade, histologic type, initial residual disease after surgery, CA 125 normalization period) to determine which patients present a high risk of relapsing after CHR and could be included in therapeutic protocols for consolidation treatment. Univariate analysis showed that the combination of CA 125 normalization < 8 weeks with absence of macroscopic tumoral residue after initial surgery permits the definition of a group with a very good prognosis, while for patients with CA 125 normalization period > 8 weeks and an initial macroscopic residual tumor, the prognosis is relatively poor (progression-free survival 100% vs. 47%, at 2 years P < 0.05). Using the Cox multivariate analysis, only the initial tumoral residue is of prognostic significance for progression-free survival; there is no prognostic significance for overall survival. The therapeutic strategy for ovarian cancer may be improved for patients in CHR after second-look surgery by determining those at high risk, making it possible to confine consolidation treatment trials to such a group.

Complete cytoreductive surgery is feasible and maximizes survival in patients with advanced epithelial ovarian cancer: a prospective study

OBJECTIVE

Despite correlation between the completeness of surgical cytoreduction and survival for patients with advanced ovarian cancer, relatively few undergo complete cytoreduction. This study was initiated to prospectively determine the ability to surgically eliminate all visible disease in patients with stage IIIC and IV epithelial ovarian cancer and the associated impact on survival.

METHODS

Between 1990 and 1996, 163 consecutive patients underwent primary cytoreduction. The goal was the excision or ablation of all visible disease prior to initiation of systemic platinum-based combination chemotherapy. A multivariate analysis determined which clinical and pathologic variables influenced the probability of achieving complete cytoreduction (logistic regression) and survival (Cox proportional hazards model).

RESULTS

One hundred thirty-nine patients (85.3%) underwent removal of all visible tumor, 22 (13.5%) had cytoreduction to </=1 cm residual disease, and 2 (1.2%) had unresected bulky disease. The median and estimated 5-year survival for the entire cohort was 54 months and 48%, respectively. The probability of achieving complete cytoreduction was influenced independently by the preoperative Gynecologic Oncology Group performance status (0-1 vs 2-3, P = 0.04), the number of mesenteric and intestinal serosal implants (</=75 vs >75 implants, P = 0.005), and stage (IIIC vs IV, P = 0.006). The probability of survival was independently influenced by age (</=61 vs >61 years, P = 0.003), volume of ascites (</=1 vs >1 liter, P = 0.01), stage (IIIC vs IV, P = 0.04), histology (clear cell and mucinous vs all other, P = 0.03), and the completeness of cytoreductive operation (complete vs incomplete cytoreduction, P = 0.02).

CONCLUSIONS

Complete cytoreduction is possible for the majority of patients and improves survival, even compared to operations with minimal (</=1 cm) residual disease. Unless their medical condition prohibits anesthesia and surgery, patients with advanced epithelial ovarian cancer should undergo primary cytoreductive surgery with the intention of complete tumor removal.

Evaluation of staging, cytoreduction and second-look operation of 119 ovarian cancer patients

OBJECTIVE

This study was conducted on patients with ovarian cancer in order to evaluate survival.

DESIGN

A retrospective study of 119 cases of ovarian cancer from January 1977 to December 1992 with observation until 1993.

LOCATION

Department of Gynecology and Obstetrics, Ribeirão Preto School of Medicine, São Paulo University.

PARTICIPANTS

Of the 119 cases, 70 (58.8%) presented epithelial carcinomas and 21 (17.6%) tumors of the sexual girdle/stroma.

DATA SOURCE

The data were obtained from the medical records of the patients.

MEASUREMENT

Statistical analysis of survival time was based on the nonparametric Mann-Whitney test with the level of significance set at P < 0.05.

RESULTS

The patients with a negative second look had a mean survival of 79.4 +/- 48.5 months versus 24.2 +/- 15.1 months for patients with a positive second look (P < 0.02).

CONCLUSIONS

It is concluded that patients with a negative second look present a better prognosis compared to those with residual disease.

Cytoreductive Surgery in Ovarian Cancer: Why, When, and How?

Retrospective evidence supports the value of optimal cytoreductive surgery in the initial therapy of patients with advanced ovarian cancer. Specialized procedures, including radical pelvic surgery, bowel resection, and diaphragm resections, are frequently necessary to accomplish optimal cytoreduction. Cytoreduction and total gross tumor removal are possible more frequently with new surgical instruments such as the Cavitron ultrasonic surgical aspirator and argon beam laser. Pelvic and periaortic lymph node resection is an important aspect of cytoreductive surgery, and systematic removal of grossly uninvolved lymph nodes may improve survival. Secondary cytoreductive surgery appears to benefit a select group of patients.

Altretamine. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic potential in cancer chemotherapy

Altretamine (hexamethylmelamine) is a cytotoxic antineoplastic agent which appears to require metabolic activation. Metabolic intermediates may act as alkylating agents; however, altretamine is not directly cross-resistant with classical alkylating agents. Objective response rates to orally administered altretamine as salvage therapy in patients with advanced ovarian cancer were 0 to 33%, with disease stabilisation in a further 8 to 78% of patients. Response rates appear to be higher in patients who have responded to previous alkylating agent or cisplatin-based therapy. There is some evidence that addition of altretamine to platinum-based combination regimens used for induction therapy of advanced ovarian cancer may improve long term survival, particularly in patients with limited residual disease. Although altretamine displays some activity in small cell lung cancer, it is unlikely to have any clinical role in the management of non-ovarian cancer. Altretamine appears to be relatively well tolerated, with gastrointestinal, neurological and haematological toxicities being the main dose-limiting adverse effects. However, assessment of accurate incidence rates for these effects is complicated by the use of altretamine with cisplatin. On the basis of the emerging body of clinical evidence, altretamine appears to have a limited role in the treatment of persistent or recurrent advanced ovarian cancer, primarily in patients who are potentially platinum sensitive yet intolerant of platinum analogues. Additionally, altretamine may be added to platinum-based regimens for induction therapy of advanced ovarian cancer. At the doses currently recommended, altretamine offers a reasonably well tolerated regimen that can be administered orally and is suitable for use on an outpatient basis.

The effect of debulking surgery after induction chemotherapy on the prognosis in advanced epithelial ovarian cancer. Gynecological Cancer Cooperative Group of the European Organization for Research and Treatment of Cancer

BACKGROUND

Although the value of primary cytoreductive surgery for epithelial ovarian cancer is beyond doubt, the value of debulking surgery after induction chemotherapy has not yet been defined. In this randomized study we investigated the effect on survival of debulking surgery.

METHODS

Eligible patients had residual lesions measuring more than 1 cm in diameter after primary surgery. After three cycles of cyclophosphamide and cisplatin, these patients were randomly assigned to undergo either debulking surgery or no surgery, followed by further cycles of cyclophosphamide and cisplatin. The study end points were progression-free and overall survival. At surgery 65 percent of the patients had lesions measuring more than 1 cm. In 45 percent of this group, the lesions were reduced surgically to less than 1 cm.

RESULTS

Of the 319 patients who underwent randomization, 278 could be evaluated (140 patients who underwent surgery and 138 patients who did not). Progression-free and overall survival were both significantly longer in the group that underwent surgery (P = 0.01). The difference in median survival was six months. The survival rate at two years was 56 percent for the group that underwent surgery and 46 percent for the group that did not. In the multivariate analysis, debulking surgery was an independent prognostic factor (P = 0.012). Overall, after adjustment for all other prognostic factors, surgery reduced the risk of death by 33 percent (95 percent confidence interval, 10 to 50 percent; P = 0.008). Surgery was not associated with death or severe morbidity.

CONCLUSIONS

Debulking surgery significantly lengthened progression-free and overall survival. The risk of death was reduced by one third, after adjustment for a variety of prognostic factors.

Long term survival by cytoreductive surgery to less than 1 cm, induction weekly cisplatin and monthly cisplatin, doxorubicin, and cyclophosphamide therapy in advanced ovarian adenocarcinoma

BACKGROUND

Survival rates for patients with advanced epithelial ovarian cancer remain low despite improved chemotherapy regimens and cytoreductive surgery.

METHODS

One hundred thirty-six patients with Stage III or IV ovarian cancer were treated with primary cytoreductive surgery followed by cisplatin induction, 1 mg/kg weekly x 4 followed by 10 cycles of cisplatin (50 mg/m2), doxorubicin (50 mg/m2), and cyclophosphamide (750 mg/m2). Second-look surgery was performed on those patients who were clinically without evidence of disease at the end of the planned chemotherapy course. Survival and progression-free survival were calculated, and prognostic factors regarding survival and progression-free survival were evaluated by both univariate and multivariate analyses.

RESULTS

Cytoreductive surgery to less than or equal to 2 cm was performed on 83% of patients and to less than 1 cm in 40%. A surgical complete response (SCR) rate of 34.9% and surgical partial response (SPR) rate of 47.6% were noted. Of the SCRs, recurrences developed in 52.7% of the patients. Estimated 5- and 8-year survival for all 136 patients was 31.2% and 21.5%, and 5- and 8-year progression-free survival was 23.9% and 20.6%, respectively. Those patients with less than 1-cm residual disease after primary surgery had significantly improved survival compared with those with 1-2 cm or greater than 2 cm (P < 0.001). Multivariate analysis identified residual disease status and age as the most significant prognostic factors associated with survival and progression-free survival.

CONCLUSION

Compared with those patients with greater than 1-cm residuum after initial surgery, a statistically significant improvement in long term survival was noted for those patients whose cancers were cytoreduced to less than 1-cm residuum.

Epirubicin. A review of its pharmacodynamic and pharmacokinetic properties, and therapeutic use in cancer chemotherapy

Epirubicin is the 4' epimer of the anthracycline antibiotic doxorubicin, and has been used alone or in combination with other cytotoxic agents in the treatment of a variety of malignancies. Comparative and noncomparative clinical trials have demonstrated that regimens containing conventional doses of epirubicin achieved equivalent objective response rates and overall median survival as similar doxorubicin-containing regimens in the treatment of advanced and early breast cancer, non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC), non-Hodgkin's lymphoma, ovarian cancer, gastric cancer and nonresectable primary hepatocellular carcinoma. Recently, dose-intensive regimens of epirubicin have achieved high response rates in a number of malignancies including early and advanced breast cancer and lung cancer. The major acute dose-limiting toxicity of anthracyclines is myelosuppression. In vitro and clinical studies have shown that, at equimolar doses, epirubicin is less myelotoxic than doxorubicin. The lower haematological toxicity of epirubicin, as well as the recent introduction of supportive measures such as colony-stimulating factors, has allowed dose-intensification of epirubicin-containing regimens, which is particularly significant because of the definite dose-response relationship of anthracyclines. Cardiotoxicity, which is manifested clinically as irreversible congestive heart failure and/or cardiomyopathy, is the most important chronic cumulative dose-limiting toxicity of anthracyclines. Epirubicin has a lower propensity to produce cardiotoxic effects than doxorubicin, and its recommended maximum cumulative dose is almost double that of doxorubicin, thus allowing for more treatment cycles and/or higher doses of epirubicin. In summary, dose-intensive epirubicin-containing regimens, which are feasible due to its lower myelosuppression and cardiotoxicity, have produced high response rates in early breast cancer, a potentially curable malignancy, as well as advanced breast, and lung cancers. Furthermore, there is evidence to suggest that improved response rates can improve quality of life in some clinical settings, but whether this leads to prolonged survival has not yet been determined. Recently implemented supportive measures such as colony-stimulating factors, prophylactic antimicrobials and peripheral blood stem cell support may help achieve other potential advantages of dose-intensive epirubicin-containing regimens such as reductions in morbidity and length of hospital admissions.

Malignant mixed Müllerian tumor of the fallopian tube: report of two cases and review of literature

Malignant mixed Müllerian tumors are usually found in the endometrium, vagina, cervix, and ovary. It is extremely rare for this tumor to arise in the fallopian tube, and to date only 37 tubal cases have been reported. We recently experienced 2 such cases. The clinical features, pathologic findings, diagnosis, therapy, and outcome of these 39 cases were reviewed. The clinical features and diagnosis were similar to those of primary carcinoma of the fallopian tube. Correct preoperative diagnosis was difficult. Histologically, 18 patients had homologous elements and 21 had heterologous elements in the sarcomatous components. The most common type of heterologous element was cartilage, followed by striated muscle and bone. The clinical stage (FIGO staging of ovarian carcinoma) was stage I in 15 cases, stage II in 11 cases, stage III in 8 cases, stage IV in 3 cases, and unknown in 2 cases. In all the patients except 1, the tumor was surgically removed. Postoperatively, radiotherapy was given to 9 patients, chemotherapy to 9 patients, and both to 2 patients. Sixteen patients died of the disease, after a mean period of 16.1 months. Of the 15 stage I patients, 10 survived more than 12 months. The most important prognostic factor was spread of the tumor at diagnosis.

The role of appendectomy in surgical procedures for ovarian cancer

To assess the role of appendectomy in the surgical procedures for ovarian cancer, we evaluated retrospectively the clinical charts of 435 patients who underwent surgery after diagnosis of ovarian cancer. The appendix was removed in 160 cases and pathological examination revealed 37 with metastatic implants (23%). All the patients with appendiceal metastases showed advanced disease (stages III-IV) with an incidence of 43%. Ninety-one percent (31/34) of the tumors with appendiceal involvement at the staging operation were of the serous cell type and grade II or III. No case with early stage, right ovary carcinoma showed appendiceal metastatic foci, denying the existence of a preferential lymphatic pathway. Microscopic involvement was found only in 4 patients with advanced disease (11.7%). No intra- or postoperative complication directly related to the appendectomy was recorded. We conclude, with these results, that appendectomy should be part of the cytoreductive operation for ovarian cancer.

Meta-analysis of surgery in advanced ovarian carcinoma: is maximum cytoreductive surgery an independent determinant of prognosis?

OBJECTIVE

If maximum cytoreductive surgery benefits the survival of women with advanced ovarian cancer, the median survival time of groups of such women will improve as the proportion of women undergoing maximum cytoreductive surgery is increased.

STUDY DESIGN

Fifty-eight suitable studies that encompass 6962 patients with advanced ovarian cancer were identified. Multiple linear regression was used to analyze the effects on median survival time of the following variables: the proportion of each cohort undergoing maximum cytoreductive surgery, the use of platinum-containing chemotherapy, the dose intensity of chemotherapy, the proportion of each cohort with stage IV disease, and the year of publication of the study.

RESULTS

Maximum cytoreductive surgery was associated with only a small improvement in median survival time, but platinum-containing chemotherapy improved median survival time substantially. Increased dose intensity also conferred a useful survival benefit.

CONCLUSION

Cytoreductive surgery probably has only a small effect on the survival of women with advanced ovarian cancer. The type of chemotherapy used is more important.