Continuing routine cardiac surveillance in long-term use of pegylated liposomal doxorubicin: is it necessary?

OBJECTIVE

The objective of this study was to determine the cardiac safety of high cumulative doses of pegylated liposomal doxorubicin (PLD) in patients with gynecologic malignancies and the need for routine evaluation of left ventricular ejection fraction (LVEF).

METHODS

Data were collected for all patients treated with PLD with at least one evaluation of LVEF with either Multi-Gated Acquisition (MUGA) scan or echocardiogram from January 2006 to May 2012. Evaluation of LVEF was used to detect PLD-related cardiac toxicity (defined as a decline in LVEF of greater than 10% compared to baseline measurements).

RESULTS

A total of 141 patients were included. Twenty-two patients were treated with a cumulative dose of 500 mg/m(2) or more, and five patients with 1000 mg/m(2) or more. Ten patients (7%) had a reduction in LVEF of greater than 10%, 38 had no significant change or increase in LVEF throughout the duration of treatment, and 93 did not require a follow-up evaluation of LVEF. The LVEFs of two patients dropped below 50% at cumulative doses of 1110 mg/m(2) and 1670 mg/m(2); one began with a baseline of 52%.

CONCLUSIONS

Only one patient had a clinically significant decrease in LVEF at a cumulative dose of 1670 mg/m(2), suggesting that PLD does not carry a significant risk of cardiotoxicity, as evidenced by the stability of LVEF even after treatment with large cumulative doses. Routine surveillance of LVEF does not seem to be necessary or cost effective in the absence of other risk factors.

Simultaneous occurrence of well differentiated papillary mesothelioma and endometrioid ovarian cancer: A case report

► We present a case of endometrioid ovarian cancer with concomitant well differentiated papillary mesothelioma of the peritoneum. ► Endometrioid ovarian cancer with concomitant well differentiated papillary mesothelioma is an extremely rare surgical finding of uncertain prognostic significance. ► Treatment with carboplatin and gemcitabine was given with no evidence of disease six months after diagnosis.

A multicenter, randomized, phase 2 clinical trial to evaluate the efficacy and safety of combination docetaxel and carboplatin and sequential therapy with docetaxel then carboplatin in patients with recurrent platinum-sensitive ovarian cancer

BACKGROUND

The aim of this randomized clinical trial was to evaluate the efficacy and safety of combination (cDC) and sequential (sDC) weekly docetaxel and carboplatin in women with recurrent platinum-sensitive epithelial ovarian cancer (EOC).

METHODS

Participants were randomized to either weekly docetaxel 30 mg/m(2) on days 1 and 8 and carboplatin area under the curve (AUC) = 6 on day 1, every 3 weeks or docetaxel 30 mg/m(2) on days 1 and 8, every 3 weeks for 6 cycles followed by carboplatin AUC = 6 on day 1, every 3 weeks for 6 cycles or until disease progression. The primary endpoint was measurable progression-free survival (PFS).

RESULTS

Between January 2004 and March 2007, 150 participants were enrolled. The response rate was 55.4% and 43.2% for those treated with cDC and sDC, respectively. The median PFS was 13.7 months (95% confidence interval [CI], 9.9-16.8) for cDC and 8.4 months (95% CI, 7.1-11.0) for sDC. On the basis of an exploratory analysis, patients treated with sDC were at a 62% increased risk of disease progression compared to those treated with cDC (hazard ratio = 1.62; 95% CI, 1.08-2.45; P = .02). The median overall survival time was similar in both groups (33.2 and 30.1 months, P = .2). The incidence of grade 2 or 3 neurotoxicity and grade 3 or 4 neutropenia was higher with cDC than with sDC (11.7% vs 8.5%; 36.8% vs 11.3%). The sDC group demonstrated significant improvements in the Functional Assessment for Cancer Therapy-Ovarian, Quality of Life Trial Outcome Index scores compared with the combination cohort (P = .013).

CONCLUSIONS

Both cDC and sDC regimens have activity in recurrent platinum-sensitive EOC with acceptable toxicity profiles. The cDC regimen may provide a PFS advantage over sDC.

Closure of long surgical incisions with a new formulation of 2-octylcyanoacrylate tissue adhesive versus commercially available methods

BACKGROUND

Topical 2-octylcyanoacrylate tissue adhesive is an alternative to traditional devices for closing short surgical incisions.

METHODS

An open-label, randomized study compared a new high-viscosity formulation of 2-octylcyanoacrylate with commercially available devices, including low-viscosity 2-octylcyanoacrylate, for epidermal closure of incisions > or = 4 cm requiring subcutaneous and/or deep-dermal suturing.

RESULTS

Of patients with 1 to 3 wounds, 106 were treated with high-viscosity 2-octylcyanoacrylate and 103 with commercially available devices. The day-10 rates of healing by wound were 96% and 97% for study versus control treatment and 97% and 95% for new and old 2-octylcyanoacrylate formulations versus other controls, respectively. Day-10 infection rates by wound were 4 of 145 versus 7 of 131 for study versus control treatment and 6 of 207 and 5 of 69 for new and old 2-octylcyanoacrylate versus other controls, respectively.

CONCLUSIONS

The new tissue adhesive formulation provides epidermal wound closure equivalent to commercially available devices with a trend to decreased incidence of wound infection.

Confirmatory Chest Radiographs after Central Line Placement: Are They Warranted?

OBJECTIVES

This study was designed to determine the ability of physicians to predict complications associated with the placement of central venous access devices and to decide whether a confirmatory chest radiograph is warranted after placement.

METHODS

Patients receiving central venous access on an inpatient and outpatient gynecologic oncology service were studied. Data were collected regarding patient demographics, patient history, procedural details of the placement, and the type of catheter used. The physician then predicted which patients had a reasonable potential for placement complications. All of the patients then underwent radiography, which was then compared with the original prediction.

RESULTS

Ninety-eight patients who had central venous access devices placed were included in the study. Eighty of the 81 central lines thought by the practitioner to have been placed without incident caused no significant complications; one individual in this group had a minor pneumothorax. Two of 17 patients predicted to have complications were noted to have a pneumothorax that required hospitalization. No patients in the low-risk group were hospitalized for a placement complication, whereas two hospitalizations occurred in the high-risk group.

CONCLUSION

Confirmatory chest radiographs may potentially be omitted in certain cases after line placement when experienced clinicians use good technique, good clinical judgment, and discrimination.

Effect of topotecan infusion duration on hematologic toxicity in recurrent ovarian carcinoma

In an open-label, multicenter, nonrandomized, counterbalanced study, we investigated the tolerability and antitumor profile of a 10-min infusion duration of topotecan. A total of 12 patients with evaluable recurrent ovarian cancer were enrolled into the study and treated with 1.5 mg/m2/d topotecan for 5 d of a 21-d course by either a 10-, 30-, or 120-min intravenous infusion. Patients were evaluated for tolerability and tumor response. The primary toxicity associated with topotecan was noncumulative myelosuppression. All 12 patients experienced grade 3/4 neutropenia. Grade 3/4 thrombocytopenia, leukopenia, and anemia were reported in five (42%), two (17%), and two (17%) patients, respectively. Likewise, the majority of courses were associated with hematologic toxicity, with grade 3/4 neutropenia, thrombocytopenia, leukopenia, and anemia reported in 97%, 19%, 6%, and 6% of courses, respectively. The infusion duration had little impact on the myelotoxicity profile of topotecan. The mean nadir levels for all hematologic parameters were similar for all infusion durations, and myelosuppression was reversible and returned to near-preinfusion levels prior to administering the subsequent course, irrespective of infusion duration. A complete response was obtained by three (25%) patients, and five (42%) patients achieved stable disease; therefore, 67% of patients obtained clinical benefit. The results of this study demonstrate that topotecan administered over a 10-min interval has a comparable tolerability and safety profile compared with a 30-min infusion. A 10-min infusion may result in greater patient convenience and a reduction in the consumption of healthcare resources.

Stage I ovarian carcinoma: specialty-related differences in survival and management

BACKGROUND

In patients with FIGO (International Federation of Gynecology and Obstetrics) stage I ovarian carcinoma given care with or without subspecialists, we compared completeness of initial staging and disease-free survival.

METHODS

Two groups of patients with stage I ovarian carcinoma were compared. Patients were managed by either gynecologic oncologists or community-based physicians. The two groups were compared for similarities in demographic, tumor, and substage characteristics and survival differences.

RESULTS

Fifty-four patients with stage I ovarian cancer were included. The two groups were comparable in age, gravidity, parity, grade, and substage. Substaging was determined to be adequate in 100% of the gynecologic oncologist group and 28% of the community-based group. Postoperative chemotherapy was given to 79% and 36% of the two groups, respectively. Six-year survival was 90% in the gynecologic oncologist group and 68% in the community-based group.

CONCLUSIONS

Of these two groups of patients with stage I ovarian cancer, the group managed without gynecologic oncology involvement had significantly less adequate staging, decreased administration of chemotherapy, and lower survival rates.

The prognostic implication of ascites in advanced-stage ovarian cancer

Ovarian carcinoma accounts for greater than 50% of the gynecologic cancer deaths in the United States each year. One of the central reasons for this dismal outcome is that many patients present with advanced disease. In this series, a retrospective review of 130 patients with stage III and IV invasive epithelial ovarian carcinoma was performed to determine the prognostic significance of ascites. Patients were divided into two study groups based upon the presence or absence of ascites. Survival for the entire study group was 15%, but differed markedly when separated for the presence of ascites. In these patients, ascites was associated with a statistically decreased 5-year survival of 5% versus 45% without ascites (P = 0.0001). Individuals were found to be similar in each group when examined for age, height, weight, cell type, grade, and surgical and chemotherapeutic treatment modalities. More patients proportionately with stage IIIC disease had ascites than those without ascites (P = 0.0015). More of the individuals without ascites underwent second-look laparotomies and achieved a negative result than those with ascites (P = 0.04; P = 0.0038). We conclude that ascites in the presence of stage III and IV disease produces an almost uniformly fatal outcome.

Small bowel herniation after laparoscopically assisted vaginal hysterectomy

Laparoscopically assisted vaginal hysterectomies have been done with increasing frequency in the United States. To date, minimal complications have been noted with this procedure. The authors review a series of 90 individuals and note a three percent small bowel obstruction rate. This complication is more common in this group of patients than in patients having a standard abdominal hysterectomy. Since this operation has been commonly performed, it is often possible to convert an abdominal hysterectomy to a vaginal approach, this increase in complications is exceedingly high. The authors recommend closure of lateral abdominal wall port sites under direct laparoscopic visualization to prevent this serious complication.

Recurrent ovarian sex cord tumor with annular tubules: tumor marker and chemotherapy experience

Recurrent sex cord tumor with annular tubules is an unusual ovarian cancer. The authors report a patient with recurrent disease that was ultimately followed with multiple tumor markers. During this period the patient was treated only with chemotherapy. Her regimen consisted of a combination of etoposide, bleomycin, and cisplatin. The tumor markers that were followed were CA-125, CEA, inhibin, and Müllerian-inhibiting substance (MIS). There was no elevation of the CA-125 or CEA, but inhibin and MIS proved to be effective markers. Serum inhibin and MIS correlated perfectly with her documented disease status and was brought into the normal range when the patient was disease-free. This disease-free status was proven by surgical reexploration. This report is the first documented complete response in this rare malignancy treated by chemotherapy alone with distant metastatic spread. It also gives strong linkage of inhibin and MIS as good markers in this particularly rare malignancy.

Metastatic gastric cancer presenting as a pelvic mass

Traditionally, the gynecologist is the primary physician involved in the assessment of an adnexal mass. History, physical examination, and radiologic evaluation often fail to reveal extrapelvic etiologies for an adnexal mass, especially in the premenopausal woman. Recently three premenopausal women with a pelvic mass referred to the gynecologic oncology service at the University of Kentucky were each found to have gastric carcinoma metastatic to the ovary. This paper discusses the clinical presentation of these women and the indications for the evaluation of the upper gastrointestinal tract in a patient with an adnexal mass.

Immunohistochemical staining for CA-125 in fallopian tube carcinomas

From 1981-1991, 15 patients with primary fallopian tube carcinomas were treated at the University of Kentucky Medical Center. Immunohistochemical staining for CA-125 was performed on tumor specimens from all cases. Thirteen tumors (87%) stained positively for CA-125. Antigen staining was most intense in the apical portions of carcinoma cells. Serum CA-125 levels were measured in 5 patients and were elevated in 4 (80%). There was a positive correlation between tumor and serum antigen expression in these cases. Serum CA-125 levels accurately reflected disease status in the patients studied. These data suggest that CA-125 is a useful marker in patients with fallopian tube carcinoma. Immunohistochemical localization of CA-125 in tumor tissue should predict which patients will benefit most from serial antigen determinations.

Transition from benign to malignant epithelium in mucinous and serous ovarian cystadenocarcinoma

The slides of all patients with ovarian cystadenocarcinoma treated at the University of Kentucky Medical Center from 1966-1990 were reviewed. Fifty-four serous tumors and 42 mucinous neoplasms were identified for further study. Benign epithelium adjacent to an area of borderline or malignant epithelium was observed in 74 tumors (79%) and a site of epithelial transition was noted in 38 cases (40%). The presence of associated benign epithelium was more common in borderline or well-differentiated lesions and in patients with early-stage disease. These findings are consistent with epidemiologic and molecular genetic data and suggest that certain benign serous or mucinous ovarian tumors have the potential for malignant transformation. Removal of these tumors, particularly in postmenopausal women, should result in a subsequent reduction in the frequency of ovarian cancer.

Endometrioid carcinoma of the ovary and endometriosis: the association in postmenopausal women

Histologic material from 42 patients with endometrioid carcinomas of the ovary was reviewed. Ovarian endometriosis was present in 11 cases (26%) and 8 of these patients were postmenopausal. The exact site of transition from benign to malignant epithelium was observed in 4 cases. The clinical characteristics of patients with associated endometriosis were not significantly different from those without this finding except that endometriosis was present only in patients with Grade 1 or Grade 2 carcinomas. These data suggest that ovarian endometriosis in the postmenopausal patient has the potential to undergo malignant transformation and, when detected, should be removed surgically.

Ovarian cancer screening in asymptomatic postmenopausal women by transvaginal sonography

From November 1987 to January 1991, 1300 postmenopausal women underwent screening with transvaginal sonography (TVS). Women eligible for screening were all asymptomatic with no known ovarian tumors. Ovarian volume was calculated using the prolate ellipsoid formula, and a value in excess of 8.0 cm3 was considered abnormal. Ovarian abnormalities were detected in 33 women (2.5%), and 27 underwent exploratory laparotomy. Ovarian tumors were noted in all 27 patients, including 2 primary carcinomas and 14 serous cystadenomas. The two women with ovarian carcinomas had normal results of pelvic examinations and normal serum CA-125 levels. Both women had Stage I disease, and are alive and well after conventional therapy. TVS was time efficient, easy to perform, and well-accepted by patients. Currently, there are more than 3000 patient years of follow-up in the screened population, and there have been no deaths due to ovarian cancer. A multi-institutional trial to determine the efficacy of TVS as a screening method for ovarian cancer is indicated.

Malignant schwannoma in pregnancy

We report a case of malignant schwannoma on the distal forearm in a pregnant woman with neurofibromatosis. The problems of managing concomitant pregnancy and this particular maternal malignancy are discussed, leading toward a favorable maternal-fetal outcome.