Expression III: patients' expectations and preferences regarding physician-patient relationship and clinical management-results of the international NOGGO/ENGOT-ov4-GCIG study in 1830 ovarian cancer patients from European countries

Backround

The primary aim of this study was to investigate information needs and treatment preferences of patients with ovarian cancer, focusing especially on physician-patient relationship and treatment.

Patients and methods

A questionnaire was developed based on the experiences of the national German survey 'Expression II', and was provided to patients with ovarian cancer either at initial diagnosis or with recurrent disease via Internet (online-version) or as print-out-version.

Results

From December 2009 to October 2012, a total of 1830 patients with ovarian cancer from eight European countries (Austria, Belgium, France, Germany, Italy, Poland, Romania, Spain) participated, 902 (49.3%) after initial diagnosis and 731 (39.9%) with recurrent ovarian cancer. The median age was 58 years (range 17-89). Nearly all patients (96.2%) had experienced upfront surgery followed by first-line chemotherapy (91.8%). The majority of patients were satisfied with the completeness and comprehensibility of the explanation about the diagnosis and treatment options. The three most important aspects, identified by patients to improve the treatment for ovarian cancer included: 'the therapy should not induce alopecia' (42%), 'there must be more done to counter fatigue' (34.5%) and 'the therapy should be more effective' (29.7%). Out of 659 (36%) patients, who were offered participation in a clinical trial, 476 (26%) were included.

Conclusion

This study underlines the high need of patients with ovarian cancer for all details concerning treatment options irrespective of their cultural background, the stage of disease and the patient's age. Increased information requirements regarding potential side effects and treatment alternatives were recorded. Besides the need for more effective therapy, alopecia and fatigue are the most important side effects of concern to patients.

Quality-of-life analysis of the MITO-8, MaNGO, BGOG-Ov1, AGO-Ovar2.16, ENGOT-Ov1, GCIG study comparing platinum-based versus non-platinum-based chemotherapy in patients with partially platinum-sensitive recurrent ovarian cancer

Background

MITO-8 showed that prolonging platinum-free interval by introducing non-platinum-based chemotherapy (NPBC) does not improve prognosis of patients with partially platinum-sensitive recurrent ovarian cancer. Quality of life (QoL) was a secondary outcome.

Patients and methods

Ovarian cancer patients recurring or progressing 6-12 months after previous platinum-based chemotherapy (PBC) were randomized to receive PBC or NPBC as first treatment. QoL was assessed at baseline, third and sixth cycles, with the EORTC C-30 and OV-28 questionnaires. Mean changes and best response were analysed. Progression-free survival, response rate, and toxicity are also reported for proper interpretation of data. All analyses were based on intention-to-treat.

Results

Out of the 215 patients, 151 (70.2%) completed baseline questionnaire, balanced between the arms; thereafter, missing rate was higher in the NPBC arm. At mean change analysis, C30 scores were prevalently worse in the NPBC than PBC arm, statistical significance being attained for emotional functioning, global health status/QoL, fatigue, and dyspnoea (effect sizes ranging from 0.30 to 0.51). Conversely, as for OV28 scale, the other chemotherapy side-effects item was significantly worse with PBC at three and six cycles, with a larger effect size (0.70 and 0.54, respectively). At best response analysis, improvement of emotional functioning and pain and worsening of peripheral neuropathy and other chemotherapy side-effects were significantly more frequent in the PBC arm. Progression-free survival (median 9 versus 5 months, P = 0.001) and objective response rate (51.6% versus 19.4%, P = 0.0001) were significantly better with PBC. Allergy, blood cell count, alopecia, nausea, musculoskeletal, and neurological side-effects were more frequent and severe with PBC; hand-foot skin reaction, rash/desquamation, mucositis, and vascular events were more frequent with NPBC.

Conclusion

MITO-8 QoL analysis shows that deterioration of some functioning and symptom scales is lower with PBC, with improvement of emotional functioning and pain, despite worsening of toxicity-related items.

ClinicalTrials.gov

NCT00657878.

Surgical Resection of a Cerebral Metastasis from Cervical Cancer: Case Report and Review of the Literature

Aims and background

Central nervous system metastasis from cervical carcinoma is uncommon.

Case report

We report the case of a 51-year-old woman who developed a solitary cerebral metastasis 29 months after radical hysterectomy with pelvic lymphadenectomy for a stage IB, grade III cervical cancer. The patient suddenly complained of headache, confusion and dizziness; she was submitted to emergency surgical resection of a 2×3 cm metastasis in the right frontal lobe. The postoperative course was uneventful and she completely recovered from her neurological deficit. Following surgery the patient underwent careful restaging. Massive bilateral involvement of the pelvic wall was diagnosed, and the patient received three courses of cisplatin-based chemotherapy. She developed liver and lung metastases and died 10 months later of progressive disseminated disease, without, however, any sign of recurrent or persistent cerebral involvement.

Conclusion

Neurosurgical resection should be considered in cervical cancer patients with solitary brain metastasis in the absence of systemic disease.

Brain Metastases from Cervical Carcinoma

Central nervous system (CNS) involvement by cervical carcinoma is uncommon. Out of 1,184 patients registered for invasive cervical carcinoma at our Institution between 1982 and 1994, 14 (1.18%) developed brain metastases. Median age at the time of CNS metastasis diagnosis was 52 years. Median interval between diagnosis of cervical cancer and documentation of brain involvement was 18 months. Clinical manifestation included motor weakness, headache, seizures, dizziness and visual disturbances. All lesions (8 multiple, 6 single) were contrast enhanced on computerized tomography scans and were located in the cerebrum (n=10), in the cerebellum (n=2), or in both (n=2). The CNS was the only site of detectable disease in 7 patients with recurrent disease. Eleven patients received only steroids, and 3 patients received radiotherapy. All 14 patients died, and median survival from diagnosis of brain metastases for the entire series was 4 months (range, 1-21). CNS metastases from cervical cancer are rare, and the prognosis for such patients appears poor.

Concurrent Carboplatin/5Fu and Radiotherapy Compared to Radiotherapy Alone in Locally Advanced Cervical Carcinoma: A Case-Control Study

Aims and background

Despite the introduction of innovative techniques in radiotherapy (RT) delivery, no significant improvement in survival has been achieved in the last decades. Concurrent chemoradiation therapy (CRT) is one of the several avenues being explored to improve the results.

Methods and study design

Twenty-eight women with locally advanced squamous cell carcinoma of the uterine cervix were treated with CRT comprising a combination of external and intracavitary RT, along with 3 cycles of 5-fluorouracil (5-FU) and carboplatin. Toxicity, pelvic control rate and disease-free survival achieved in this group of patients were compared in a case-control study with those of a group of 28 patients with similar clinicopathologic characteristics treated with radical RT alone at our institution.

Results

CRT was well tolerated, with 97% of the patients completing the protocol as planned. Acute toxicity, primarily hematologic, was significantly (P=0.05) higher in the cases than in the controls (25% vs 3%). One treatment-related death occurred in a stage III patient in the CRT group. The median follow-up was 55 months (range, 20–156) in the RT group and 20 months (range, 14–46) in the CRT group. Pelvic control rate, disease-free survival and overall survival were not significantly different in the two groups. Estimated 5-year survival rate was 70% and 66% respectively for the RT and CRT group.

Conclusions

Concomitant carboplatin/5-FU and radiotherapy is a safe and tolerable means of treatment for locally advanced cervical cancer. In our study, however, concurrent CRT did not result in a significant improvement in pelvic control rate or survival compared to standard conventional radiotherapy.

Brachytherapy for Isolated Vaginal Recurrences from Endometrial Carcinoma

AIMS AND BACKGROUND

Isolated vaginal recurrences of endometrial carcinoma are rare, and prognostic factors that predict treatment outcome are still not well defined. The aim of the present study was to evaluate the results of brachytherapy in isolated vaginal recurrences from endometrial carcinoma.

METHODS

Thirty-five patients with isolated vaginal recurrences were treated with brachytherapy with intravaginal ovoids or cylinders that were calculated to deliver 6000 to 7000 cGy at the surface. Patients were assessed for size and location of recurrence at presentation, response and complications from therapy.

RESULTS

Treatment was well tolerated by most patients. Grade 2 toxicity occurred in 4 patients (3 cases of partial vaginal stenosis and one proctitis). Complete response to radiation was observed in all patients, and an overall 9 failures were observed (4 local, 4 distant and 1 local plus distant). Twenty patients (57%) were alive without evidence of disease at 3 to 11 years following treatment. Site of vaginal recurrence (upper third versus others) and long (more than 12 months versus less than 12 months) interval from hysterectomy were the only factors significantly related to local failures.

CONCLUSIONS

Isolated vaginal recurrences following hysterectomy for endometrial carcinoma can be treated with brachytherapy with a low rate of severe toxicity.

Laparoscopic surgery in the treatment of stage I adult granulosa cells tumors of the ovary: Results from the MITO-9 study

OBJECTIVE

Surgery represents the mainstay of treatment of stage I adult type granulosa cell tumors of the ovary (AGCTs). Because of the rarity and indolent course of the disease, no prospective trials are available. Open surgery has long been considered the traditional approach; oncological safety of laparoscopy is only supported by small series or case reports. The aim of this study was to compare the oncological outcomes between laparoscopic and open surgery in stage I AGCTs treated within the MITO (Multicenter Italian Trials in Ovarian cancer) Group.

METHODS

Data from patients with stage I AGCTs were retrospectively collected. Clinicopathological features were evaluated for association with relapse and death. Survival curves were calculated using the Kaplan-Meier method and compared with the log-rank test. The role of clinicopathological variables as prognostic factors for survival was evaluated using Cox's regression model.

RESULTS

223 patients were identified. Stage 1A, 1B and 1C were 61.5%, 1.3% and 29.6% respectively. 7.6% were apparently stage I. Surgical approach was laparoscopic for 93 patients (41.7%) and open for 130 (58.3%). 5-years DFS was 84% and 82%, 10-years DFS was 68% and 64% for the laparoscopic and open-group (p = 0.6).5-years OS was 100% and 99%, 10 years OS was 98% and 97% for the laparoscopic and open-surgery group (p = 0.8). At multivariate analyses stage IC, incomplete staging, site of primary surgery retained significant prognostic value.

CONCLUSION

The present study suggests that surgical route does not affect the oncological safety of patients with stage I AGCTs, with comparable outcomes between laparoscopic and open approach.

The role of staging and adjuvant chemotherapy in stage I malignant ovarian germ cell tumors (MOGTs): the MITO-9 study

Background

Surgery followed by platinum-based chemotherapy is the standard of care for MOGCTs, except for stage IA dysgerminoma and stage IA grade 1 immature teratoma where surveillance only is recommended. The role of adjuvant chemotherapy and surgical staging is debated.

Patients and methods

Data from 144 patients with stage I MOGTs were collected among MITO centers (Multicenter Italian Trials in Ovarian Cancer) and analyzed.

Results

Fifty-five (38.2%) patients were affected by dysgerminomas, 49 (34%) by immature teratomas, 26 (18.1%) by yolk sac tumors and 14 (9.7%) by mixed tumors. Seventy-three (50.7%) patients receive surgery plus chemotherapy, while 71 (49.3%) patients underwent surgery alone. The latter group included 32 dysgerminomas (14 IA-13 Ix, 3 IB, and 2 IC), 34 immature teratomas (20 1A-13 IA grade 1, 6 Ix, 1 IB, and 7 IC), 4 mixed tumors and 1 yolk sac tumor. Forty-four patients did not received chemotherapy, even if it would have been indicated by recommended approach. 94 (65.3%) patients received peritoneal surgical staging. Twenty-three (15.9%) developed a recurrence. Incomplete surgical staging was associated with recurrence (P < 0.05; OR 2.37) at Cox regression analysis. Seven patients died. Four patients were affected by yolk sac tumors, two by mixed tumors and one by immature teratoma. Five patients died for disease, one for acute leukemia and one for suicide. Prognostic parameter analyses showed that yolk sac component is a predictor for survival (P < 0.05). Five-years OS rates were 96.8% and 88.7% in the surgically staged and the incomplete staged group, respectively, while 93.8% and 94.1% in the standard treatment and in the surveillance group, respectively.

Conclusions

This study shows that surveillance seems not to affect survival; chemotherapy should be reserved for relapse resulting in high cure rate. Incomplete peritoneal surgical staging is associated with recurrence. Yolk sac histology worsens the prognosis.

Tertiary cytoreductive surgery in recurrent epithelial ovarian cancer: A multicentre MITO retrospective study

OBJECTIVES

To evaluate the impact of tertiary cytoreductive surgery (TCS) on survival in recurrent epithelial ovarian cancer (EOC), and to determine predictors of complete cytoreduction.

METHODS

A multi-institutional retrospective study was conducted within the MITO Group on a 5-year observation period.

RESULTS

A total of 103 EOC patients with a ≥6month treatment-free interval (TFI) undergoing TCS were included. Complete cytoreduction was achieved in 71 patients (68.9%), with severe post-operative complications in 9.7%, and no cases of mortality within 60days from surgery. Multivariate analysis identified the complete tertiary cytoreduction as the most potent predictor of survival followed by FIGO stage I-II at initial diagnosis, exclusive retroperitoneal recurrence, and TCS performed ≥3years after primary diagnosis. Patients with complete tertiary cytoreduction had a significantly longer overall survival (median OS: 43months, 95% CI 31-58) compared to those with residual tumor (median OS: 33months, 95% CI 28-46; p<0.001). After multivariate adjustment the presence of a single lesion and good (ECOG 0) performance status were the only significant predictors of complete surgical cytoreduction.

CONCLUSIONS

This is the only large multicentre study published so far on TCS in EOC with ≥6month TFI. The achievement of postoperative no residual disease is confirmed as the primary objective also in a TCS setting, with significant survival benefit and acceptable morbidity. Accurate patient selection is of utmost importance to have the best chance of complete cytoreduction.

Bowel dysfunction following nerve-sparing radical hysterectomy for cervical cancer: a prospective study

OBJECTIVE

To objectively assess anorectal dysfunction following nerve-sparing radical hysterectomy in stage I-II cervical carcinoma patients.

MATERIAL AND METHODS

Between 2008 and 2012, 21 patients with primary cervical cancer stage FIGO I-II were enrolled in this prospective study. All women underwent nerve-sparing radical hysterectomy. Anorectal manometry was performed preoperatively and 6 months after surgery. A paired Student t test was used to assess the statistical difference between the manometric evaluations. A p value <0.05 was considered statistically significant.

RESULTS

Twenty-one patients were available for follow-up. Maximal and mean anal resting and squeezing pressures were unaffected by the surgical procedure, rectoanal inhibitory reflex and length of the high anal pressure zone did not change after the operation. The minimal volume to elicit rectal sensation, urge to defecate and maximal tolerable volume did not change significantly in the postoperative period, although they decreased in 2 and increased in 3 patients. In addition, rectal compliance did not change after surgery. Furthermore, no significant differences were found between patients who were or were not treated with adjuvant radiotherapy.

CONCLUSIONS

Our findings suggest that nerve-sparing radical hysterectomy for cervical cancer does not seem to be associated with long-term anorectal dysfunction. © 2014 S. Karger AG, Basel.

The impact of lymph vascular space invasion on recurrence and survival in patients with early stage endometrial cancer

The aim of this study was to determine impact of lymph vascular space involvement (LVSI) on recurrence and survival in early stage of endometrial cancer. From 1991 through 2010, all endometrial cancer patients at University Hospital of Bari, Italy were identified. The Log-rank test and Kaplan-Meyer methods were used for time-to-event analysis to evaluate the effects of on lymph vascular space involvement recurrence rate and survival time. Of the 560 endometrial cancer patients, 525 underwent primary surgery. Of those, 399 had early stage disease. Three hundred and forty women were not found to have LVSI, whereas 59 were found to have lymph vascular space involvement. Forty-nine (12%) patients developed a recurrence and 20 of them showed lymph vascular space involvement. The statistical analysis demonstrated that LVSI was strongly associated with a poor survival (P < 0.0001). Lymph vascular space involvement is associated with a high risk of recurrence and poor overall survival in early stage of endometrial cancer; therefore, the clinical decision to decide whether or not a patient with early stage endometrial cancer should receive adjuvant therapy should be included the evaluation of lymph vascular space involvement.

Antimicrobial Prophylaxis in Laparoscopic Gynecologic Surgery: A Prospective Randomized Study Comparing Amoxicillin-Clavulanic Acid with Cefazolin

Numerous studies have been published in recent years about antimicrobial prophylaxis in gynecologic surgery, but the optimal drug and schedule for the different surgical procedures is still a matter of debate. The aim of the present study was to compare two ultra-short term antimicrobial prophylaxis regimens (amoxicillin-clavulanic acid and cefazolin) in preventing infections following laparoscopic gynecologic operations. Three hundred sixty women hospitalized for a laparoscopic gynecologic surgery procedure were included in the study between January 1999, and December 2001. Patients were randomly allocated to receive amoxicillin-clavulanic acid (2.2 g) [Group A] or cefazolin (2 g) [Group B] as a single dose 30 minutes before surgery. Each patient was assessed daily until discharge to evidence febrile status and the presence of infections at the operative site, urinary tract and respiratory tract. In the amoxicillin-clavulanic acid (Group A) and cefazolin (Group B) groups, overall 164 and 172 patients, respectively, were evaluable for prophylactic efficacy at hospital discharge. Infectious complications were infrequent in both groups with febrile morbidity occurring in only one patient (0.6%) in the amoxicillin-clavulanic group. No sign of infections at the surgical site, urinary tract and respiratory tract was observed in either group. No death due to sepsis was recorded. It is concluded that ultra-short term prophylaxis with both amoxicillin-clavulanic acid and cefazolin is safe and effective in elective laparoscopic gynecologic surgery.

"Intestinal-type" mucinous adenocarcinoma of the vulva: a report of two cases

BACKGROUND

"Intestinal-type" mucinous carcinoma of the vulva is extremely rare with very few cases reported in the literature.

CASE REPORT

The authors report two patients who had diagnosis of intestinal-type mucinous adenocarcinoma of the vulva after excisional biopsy. In both cases, restaging was perfomed with total body computed tomography (CT) scan, gastroscopy, and colonoscopy that showed no other site of disease. A radical vulvectomy with bilateral systematic inguinal lymphadenectomy was performed, and in both cases no residual disease was found. A patient developed metastatic (liver, bone marrow) colonic cancer 36 months after primary surgery, received multiple lines of chemotherapy, and died of disseminated disease 18 months after diagnosis. The other patient was found to have dysplastic polyp in the sigmoid colon, and is alive without disease at 39 months after primary diagnosis.

CONCLUSION

Intestinal-type mucinous carcinoma of the vulva has a poor prognosis. Strict endoscopic follow-up of the colon is mandatory in such cases, considering the high propensity of associated gastrointestinal (GI) tumors.

Prognostic factors and outcomes in 28 cases of uterine leiomyosarcoma

OBJECTIVES

It was the aim of this study to evaluate clinicopathological characteristics and prognostic factors of uterine leiomyosarcomas (LMS).

METHODS

Twenty-eight patients with uterine LMS were evaluated in this retrospective study. Their features and survival were analyzed by Kaplan-Meier and log-rank tests.

RESULTS

The median age of the patients was 52 years (range 25-74). Nine patients had a disease with a mitotic count <10/10 high-power fields. Twenty-one patients presented with stage I disease, 1 with stage II and 6 with stage IV. Twelve patients underwent total hysterectomy and bilateral salpingo-oophorectomy, 2 simple hysterectomy, 5 myomectomy and 9 more comprehensive surgical treatments. Adjuvant chemotherapy was administered to 16 patients, whereas chemoradiation was given only to 2 patients. Fifty percent presented with recurrence of the disease. The median overall survival was 46 months. Age, mitotic count, type of surgery, adjuvant therapy, recurrence and clinical response to chemotherapy were not found to affect survival, while the menopausal status and FIGO (International Federation of Gynecology and Obstetrics) stage were found to be prognostic factors.

CONCLUSION

In our series, the menopausal state and FIGO stage were found to be prognostic factors related to survival.

Predictors of survival in patients with recurrent ovarian cancer undergoing secondary cytoreductive surgery based on the pooled analysis of an international collaborative cohort

BACKGROUND

This study aims to identify prognostic factors and to develop a risk model predicting survival in patients undergoing secondary cytoreductive surgery (SCR) for recurrent epithelial ovarian cancer.

METHODS

Individual data of 1100 patients with recurrent ovarian cancer of a progression-free interval at least 6 months who underwent SCR were pooled analysed. A simplified scoring system for each independent prognostic factor was developed according to its coefficient. Internal validation was performed to assess the discrimination of the model.

RESULTS

Complete SCR was strongly associated with the improvement of survival, with a median survival of 57.7 months, when compared with 27.0 months in those with residual disease of 0.1-1 cm and 15.6 months in those with residual disease of >1 cm, respectively (P<0.0001). Progression-free interval (≤23.1 months vs >23.1 months, hazard ratio (HR): 1.72; score: 2), ascites at recurrence (present vs absent, HR: 1.27; score: 1), extent of recurrence (multiple vs localised disease, HR: 1.38; score: 1) as well as residual disease after SCR (R1 vs R0, HR: 1.90, score: 2; R2 vs R0, HR: 3.0, score: 4) entered into the risk model.

CONCLUSION

This prognostic model may provide evidence to predict survival benefit from secondary cytoreduction in patients with recurrent ovarian cancer.

Is surgical restaging indicated in apparent stage IA pure ovarian dysgerminoma? The MITO group retrospective experience

OBJECTIVE

Conservative surgery followed by platinum-based chemotherapy is considered the standard approach for pure ovarian dysgerminoma (POD), except for correctly staged IA patients. The aim of study was to evaluate the outcome of IA POD patients with incomplete surgical staging in order to define the proper management.

METHODS

Data concerning primary treatment and recurrence were reviewed for 26 patients with stage IA POD treated in MITO (Multicenter Italian Trials in Ovarian Cancer) centers.

RESULTS

Median age was 22.5years. Primary surgery was fertility sparing for 17 patients (65.4%) and radical surgery was performed in 9 patients due to older age or gonadal dysgenesis. Only five patients (19.2%) had complete surgical staging; 38.5% had lymph node dissection, 46.2% had peritoneal biopsies and/or omentectomy and 65.4% had peritoneal washing. Seven patients received adjuvant chemotherapy. Overall recurrence rate was 11.5%: all recurrences occurred in the group submitted to incomplete staging procedure. No patients treated with adjuvant chemotherapy relapsed. One patient had pelvic recurrence, one patient relapsed in the abdomino-pelvic peritoneum and lymph nodes and the third patient showed a peritoneum, lymph nodal and residual ovary relapse. All patients with recurrence were cured by salvage therapy: 2 patients were treated with surgery plus chemotherapy and one only with chemotherapy. After a median follow-up of 100months all patients are alive without evidence of disease. Six patients opted for conception and delivered healthy infants, two with IVF with donor oocyte.

CONCLUSIONS

IA POD prognosis is excellent. Conservative surgery with a complete surgical staging is the gold standard. Patients with incomplete staging could undergo surgical restaging or surveillance. Chemotherapy should be reserved to relapse with excellent chances of therapeutic success.

Long-term topotecan therapy in recurrent or persistent ovarian cancer

BACKGROUND

The objective of this study was to evaluate feasibility, safety and clinical outcome of long-term therapy with topotecan (Hycamtin) in recurrent or persistent ovarian cancer.

PATIENTS AND METHODS

A retrospective chart review was conducted on all patients treated with topotecan (TPT) at the Department of Obstetrics and Gynecology, University of Bari, Italy between 1999 and 2007. Pertinent clinicopathologic information, response and toxicity following treatment with TPT were collected. TPT was given at a dosage ranging between 1.5 and 1.0 mg/m2 every three to four weeks. All patients were evaluated for toxicity acording to the CTC and response according to the RECIST response criteria. Time to progression (TTP) was calculated from initiation of TPT treatment and start of the next chemotherapy regimen.

RESULTS

A total of 30 patients received TPT for at least eight cycles for recurrent ovarian (22), fallopian tube (3) or primary peritoneal carcinoma (5). A total of 432 cycles of chemotherapy were given, with an average of 14.4 cycles per patient (range 8-22). Dose reduction was necessary in 20 patients (66%). About half of the patients required blood transfusions and growth factors. Non hematologic toxicity was mild and manageable. Responses were observed in 16/30 patients (53%), the remaining having SD. Median time to treatment progression was 28 months (range 9-88).

CONCLUSION

Long-term treatment with topotecan in recurrent/persistent ovarian cancer is feasible with limited evidence of cumulative toxicity. The results of this retrospective analysis suggest a potential role for late response and survival benefit for those patients without disease progression who continue topotecan therapy beyond six cycles of treatment.

Spleen involvement in women with ovarian cancer

The aim of this study was to determine the prognostic factors of spleen metastases in ovarian cancer. A retrospective chart review was conducted and ten patients with spleen metastases were evaluated. Eight were Stage III, one Stage I and one Stage IV. One patient had a spleen metastasis at the time of ovarian cancer diagnosis, whereas, the remaining patients 23.4+12 months after ovarian cancer diagnosis. Spleen involvement is a late complication that rarely occurs in ovarian cancer and confers a poor prognosis. The interval time between ovarian cancer diagnosis and appereance of spleen involvement is the most important prognostic factor.

Conservative management of uterine leiomyosarcoma: report of a failure

BACKGROUND

Conservative management of uterine leiomyosarcoma has rarely been reported in the literature.

CASE REPORT

A 26-year-old woman was diagnosed with uterine leiomyosarcoma after resection of a 11 cm uterine mass. Conservative management was proposed, demolitive surgery was not performed and the patient received four courses of chemotherapy. Four months after completion of chemotherapy the patient developed a local recurrence and died of disease 48 months after the primary diagnosis.

CONCLUSION

Reporting a failure after conservative management of uterine leiomyosarcoma is important in order to try to evaluate correct indications for fertility-sparing surgery.

Is there a role for neoadjuvant chemotherapy in early invasive cervical carcinoma?

OBJECTIVE

The purpose of this study was to determine if a survival advantage may exist from neoadjuvant chemotherapy (NACT) followed by radical surgery in early invasive (Stage IB1 and IIA) cervical carcinoma.

METHODS

Using information from studies published on the topic of NACT in cervical carcinoma along with baseline control rates of standard treatment and patterns of failure, an estimate of how many patients with early invasive cervical cancer would benefit from this procedure was calculated.

RESULTS

NACT followed by tailored radical surgery could result in a significant decrease (about 40%) in recurrence rate (13 vs 22%) and ultimately in survival compared to conventional treatment in early invasive cervical cancer. Moreover the introduction of NACT in all patients should result in a 75% decrease of adjuvant radiotherapy (10 vs 40%), and probably in a decrease in surgical and radiation related complications.

CONCLUSION

A fraction of patients with early invasive cervical cancer (high-risk Stage IB-IIA cervical cancer) could benefit from NACT followed by tailored radical surgery. A randomized controlled trial to test this research question is very difficult due to the large population required. A subset population is identified which may benefit from NACT.

Neoadjuvant Chemotherapy: An Alternative Option of Treatment for Locally Advanced Cervical Cancer

Although the incidence of cervical cancer has declined in both North America and Europe, it still represents the second most common cancer in women and the fifth most common malignancy worldwide. Most patients in the developed countries present with disease either confined to the cervix or with limited extension beyond it. Historically, the standard treatment was usually radiotherapy or radical hysterectomy with node dissection. In 1999, five randomized clinical trials performed by the Gynecologic Oncology Group, the Radiation Therapy Oncology Group and the Southwest Oncology Group have demonstrated a significant outcome advantage when cisplatin-based chemotherapy was administered during radiation in patients with cervical cancer. In the current review, we will analyze the role of neoadjuvant chemotherapy followed by radiotherapy and surgery as an alternative option treatment to the standard chemoradiation for locally advanced cervical cancer (stage Ib2 or larger).

Antimicrobial prophylaxis in vaginal gynecologic surgery: a prospective randomized study comparing amoxicillin-clavulanic acid with cefazolin

The aim of this prospective, randomized study was to compare amoxicillin-clavulanic acid with cefazolin as ultra-short term prophylaxis in vaginal gynecologic surgery. It was conducted at the Department of Obstetrics and Gynecology, University of Bari. Patients were randomly allocated to receive amoxicillin-clavulanic acid (2.2 g) [Group A] or cefazolin (2 g) [Group B] as a single dose 30 minutes before surgery. Each patient was assessed daily until discharge to evidence febrile status and the presence of infections at the operative site, urinary tract and respiratory tract. In the amoxicillin-clavulanic acid (Group A) and cefazolin (Group B) groups, overall 88 and 90 patients, respectively, were evaluable for prophylactic efficacy at hospital discharge. Infectious complications were infrequent in both arms, with febrile morbidity occurring in 4 (4.5%) and 16 (8.9%) patients respectively in the amoxicillin-clavulanic acid and cefazolin groups (p=0.016). Urinary tract infections were higher but not significantly in the amoxicillin-clavulanic acid group (6.8% versus 4.4 %), whereas asymptomatic bacteriuria was detected in 2.2% of the patients in both groups. There was no respiratory tract infection or septic death in either group. It is concluded that ultra-short term prophylaxis with both amoxicillin-clavulanic acid and cefazolin is safe and effective in elective vaginal gynecologic surgery.

A rare case of choroidal metastasis presented after conservative management of endometrial cancer

Hematogenous dissemination from endometrial cancer is quite rare. We report a 31-year-old woman who developed choroidal metastasis following conservative management of early-stage endometrial carcinoma. She had received kidney transplantation and was taking steroids and cyclosporine. Three years after hysterectomy for persistent endometrial carcinoma, she developed multiple metastatic disease (to both lungs and right pelvis), and while on treatment with paclitaxel and carboplatin, she complained of a rapid visual deterioration. Ophthalmologic evaluation revealed a metastatic choroidal tumor associated with multiple central nervous system metastases. The patient refused further treatment and died 1 month after diagnosis of choroidal involvement. In conclusion, this is the first reported case of choroidal metastasis from endometrial cancer and highlights the need to consider immunosuppressive treatment as an absolute contraindication to conservative fertility-sparing treatment in gynecological malignancies.

Extending the platinum-free interval (PFI) with a non-platinum therapy in platinum (P)- sensitive recurrent ovarian cancer (OC): Results from the SOCRATES retrospective study

5093

Background: Chance of response to P is correlated to PFI (Markman, J Clin Oncol 1991). It has been proposed that extending PFI by interposing non-P therapy increase activity of delayed P retreatment in patients (pts) with P-sensitive recurrent OC, but this strategy is based on data from small series. The SOCRATES study retrospectively assessed the pattern of treatment of a cohort of pts with P-sensitive recurrent OC. Methods: Data of pts treated between 2000 and 2002 at 37 centers were collected in 2005. Pts with recurrent OC were eligible if P-sensitive [interval from end of first line to relapse (RFI) > 6 months]. Results: Data on chemotherapy at relapse were available in 428 pts. RFI was 6–12 months in 40% and >12 months in 60%. Pts received a 2nd (100%), 3rd (80%), 4th (50%), 5th (28%), 6th (12%) line of chemotherapy. 282 pts (65.9%) received P at first relapse (Group A) after a median RFI of 19 months, with a 74.4% response rate (RR) out of 246 evaluable pts. 67 pts (15.7%) received non-P at first relapse after a median RFI of 9.6 months, with a RR of 44.6% out of 56 evaluable pts, and then received P at later relapse after a median PFI of 23 months, with a 57.4% RR out of 47 evaluable pts (Group B). 79 pts (18.5%), with a median RFI of 8.4 months, had a on-P 2nd line with a RR of 28.8% out of 66 evaluable pts, and never received P later (Group C). The difference in RR to P given as 2nd line and delayed P is statistically significant (p = 0.02, Fisher exact test). Median overall survival was 27.2, 26.1 and 16.8 months for Group A, B and C, respectively. Conclusions: With the limits of a retrospective study, our data show that, although P was given in the group B after a similar PFI than in the group A, due to the interposition of a non-P therapy, activity of P was higher when given immediately after relapse than when postponed at subsequent lines. Overall, these data suggest that P-sensitive pts should receive P as soon as possible, and delaying it may preclude the chance of receiving the best treatment. (Study sponsored by GlaxoSmithKline).

No significant financial relationships to disclose.

Neoadjuvant chemotherapy in cervical cancer: a 67 patients experience

The purpose of this study was to evaluate the efficacy and toxicity of neoadjuvant chemotherapy in patients with locally advanced cervical cancer. Between 1992 and 2003, all consecutive women with locally advanced cervical cancer receiving neoadjuvant chemotherapy were identified. Sixty-seven patients received neoadjuvant chemotherapy: 34 had stage I disease, 28 had stage II disease, and 5 had stage III disease. Clinical response to neoadjuvant chemotherapy occurred in 61 patients, including six with complete and 55 with partial response; five women showed stable disease and one progressed. After neoadjuvant chemotherapy, 58 women underwent surgery, whereas the remaining nine received radiation. Hematologic toxicity was seen in 14 patients, with most of them consisting in severe anemia. The 5-year survival rate and median survival were 63% and 93 months. In univariate analysis, response to neoadjuvant chemotherapy, treatment after neoadjuvant chemotherapy, cervical stromal invasion >50%, and lymph node involvement were important prognostic factor responsible for survival. Neoadjuvant chemotherapy followed by surgery seems to be tolerated and active in the treatment of locally advanced cervical cancer and might be an alternative choice of therapy to chemoradiation. A prospective randomized trial with a larger number of cases is needed.

Neoadjuvant chemotherapy in advanced ovarian cancer: a case-control study

The aim of this study was to compare the outcome of patients with advanced ovarian carcinoma treated with neoadjuvant chemotherapy (NACT) with those treated conventionally with primary debulking surgery. From 1994 to 2003, all consecutive cases of advanced-stage epithelial ovarian carcinoma treated with NACT at the University of Bari were identified. A well-balanced group of women who underwent primary debulking surgery followed by platinum-based chemotherapy was selected as controls. Kaplan-Meier and Cox proportional hazards analyses were used to determine the predictors for survival. Thirty women with advanced-stage epithelial ovarian carcinoma were treated with NACT and compared to 30 patients who underwent primary debulking surgery. Patients in the NACT were significantly older and had a poorer performance status compared to the controls. However, no statistical difference was observed in overall disease-specific survival (P= 0.66) and disease-free survival (P= 0.25) between the two groups. Although patients in the NACT group are significantly older and have a poorer performance status, this treatment modality does not compromise survival. Prospective randomized trials comparing NACT to conventional treatment to determine the quality of life and cost/benefit outcomes are now appropriate for women presenting advanced epithelial ovarian cancer.

[Reconstruction with skin flaps of the posterior aspect of the thighs after total pelvic evisceration with removal of vulvo-perineal soft tissues in recurrent vulvar squamous carcinoma]

We report of a case of a fortythree years old women affected by squamous cell cancer of the vulva (T3N0M0). Despite curative treatment (radical vulvectomy with bilateral inguinal and femoral lymphadenectomy), after 41 months she had a local recurrence, retreated with surgery and radiotherapy; another recurrence, after 29 months was treated with chemotherapy, without results. Because of local diffusion with infiltration of the urethra and anus, the patient was submitted to demolitive operation (total pelvic evisceratio, excision of pelvic and perineal soft tissues and reconstruction with rotating skin flaps of the posterior face of the thighs). After two years of follow up, the patient is alive without evidence of disease.

Hormone replacement therapy on ovarian and uterine cancer risk and cancer survivors: how shall we do no harm?

This article will focus on the results of the Women's Health Initiative on the effects of hormone replacement therapy on coronary heart disease, stroke, venous thromboembolism, breast cancer, and colorectal cancer. Data from other relevant trials, including the most recent data on ovarian and uterine cancer risk and on gynecologic cancer patients, are also discussed to provide some guidelines on prescribing hormone replacement therapy in clinical practice, particularly in gynecologic cancer survivors.

Receptorial and mitochondrial apoptotic pathways in normal and neoplastic human endometrium

Under normal conditions, in human endometrium, apoptotic and antiapoptotic factors play an important role in tissue homeostasis. Abnormalities of apoptosis, a process implicated in several events in the reproductive organs, may contribute to neoplastic transformation. The present study aimed to investigate the involvement of both the receptorial and the mitochondrial pathways of apoptosis in normal endometrium and in endometrial carcinoma, by measuring caspase-3 and caspase-8 activities and cytosolic cytochrome c levels. Twelve endometrial carcinomas and nine normal endometrial specimens (four in mild proliferative phase, five in late secretory phase) were included in this study. Cytosolic fractions, obtained by differential centrifugation of tissue homogenates, were analyzed for caspase-3 and caspase-8 activities, as well as for cytochrome c content. Caspase-8 activity in normal secretory phase endometrium was higher than that in the proliferative phase and in the endometrial carcinoma. Moreover, higher cytochrome c levels were detected in endometrial carcinoma with respect to normal secretive endometrium. No significant differences were found in caspase-3 activity between normal and pathologic endometrium. The results obtained suggest that in normal endometrium, apoptosis takes place through the activation of both receptorial and mitochondrial pathways. Defects in both these pathways may contribute to the development of endometrial carcinoma.

Hormone replacement therapy on ovarian and uterine cancer risk and cancer survivors: how shall we do no harm?

This article will focus on the results of the Women's Health Initiative on the effects of hormone replacement therapy on coronary heart disease, stroke, venous thromboembolism, breast cancer, and colorectal cancer. Data from other relevant trials, including the most recent data on ovarian and uterine cancer risk and on gynecologic cancer patients, are also discussed to provide some guidelines on prescribing hormone replacement therapy in clinical practice, particularly in gynecologic cancer survivors.

Clinical features of hepatic metastasis in patients with ovarian cancer

The purpose of this study was to investigate the clinical features of hepatic metastasis in patients with epithelial ovarian cancer. From 1998 to 2002, all women with hepatic metastasis from ovarian cancer were identified at the University of Bari. Twenty-nine patients identified included one having stage IIC, one stage IIIA, two stage IIIB, 17 stage IIIC, and eight stage IVB. Eight women had hepatic metastasis at the time of the diagnosis of ovarian cancer (group I), 10 patients had hepatic metastasis as first recurrence (group II), and 11 (group III) as a second relapse. The median survival from the time of liver metastasis diagnosis was 19 months in group I patients, 24 months in group II patients, and 10 months in group III patients. No statistical differences in survival were seen among the three groups (P = 0.7). Cell type, performance status at the time of the primary tumor diagnosis, number of hepatic lesions, the presence of other sites of disease at the time of hepatic metastasis, and platinum-based chemotherapy were significantly related to survival. Better performance status, serous cell-type tumor, single hepatic lesion, the absence of other sites of disease, and platinum-based chemotherapy are good prognostic factors.