Management of non-epithelial ovarian tumours

Personalized prescription of imatinib in recurrent granulosa cell tumor of the ovary: case report

Ovarian cancer is the fifth leading cause of cancer-related female mortality and the most lethal gynecological cancer. In this report, we present a rare case of recurrent granulosa cell tumor (GCT) of the ovary. We describe the case of a 26-yr-old woman with progressive GCT of the right ovary despite multiple lines of therapy who underwent salvage therapy selection based on a novel bioinformatical decision support tool (Oncobox). This analysis generated a list of potentially actionable compounds, which when used clinically lead to partial response and later long-term stabilization of the patient's disease.

A Resident's Perspective of Ovarian Cancer

Identifying, understanding, and curing disease is a lifelong endeavor for any medical practitioner. Equally as important is to be cognizant of the impact a disease has on the individual suffering from it, as well as on their family. Ovarian cancer is the leading cause of death from gynecologic malignancies. Symptoms are vague, and the disease is generally at an advanced stage at diagnosis. Efforts have been made to develop methods to identify ovarian cancer at earlier stages, thus improving overall mortality. Transvaginal ultrasound (TVUS), with and without laboratory tests, can be used to screen for ovarian cancer. For over thirty years, the University of Kentucky Markey Cancer Center Ovarian Cancer Screening Program has been studying the efficacy of TVUS for detecting early stage ovarian cancer. After 285,000+ TVUS examinations provided to over 45,000 women, the program has demonstrated that regular TVUS examinations can detect ovarian cancer at early stages, and that survival is increased in those women whose ovarian cancer was detected with screening and who undergo standard treatment. These results demonstrate the utility of TVUS as an efficacious method of ovarian cancer screening.

Molecular manipulation of keratin 8/18 intermediate filaments: modulators of FAS-mediated death signaling in human ovarian granulosa tumor cells

Background

Granulosa cell tumors (GCT) are a rare ovarian neoplasm but prognosis is poor following recurrence. Keratin intermediate filaments expressed in these tumors are a diagnostic marker, yet paradoxically, may also constitute a target for therapeutic intervention. In the current study, we evaluated keratin 8/18 (K8/18) filament expression as a mechanism of resistance to apoptosis in GCT, specifically focusing on regulation of the cell surface death receptor, Fas (FAS).

Methods

The GCT cell line, KGN, was transiently transfected with siRNA to KRT8 and KRT18 to reduce K8/18 filament expression. Expression of K8/18, FAS, and apoptotic proteins (PARP, cleaved PARP) were evaluated by fluorescence microscopy, flow cytometric analysis, and immunoblotting, respectively. The incidence of FAS-mediated apoptosis in KGN cells was measured by caspase 3/7 activity. All experiments were performed independently three to six times, using a fresh aliquot of KGN cells for each experiment. Quantitative data were analyzed by one- or two-way analysis of variance (ANOVA), followed by a Tukey’s post-test for multiple comparisons; differences among means were considered statistically significant at P < 0.05.

Results

Control cultures of KGN cells exhibited abundant K8/18 filament expression (~90 % of cells), and minimal expression of FAS (<25 % of cells). These cells were resistant to FAS-activating antibody (FasAb)-induced apoptosis, as determined by detection of cleaved PARP and measurement of caspase 3/7 activity. Conversely, siRNA-mediated knock-down of K8/18 filament expression enhanced FAS expression (> 70 % of cells) and facilitated FasAb-induced apoptosis, evident by increased caspase 3/7 activity (P < 0.05). Additional experiments revealed that inhibition of protein synthesis, but not MEK1/2 or PI3K signaling, also prompted FasAb-induced apoptosis.

Conclusions

The results demonstrated that K8/18 filaments provide resistance to apoptosis in GCT by impairing FAS expression. The abundance of keratin filaments in these cells and their role in apoptotic resistance provides a greater mechanistic understanding of ovarian tumorgenicity, specifically GCT, as well as a clinically-relevant target for potential therapeutic intervention.

Posttreatment surveillance and diagnosis of recurrence in women with gynecologic malignancies: Society of Gynecologic Oncologists recommendations

Although gynecologic cancers account for only 10% of all new cancer cases in women, these cancers account for 20% of all female cancer survivors. Improvements in cancer care have resulted in almost 10 million cancer survivors, and this number is expected to grow. Therefore, determining the most cost-effective clinical surveillance for detection of recurrence is critical. Unfortunately, there has been a paucity of research in what are the most cost-effective strategies for surveillance once patients have achieved a complete response. Currently, most recommendations are based on retrospective studies and expert opinion. Taking a thorough history, performing a thorough examination, and educating cancer survivors about concerning symptoms is the most effective method for the detection of most gynecologic cancer recurrences. There is very little evidence that routine cytologic procedures or imaging improves the ability to detect gynecologic cancer recurrence at a stage that will impact cure or response rates to salvage therapy. This article will review the most recent data on surveillance for gynecologic cancer recurrence in women who have had a complete response to primary cancer therapy.

Feasibility and efficacy of laparoscopic management of ovarian cancer

AIMS

The aim of this study was to evaluate the feasibility and efficacy of laparoscopically-assisted staging surgery for ovarian cancer.

METHODS

Twenty four patients were evaluated. Among them, nineteen underwent initial laparoscopic staging surgery and five patients who were incompletely staged by other institutions underwent complete restaging surgery. The procedure included pelvic lymphadenectomy, paraaortic lymphadenectomy, multiple biopsies, washing cytology, infracolic omentectomy, and appendectomy. Laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy were performed on all patients except one. Parameters such as tumor diameter, operating time, estimated blood loss, length of hospital stay, number of harvested lymph nodes, intraoperative and postoperative complications, and recurrence were evaluated.

RESULTS

The patients' mean age was 52.8 +/- 11.3 years and the mean parity was 2.5 +/- 1.6. The mean diameter of the tumors was 8.4 +/- 3.3 cm, the mean operating time was 253.7 +/- 65.7 minutes, and the mean blood loss was 567.0 +/- 170.9 mL. The mean postoperative hospital stay was 10.6 +/- 4.0 days. The mean number of harvested pelvic lymph nodes was 22.5 +/- 8.9 and the mean number of harvested paraaortic lymph nodes was 11.0 +/- 5.8. None of the operations were switched to laparotomy. There were no major intraoperative complications, however, port site metastasis developed postoperatively in one patient.

CONCLUSION

Comprehensive laparoscopically-assisted staging surgery, performed by a specialized laparoscopic oncologist with sufficient laparoscopic experience and a well-trained operating team, is both feasible and effective in treating ovarian cancers.

Germ cell tumors of the ovary

PURPOSE

Malignant ovarian germ cell tumors (MOGCTS) are rare but curable at all stages of disease. This review gives an outline of the management of this disease.

METHODS

We performed a literature search in the PubMed of almost all relevant articles concerning MOGCTs on pathology, prognostic factors, surgery, post-operative therapy and late effects of therapy. The available literature is mainly composed of retrospective reviews and articles.

RESULTS

Prognostic factors include stage, amount of residual tumor, histologic type and raised tumor markers. For patients with early stage disease, cure rates approach 100%, while for those with advanced-stage disease are at least 75%. Appropriate surgical treatment for patients where fertility needs to be preserved consists in laparotomy with unilateral salpingo-oophorectomy (USO) and resection of all visible disease. For patients with advanced-stage disease, the role and the extent of debulking surgery remain controversial despite its routine use. However, it is suggested a benefit from minimal residual disease at completion of primary surgical cytoreduction with both non-platinum and platinum-based chemotherapy regimens. Second-look surgery clearly is not indicated in patients with early stage non-dysgerminoma or in all patients with dysgerminoma. However, teratoma patients may benefit from secondary cytoreduction. Three courses of bleomycin, etoposide and cisplatin (BEP) is the current standard adjuvant chemotherapy and four courses of BEP are recommended in case of bulky residual tumor after surgery. More evidence is required to show that surveillance is a safe option. There is a hint that high-dose chemotherapy may play a role in relapsed patients. The majority of MOGCTs patients who undergo fertility-sparing surgery and chemotherapy retain their gonadal and reproductive function. There is an increasing concern about life-threatening long-term effects of treatment.

CONCLUSION

MOGCTs are rare neoplasms that affect girls and young women and have excellent prognosis at all stages of disease with optimal therapy. The majority of MOGCTs patients retain their reproductive function.

Management of ovarian stromal cell tumors

PURPOSE

To describe the clinical management of ovarian stromal cell tumors, which are a heterogeneous group of neoplasms that develop from the sex cords and the ovarian stroma.

DESIGN

We reviewed the current evidence on the clinical management of these relatively rare ovarian malignancies, which are typically detected at an early stage and may recur as late as 30 years following the initial treatment. The overall prognosis is favorable with a long-term survival ranging from 75% to 90% for all stages. Adult granulosa cell tumor (GCT) is the most common malignancy among these tumors.

RESULTS

Surgery is the cornerstone of initial treatment. In women of childbearing age and with disease limited to one ovary, a fertility-sparing surgery can be a reasonable approach. Tumor stage represents the most important clinical parameter of prognostic relevance. The value of postoperative adjuvant therapy for high-risk patients has not been proven by prospective randomized studies. Platinum-based chemotherapy is used currently for patients with advanced stages or recurrent disease, with an overall response rate of 63% to 80%. Taxane and platinum combination chemotherapy seems to be a reasonable candidate for future trials. Little evidence exists for the use of radiation or hormonal therapy, and these modalities should be restricted to selected cases. Given the propensity of GCT for late relapse, prolonged follow-up is required.

CONCLUSION

Surgery remains the most effective treatment for ovarian stromal tumors and, whenever feasible, for relapsing disease. Platinum-based chemotherapy is currently used in metastatic or recurrent tumors.

Controversies in the management of germ cell tumours of the ovary

PURPOSE OF REVIEW

Ovarian germ cell tumours are rare, but curable at all stages of disease. This review gives an outline of the main controversies regarding the management of this disease.

RECENT FINDINGS

Pelvic malignancies are very rare during pregnancy, which should avoid the need for radical surgery or termination in these patients. Also during pregnancy, AFP-L2 looks to be a promising tumour marker in detecting relapse. Malignant transformation of mature teratomas may be predicted by preoperative squamous cell antigen and tumour size. OCT4 immunohistochemistry has been shown to be a very useful adjunct in the diagnosis of dysgerminomas. The traditional method for grading immature teratomas is challenged by a new classification. Patients receiving cisplatin-based chemotherapy are at a higher risk of developing cardiovascular risk factors. There is a hint that high-dose chemotherapy may play a role in relapsed patients.

SUMMARY

Rarity of the disease means many controversies are difficult to resolve, with much reliance on using data from testicular cancer studies. Many clinicians still advocate adjuvant chemotherapy for stage I nondysgerminomatous tumours of grade 2 and above despite good evidence that surveillance is a safe option, and increasing concerns about life-threatening long-term effects of treatment.

Preservation of ovarian function, reproductive ability and emotional attitudes in patients with malignant ovarian tumors

OBJECTIVES

Although cancer is predominantly a disease of aging, an increasing number of women survive malignancies before or during their reproductive years, which may interfere with their fertility potential. Although a variety of studies have tried to document the impact of conservative treatment aimed at preserving ovarian function and reproductive ability, little information has been available regarding survivors' attitudes, emotions, and choices to have children. The aim of this study is to evaluate the reproductive history, experiences, attitudes, and emotions with regard to having children in conservatively treated patients with Stage I epithelial ovarian cancer, any stage LMP tumors, malignant ovarian germ cell tumors (MOGCTs) and Stage I sex cord-stromal tumors (SCSTs).

STUDY DESIGN

Between 1986 and 2000, a total of 75 patients with primary malignant ovarian tumors underwent conservative treatment. Out of 75 patients in the study, 14 women (19%) presented Stage I epithelial ovarian cancer, 23 (31%) LMP tumors, 33 (43%) MOGCTs, and five (7%) SCSTs. Information was obtained from medical records and from a questionnaire mailed to all patients who were at least 15 years old at the time of the diagnosis (68 subjects). Median time of follow-up was 102 months (35-192 months). There were four (5.2%) clinical recurrences within 35 months. Only 20 patients (49%) had tried to conceive after the completion of their treatment; of these, 15 women (75%) succeeded and delivered 19 healthy children. Seventy percent (32/41) of the respondents claimed that their disease did not have any impact on their desire to have children. Whereas 51% (21/41) fear that their ovarian disease could have damaged their reproductive potential, 76% (31/41) are not concerned about the effects of the treatment they received on offspring. The impact of the disease on the patients' attitudes toward life was reported as positive.

CONCLUSION

The results from our study, in agreement with the data from the literature, confirm that management of Stage I (grade 1, grade 2) epithelial ovarian cancer, any stage LMP tumors, MOGCTs and Stage I SCSTs with fertility-sparing surgery is a safe, practicable treatment option. Though preliminary, this survey provides insight into the attitudes and experiences of young women ovarian cancer survivors regarding fertility.

Chemotherapy-induced alterations in ovarian sex cord tumor with annular tubules (SCTAT): A diagnostic challenge

We present a case of ovarian sex cord tumor with annular tubules (SCTAT) in a patient that received neoadjuvant chemotherapy with 3.5 years of follow-up. Neo-adjuvant chemotherapy is a common practice in advanced cases of ovarian carcinoma and is rarely applied in nonepithelial ovarian tumors. Chemotherapy-induced morphologic alterations of the subsequently resected tissue samples are well recognized; in this case, chemotherapy-induced cytoarchitectural changes created diagnostic difficulties in the subsequently resected specimen.

Pregnancy outcomes and menstrual function after fertility sparing surgery for pure ovarian dysgerminomas

MATERIALS AND METHODS

The medical records of 23 patients with pure ovarian dysgerminoma treated by conservative surgery at SSK Ankara Maternity Hospital between 1991 and 2001 were reviewed retrospectively. Pregnancy outcomes and menstrual function after conservative surgery were analyzed.

RESULTS

Seven patients (30%) were incompletely staged and were assumed to be stage IA due to intraoperative findings. Fifteen patients (70%) were surgically staged. As a result 15 patients (65.2%) were diagnosed to be stage I while 2 patients (8.6%) were staged II and 6 patients (26%) were staged III. Wedge biopsy of contralateral ovary was performed in 17 patients (74%) and tumor was diagnosed in 2 (11.7%). Adjuvant chemotherapy was applied in 16 (70%) of the cases. BEP (bleomycin, etoposide, and cisplatin) was the most frequently used regimen (39%). Recurrences were seen in 3 (13%) patients. The sites of recurrences were contralateral ovary in all cases. Recurrences were treated with surgery and radiotherapy. None of the patients died of disease. Nine patients were sexually active. Five of these patients had prior live births. Three of the primiparous patients delivered after treatment. Five pregnancies occurred in 3 nulliparous patients at the time of primary surgery. Three of these reached term and healthy babies were delivered. One pregnancy was terminated at 18 weeks of gestation due to anencephaly and a dilatation and curettage was performed at 6th week in another patient. Menstrual problems occurred in 4 (17.3%) of the 23 patients.

CONCLUSION

Fertility sparing treatments are safe in patients with pure ovarian dysgerminoma.

Dysgerminoma in a patient with a tumor of the neck. Empiric treatment of stage IV dysgerminoma

The evolution of therapy for malignant ovarian germ cell tumors is one of the true success stories in oncology. Treatment outcome has improved greatly thanks to cisplatin-based combination chemotherapy. According to the well-established treatment guidelines for advanced cases, we treated a case of stage IV undifferentiated germ cell tumor in which we were able to preserve the patient's fertility. We concluded that the PEP regimen is an effective treatment for the patient with metastatic germ cell tumor.