Chemotherapy of granulosa cell tumors

A phase II study of paclitaxel for the treatment of ovarian stromal tumors: An NRG Oncology/ Gynecologic Oncology Group Study

OBJECTIVE

To estimate the probability of complete clinical response and toxicity of paclitaxel as second-line chemotherapy in measurable disease patients with malignant tumors of the ovarian stroma, and to evaluate the value of inhibin for predicting response.

METHODS

Thirty-one patients with histologically confirmed ovarian stromal tumor were enrolled from 2000 to 2013. Patients were required to have measurable recurrent disease, and to have received only one prior chemotherapy regimen. Paclitaxel 175 mg/m2 was administered over a 3 hour infusion, cycling every 21 days. Inhibin levels were drawn within two weeks of initiation of treatment.

RESULTS

Of 31 women enrolled, there was only one complete response (3.2%), and partial response in eight of 31 cases (25.8%). The pretreatment inhibin level for the single patient who had complete response was 88 pg/mL. Median progression-free survival was 10.0 months and overall survival was 73.6 months. Myelosuppression was common with 12 of 31 patients (38.7%) suffering grade 3 or 4 neutropenia, leukopenia, or anemia.

CONCLUSION

There were too few complete responses to warrant continued evaluation of paclitaxel as a single agent treatment for women with recurrent malignant ovarian stromal tumors with measurable disease according to the primary objective of the study. Toxicity of the regimen was acceptable. Pretreatment inhibin is not a reliable tumor marker as it was not elevated in the majority of patients.

Fertility-sparing surgery for advanced juvenile granulosa cell tumor of the ovary

BACKGROUND

Juvenile granulosa cell tumors (JGCT) of the ovary are rare. They usually present in children and adolescents. About 90% are diagnosed in early stage (FIGO I) with a favorable prognosis. More advanced stages (FIGO II-IV) usually have a poor clinical outcome.

CASE

We report a case of long-term survival of a teenager with Stage III JGCT treated with aggressive debulking and thorough staging, but conservative surgery relative to the uterus, contralateral uninvolved ovary, and fallopian tube, plus combination chemotherapy. Her tumor recurred twice, 18 months and 17 years later, for which she had 2 additional surgeries and more chemotherapy. Our patient achieved 2 pregnancies and had 3 children.

SUMMARY AND CONCLUSIONS

With fertility sparing surgery, patients may be able to achieve pregnancies and children.

Effectiveness of Chemotherapy in Measurable Granulosa Cell Tumors: A Retrospective Study and Review of Literature

Objective

Patients with irresectable granulosa cell tumors (GCTs) often receive chemotherapy. The effectiveness of this approach, however, is uncertain. The aim of our study was to assess the response rate to chemotherapy for residual and recurrent inoperable GCT.

Methods

All consecutive chemotherapy-naive patients in 3 referral hospitals who were treated with chemotherapy for residual or recurrent GCT between 1968 and 2011 were included. Main outcome was the response according to Response Evaluation Criteria in Solid Tumor criteria. A literature search in MEDLINE through PubMed was performed, from inception to August 19, 2013.

Results

Twenty-seven patients with a GCT who received chemotherapy were identified. Eighteen patients were not evaluable because they had either no measurable disease, or no imaging was performed before and after chemotherapy. One of the 9 evaluable patients (11%) had a complete response, and 1 patient (11%) had a partial response, resulting in a response rate of 22% (95% confidence interval, 0%–49%). Seven patients (78%) had stable disease (range, 2–50 months), and none had progressive disease. Fifteen studies that assessed response rates to chemotherapy on measurable disease in a total of 224 patients showed a response rate of 50% (95% confidence interval, 44%–57%). Strict criteria of response, however, were not uniformly applied in the majority of these published series.

Conclusions

In the present study, we present only a moderate beneficial effect of chemotherapy in patients with irresectable GCT with measurable disease. Comparison with previous studies is hampered by a lack of standardized response evaluation in the majority of studies. Given the toxicity of platinum-based chemotherapy, administering this treatment should be a well-considered decision.

Granulosa Cell Tumor of the Ovary: Tumor Review

Granulosa cell tumors of the ovary are rare neoplasms that originate from sex-cord stromal cells. The long natural history of granulosa cell tumors and their tendency to recur years after the initial diagnosis are the most prominent of their characteristics. The secretion of estradiol is the reason for signs at presentation such as vaginal bleeding and precocious puberty. Abdominal pain and hemoperitoneum, which occasionally can occur, are attributable to tumor rupture. The most common finding in pelvic examination is a tumor mass, which is subsequently confirmed with imaging techniques. Surgery is the mainstay of initial management for histological diagnosis, appropriate staging, and debulking. A more conservative unilateral salpingo-oophorectomy is indicated in patients with stage I disease and patients of reproductive age. Total abdominal hysterectomy with bilateral salpingo-oophorectomy is the appropriate surgical treatment for postmenopausal women and those with more advanced disease. The stage of disease is the most important prognostic factor associated with the risk of relapse. There are no clear conclusions regarding the role of postoperative chemotherapy or radiotherapy in stage I disease and in those with completely resected tumor. The use of adjuvant chemotherapy or radiotherapy has sometimes been associated with prolonged disease-free survival and possibly overall survival. Chemotherapy is the treatment of choice for patients with advanced, recurrent, or metastatic disease, and BEP (bleomycin, etoposide, and cisplatin) is the preferred regimen. Although the overall rate of response to treatment is high, the impact of treatment on disease-free or overall survival is unknown. Prolonged surveillance is mandatory because tumors tend to recur years after the initial diagnosis.

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.

Granulosa cell tumor of the ovary

Ovarian granulosa cell tumors (GCTs) are uncommon neoplasms that arise from the sex-cord stromal cells of the ovary. GCTs are characterized by long natural history and their tendency to recur years after the initial diagnosis. They present with symptoms and signs due to estradiol secretion, including vaginal bleeding and precocious puberty. Occasionally, tumor rupture causes abdominal pain and hemoperitoneum. GCT is usually associated with a mass on pelvic examination which is subsequently confirmed with imagine techniques. Surgery is the mainstay of initial management for histological diagnosis, appropriate staging and debulking surgery. In patients with stage I disease and those in reproductive age a more conservative unilateral salpingo-oophorectomy is indicated. In postmenopausal women and those with more advanced disease a total abdominal hysterectomy with bilateral salpingo-oophorectomy is the appropriate surgical treatment. The most important prognostic factor associated with a higher risk of relapse is the stage of disease. The role of post-operative chemo- or radiotherapy in stage I disease and those with completely resected tumor has not been defined. Nevertheless, the use of adjuvant chemotherapy or radiotherapy has sometimes been associated with prolonged disease-free survival and possibly overall survival. Chemotherapy should be considered for patients with advanced, recurrent or metastatic disease and the BEP (bleomycin, etoposide, cisplatin) is the currently preferable regimen. Although overall response rate (RR) is high, the impact on disease-free or overall survival is unknown. Due to their tendency to recur years after the initial diagnosis, prolonged surveillance is essential.

Long natural history of recurrent granulosa cell tumor of the ovary 23 years after initial diagnosis: a case report and review of the literature

BACKGROUND

Granulosa cell tumors (GCTs) of the ovary are rare, hormonally active neoplasms characterized by endocrine manifestations, an indolent course, and late relapse.

CASE

We report a case of a prolonged history of ovarian GCT managed primarily with repeat surgical resections.

CONCLUSION

This case illustrates the benefits of cytoreductive surgery for the management of recurrent disease, the use of serum tumor markers to help guide therapy, and the importance of extended follow-up.

Granulosa cell tumor of the ovary

Adult granulosa cell tumor (GCT) of the ovary is oftentimes a hormonally active, stromal cell neoplasm that is distinguished by its ability to secrete sex steroids such as estrogen. Patients may present with vaginal bleeding caused by endometrial hyperplasia or uterine cancer as a result of prolonged exposure to tumor-derived estrogen. In addition, GCT is a vascular tumor that may occasionally rupture and result in abdominal pain, hemoperitoneum, and hypotension, mimicking an ectopic pregnancy in younger patients. GCT is usually associated with a mass on pelvic examination that is subsequently confirmed on ultrasonography. Surgery is required for definitive tissue diagnosis, staging, and tumor debulking. In older women, a total abdominal hysterectomy and bilateral salpingooophorectomy are typically performed. In women of childbearing age, a more conservative unilateral salpingo-oophorectomy may be performed, assuming that careful staging reveals that the disease has not extended outside of the involved ovary and that a concomitant uterine cancer has been excluded. Survival of patients with GCT is generally excellent because most patients present with early-stage disease, although certain high-risk patient groups may be identified. Stage is the most important prognostic factor, with a higher risk of relapse being associated with stages II through IV disease. In addition, patients with stage I disease associated with features such as large tumor size, high mitotic index, or tumor rupture may also be at higher risk in some series. The value of postoperative adjuvant therapy for high-risk patients has not been investigated by prospective randomized trials, which are difficult to perform because of the rarity of this tumor. Nonetheless, the use of adjuvant chemotherapy or radiation has sometimes been associated with prolonged disease-free survival in patients with high-risk features. Because of the propensity of GCT to recur years after initial diagnosis, prolonged surveillance with serial physical examination and serum tumor markers such as estradiol and inhibin is reasonable.

Clinical parameters and treatment results in recurrent granulosa cell tumor of the ovary

OBJECTIVE

The objectives of this study were to evaluate the patients' characteristics and treatment results for 11 recurrent granulosa cell tumors (GCT) of the ovary.

METHODS

Tumor registries were screened retrospectively for all patients treated between 1979 and 1999 for ovarian tumors at the University of Istanbul. All information about these patients was obtained from operation, pathology, and follow-up reports. Then the clinical data were extracted. The patients were classified in stages according to FIGO criteria. There were 952 ovarian carcinomas, of which 45 were GCT. Eleven of 45 patients (24%) developed recurrent disease on follow-up.

RESULTS

All patients but one had advanced (III-IV) disease at diagnosis. The median progression-free interval (PFI) was 16 months (range, 5-39 months) with a marked difference in PFI between patients receiving (24 months) and not receiving (8 months) initial chemotherapy. Among patients received chemotherapy (six patients), two complete and two partial responses were observed, for an overall response rate of 67%. The median survival for all patients was 26 (4-73) months with a longer survival (38 versus 8 months) for patients retreated with a platinum-containing regimen.

CONCLUSIONS

Despite the fact that small number of treated cases does not allow an adequate evaluation, retreatment with cis-platinum-containing regimens may be the treatment of choice for patients with recurrent disease.

Hemoperitoneum is an initial presentation of recurrent granulosa cell tumors of the ovary

Ovarian sex cord-stromal tumors account for less than 5% of all ovarian carcinoma, of which granulosa cell tumors account for 70%. These tumors have a propensity for indolent growth and late recurrence; they may even occur 25 years after initial treatment. We report a 44-year-old woman with hemoperitoneum (acute abdomen) after initial treatment 10 years earlier for granulosa cell tumor of the ovary. This case re-emphasizes the need for long-term follow-up in patients with stromal cell tumors of the ovary and considers the possibility of recurrence when presented with acute abdomen after conservative treatment.

Cisplatin (P), vinblastine (V) and bleomycin (B) combination chemotherapy in recurrent or advanced granulosa(-theca) cell tumours of the ovary. An EORTC Gynaecological Cancer Cooperative Group study

The aim of this study was to investigate the clinical activity and toxicity of a modified PVB regimen (cisplatin, vinblastine and bleomycin) in patients with advanced or recurrent, pure granulosa cell tumours (GCTs) or mixed granulosa-theca cell tumours (GTCTs). The PVB regimen consisted of cisplatin (P) 20 mg/m2 intravenous (i.v.) days 1-5, vinblastine (V) 0.15 mg/kg i.v. days 1-2 and bleomycin (B) 30 mg i.v. on day 2, and 15 mg on day 15, for 28 days. 38 eligible patients were entered in this trial. Prior to PVB all patients underwent surgery and 13 received postoperative radio- or other prior chemotherapy. The median number of PVB cycles was 4 in both groups. In the group of 25 patients who had received prior surgery only, 7 and 6 patients had complete and partial responses, respectively (response rate: 52%, 95% confidence limits: 31.3-72.2%). At a median follow-up of 39 months, 6 patients were alive with no evidence of disease, 6 were alive with disease, 12 died due to malignant disease and 1 died due to intercurrent disease. The median time to progression was 13.9 months. The median survival was 25.4 months. 3-year survival was 49% (95% confidence limits: 29-69%). In the group of 13 patients who had previously received postoperative radio- or chemotherapy, 5 complete and 5 partial responses were observed on PVB (response rate: 77%, 95% confidence limit: 46.2-95.0%). At a median follow-up of 50 months, 6 patients were still alive, only 1 without evidence of disease, 6 died due to malignant disease and 1 died due to intercurrent disease. The median time to progression was 19.3 months. The median duration of survival was 41.1 months. Accompanying toxicity was distributed in a similar pattern for both groups. Severe toxicity was mainly documented as haematological toxicity, nausea/vomiting and alopecia. Furthermore cisplatin-related peripheral neurotoxicity and mild/moderate signs of bleomycin-related pulmonary toxicity were observed. The present data confirm the therapeutic activity of the PVB regimen in advanced/recurrent GCTs. The response rate was moderately high compared with previous studies, with a median duration of response of 20 months for both groups.

Bleomycin, etoposide, and cisplatin combination therapy of ovarian granulosa cell tumors and other stromal malignancies: A Gynecologic Oncology Group study

OBJECTIVES

The objectives of this study were to assess efficacy and toxicity of the combination of bleomycin, etoposide, and cisplatin (BEP) in this Phase II trial as first-line therapy for ovarian stromal malignancies.

METHODS

Patients with incompletely resected Stages II-IV or recurrent cancer underwent surgical debulking. There were two bleomycin-related deaths early in the trial; thus, the initial schedule of bleomycin (20 units/m2 x 9 weeks for a maximum dose of </=30 units x 9) was changed, without subsequent mortality. The final dose schedule was 20 units/m2 bleomycin iv push day 1 every 3 weeks x 4, 75 mg/m2 etoposide days 1-5 every 3 weeks x 4 and 20 mg/m2 cisplatin days 1-5 every 3 weeks x 4. The frequency of negative second-look surgery was the primary outcome measure.

RESULTS

Seventy-five women were entered; 18 were excluded. Grade 4 myelotoxicity occurred in 61% of the patients. The end point used for response was negative second-look laparotomy. Thirty-seven percent (14/38) of the patients undergoing second-look laparotomy had negative findings. The six complete responders were of long median duration (24.4 months). Patients with measurable disease were at the highest risk of progression and death.

CONCLUSIONS

BEP appears to be an active combination regimen for first-line chemotherapy of malignant tumors of the ovarian stroma. Myelotoxicity was tolerable.

Juvenile granulosa cell tumors of the ovary in children and adolescents: results from 33 patients registered in a prospective cooperative study

Clinical and pathological data from 33 prospective registered patients who suffered from juvenile granulosa cell tumors (JGCT) were evaluated according to treatment and outcome. The median age at the time of diagnosis was 7.6 years (range, 6 months to 17.5 years). Fourteen patients showed signs of a pseudo-precocious puberty. In 1 patient premenarcheal bleeding was the only clinical symptom of the disease. A pelvic tumor or an abdominal distention was found in 6 children, revealing signs of an acute abdomen in 3 children. Tumor staging was performed according to the FIGO (International Federation of Gynecology and Obstetrics) classification for ovarian tumors. Twenty children and adolescents were classified as FIGO stage Ia; 8 children had stage Ic tumors. In 4 patients stage IIc and in 1 patient stage IIIc tumors were observed. For local tumor control all 33 patients underwent tumor resection and oophorectomy, which was complete in 28 patients. Adjuvant combination chemotherapy was used in 1 girl who presented with high mitotic pathological index features in FIGO stage Ia. In 8 other children between FIGO stage Ic and IIIc, treatment was also intensified by multidrug chemotherapy. After a follow-up period of 168 months, an event-free survival of 0.75 +/- 0.07 was observed. From our data we conclude that multidrug chemotherapy including cisplatin-based regimens may be useful to enhance treatment results of JGCT, especially in advanced FIGO stages.

Chemotherapy of ovarian germ cell tumors and sex cord stromal tumors

Malignant ovarian germ cell tumors (OGCT) and sex cord stromal tumors (SCST) are much less common than epithelial ovarian cancer, each accounting for less than 5% of all ovarian malignancies. The combination of vincristine, dactinomycin, and cyclophosphamide (VAC) became the standard chemotherapy for patients with OGCT in the 1970s; it produced excellent sustained remission rates in patients with stage I disease but less than 50% sustained remission rates in those with metastatic tumor. With the introduction of cisplatin for the treatment of testicular cancer in the late 1970s, platinum-based regimens replaced the VAC regimen by the mid-1980s. Currently, the most popular regimen for all patients with OGCT is the combination of bleomycin, etoposide, and cisplatin (BEP). The BEP regimen appears to be superior to VAC, with sustained remission rates of more than 75% in patients with metastatic tumor. For patients with metastatic pure dysgerminoma, chemotherapy appears to have supplanted radiotherapy as standard treatment with the advantage of preserving fertility in most patients. For patients with SCST, no standard therapy exists. Surgery alone is currently acceptable treatment for all patients with SCST except those with metastatic disease, sarcomas, or Sertoli-Leydig cell tumors with poor differentiation or heterologous elements. Currently, platinum-based combination chemotherapy is favored for these latter patients but activity with such regimens is only modest.

Granulosa cell tumor of the ovary: a study of 18 cases

In a study of 18 patients diagnosed with ovarian granulosa cell tumor between 1961 and 1992, clinical and pathologic findings were evaluated. Of the 18 patients, 15 (83.3%) were diagnosed in Stage I and three (16.7%) in Stage III or IV. Six patients (33.3%) underwent conservative surgery and in 12 (66.7%) total abdominal hysterectomy and bilateral salpingo-oophorectomy was performed. At follow-up three patients (16.6%) had died of disease, three, 16 and 288 months, respectively, after initial surgery. The actuarial 5-year survival rate for Stage I was 100%, while that for Stages III and IV combined was 33.3% (P < 0.05). It is concluded that for patients with Stage IA, unilateral oophorectomy seems to be adequate treatment and for those with more than Stage IA, surgery should include total abdominal hysterectomy and bilateral salpingo-oophorectomy. Postoperative adjuvant chemotherapy is advocated for patients in whom spread of tumor beyond the ovaries has occurred.

Cisplatin-containing regimen in advanced or recurrent granulosa cell tumours of the ovary

The efficacy of combination chemotherapy in advanced or recurrent disease of granulosa cell tumours is still not well defined. Ten patients with advanced or recurrent granulosa cell tumours were treated with cisplatin, adriamycin and cyclophosphamide (CAP). Prior to chemotherapy all patients underwent surgical treatment. No patient received prior hormonochemotherapy or radiotherapy. Five complete responses (three pathologically documented) and one partial response were obtained for a total response rate of 60%. One pathologically-complete responder relapsed after 48 months from the onset of chemotherapy, but responded completely to debulking surgery and radiotherapy and remains well with no evidence of disease 87+ months. Five patients are still alive with no evidence of disease at 10+, 26+, 41+, 46+, 87+ months, 1 is still alive with disease and 4 have died at 20, 22, 28 and 60 months despite further treatment. Additional cooperative clinical trials are required to determine the exact efficacy of cisplatin chemotherapy in granulosa cell tumours.

cis-platinum/vinblastine/bleomycin combination chemotherapy in advanced or recurrent granulosa cell tumors of the ovary

Seven consecutive patients with advanced/recurrent granulosa cell tumors were treated with PVB (cis-platinum, 20 mg/m2, Days 1-5; vinblastine, 6 mg/m2, Days 1 and 2; and bleomycin, 18 mg/m2, Days 2, 9, and 16). The median age at the start of PVB treatment was 53 years (15-57); three patients had stage III disease and four presented with abdominal recurrences. Prior to PVB, all but one patient underwent surgical treatment, and in six patients gross residual disease was documented. No patient received prior chemotherapy or radiotherapy. The median number of PVB cycles was 5. Three complete (one pathologically documented) and one partial response were observed, for an over-all response rate of 66%. Two complete responders were alive without evidence of disease 7 and 26 months from the start of treatment; the remaining patient relapsed at 15 months. Two patients progressed during treatment, and one died because of sepsis in agranulocytosis. Signs of peripheral neurotoxicity were documented in three patients. The present data confirm the therapeutic activity of the PVB regimen in advanced/recurrent granulosa cell tumors, but the cost/benefit ratio should be clearly assessed.

Cyclophosphamide, adriamycin, and cis-platinum for the treatment of advanced granulosa cell tumor, using serum estradiol as a tumor marker

Two cases of advanced granulosa cell tumor are described, in both of which chemotherapy comprising cyclophosphamide, adriamycin, and cis-platinum resulted in an objective partial response with marked symptomatic improvement. In one case the response continues at 12 months, in the other the response lasted for 5 months. In both cases elevated serum estradiol levels fell during treatment. A literature review reveals two previous cases in which this combination has been reported as being effective in advanced granulosa cell tumor, but this is the first report of the use of serum estradiol as a tumor marker.