Phase II study of liposomal doxorubicin in platinum- and paclitaxel-refractory epithelial ovarian cancer

PURPOSE

Stealth liposomal doxorubicin (Alzal Corp, Palo Alto, CA) has a slower clearance rate than free doxorubicin, resulting in sustained serum levels. Liposomal encapsulation also leads to increased concentration of drug in tumor tissue. Meta-analysis of previous studies has shown that doxorubicin has activity in epithelial ovarian cancer. The current study was developed to examine the activity of Stealth liposomal doxorubicin in platinum- and paclitaxel-refractory ovarian cancer.

PATIENTS AND METHODS

Patients had epithelial ovarian cancer that either progressed on or recurred within 6 months of completion of platinum and paclitaxel chemotherapy. All patients had measurable disease. Stealth liposomal doxorubicin was administered at 50 mg/m(2) every 4 weeks as a 1-hour infusion.

RESULTS

Eighty-nine patients were treated and included in an intent-to-treat analysis. There were 82 patients who were platinum and paclitaxel refractory and met all study criteria. There was one complete response and 14 partial responses, for a total response rate of 16.9% (95% confidence interval [CI], 9.1% to 24.6%). For platinum- and paclitaxel-refractory patients, the response rate was 18.3% (95% CI, 9.9% to 26.7%). Median time to progression was 19. 3 weeks for the entire population. Ten patients (11.2%) withdrew because of adverse events related to the drug (palmar-plantar erythrodysesthesia [PPE], n = 3; asthenia, n = 2; cardiac, n = 2; neutropenia, n = 1; stomatitis, n = 1; and edema, n = 1). There were no drug-related fatal events. There were only eight grade 4 adverse events attributable to the drug. Stomatitis, PPE, and skin lesions were managed with dose reductions and delays in most cases.

CONCLUSION

Stealth liposomal doxorubicin has activity in refractory epithelial ovarian cancer. PPE and stomatitis can usually be managed by dose adjustment. The ease of administration makes this an attractive agent.

Expectations about alternative therapies and women with gynecological cancer

Women with gynecological cancers are exploring and using 'alternative medicine(s)', as are other cancer patients and much of Western society. On behalf of their patients, physicians must understand something of its history, terms, types, who uses it and why and where to find answers, as well as being prepared to open and engage in dialogue about alternative medicine with their patients.

Absence of estrogen and progesterone receptors in glassy cell carcinoma of the cervix

OBJECTIVE

To evaluate the estrogen and progesterone receptor status of glassy cell carcinoma of the cervix to assess the possible implications of hormone replacement therapy in these patients.

METHODS

The estrogen and progesterone receptor status of 13 glassy cell carcinomas was evaluated by immunohistochemistry using commercial monoclonal antibodies and a streptavidin-biotin detection system.

RESULTS

No immunohistochemically detectable estrogen or progesterone receptor protein was present in tumor cells, although both receptors were identified in the adjacent normal cervical tissue.

CONCLUSION

The absence of estrogen and progesterone receptors in glassy cell carcinoma suggests that this tumor would not be hormonally responsive and that these patients can be safely treated with hormone replacement therapy. Further studies are indicated to confirm this observation.

S-Phase fraction, p53, and HER-2/neu status as predictors of nodal metastasis in early vulvar cancer

OBJECTIVE

Our aim was to determine the value of the S-phase fraction, p53, and HER-2/neu status as predictors of inguinal nodal metastasis in early vulvar cancer.

METHODS

The charts of 100 consecutive patients with invasive squamous cell cancer of the vulva were reviewed and a cohort of patients with clinical stage I or II disease treated primarily with radical surgery and inguinal node dissection was identified. Within this cohort, all node-positive patients were matched with node-negative controls by depth of invasion. Tumor from the 13 node-positive patients and 26 controls was then analyzed by flow cytometry and immunohistochemistry.

RESULTS

The median value of the S-phase fraction was higher in tumor from patients with inguinal nodal metastasis (median, 18.2; 25th-75th percentile: 13.9-28.3) than in node-negative patients (median, 8.9; 25th-75th percentile: 5.4-15.6) (P = 0.01). The presence of the HER-2/neu immunopositivity was also found to be associated with nodal metastasis (OR 4.05, 95% CI 1.0-16.6), but we found no evidence that DNA index or the presence of p53 immunopositivity was associated with nodal metastasis.

CONCLUSION

Early vulvar cancer patients with inguinal node metastasis have a significantly higher S-phase fraction and are more likely to have HER-2/neu immunopositivity when compared to those without nodal metastasis.

Prognostic value of clinical variables in ovarian cancer

OBJECTIVE

To test the hypothesis that clinical variables, including the patient's symptoms, symptom severity, and co-morbidity, affect the survival rate in patients with ovarian cancer.

METHODS

We reviewed the records of 137 cases of ovarian cancer diagnosed and treated between January 1987 and June 1992, and extracted data regarding patients' demographic characteristics, symptoms, medical co-morbidity, stage of disease, tumor histology and grade, treatment, and clinical course.

RESULTS

Once cases of borderline tumors were excluded, the overall 3-year and 4-year mortality rate were 38% and 49%, respectively. There was an decrease in 4-year survival with more advanced symptom type ranging from 85% in asymptomatic women to 38% in women with complex symptoms (log rank, p = 0.005). Medical co-morbidity was not found to affect survival in the cohort studied. We performed multivariable analysis using a Cox proportional hazards model and confirmed that the symptom stage was highly prognostic even after controlling for FIGO stage, age and co-morbidity (p = 0.004).

CONCLUSION

We found that clinical variables such as patient's symptoms, were associated with prognosis. Symptom classification is a necessary and important component in a system of prognostic stratification for ovarian cancer.

Synchronous endometrioid tumors of the ovary and endometrium. A clinicopathologic study of 22 cases

OBJECTIVE

To analyze a group of 22 patients with synchronous endometrioid tumors of the ovary and endometrium.

STUDY DESIGN

A retrospective chart review was undertaken and information collected on patient age, parity, tumor grade and stage, presence of coexisting endometriosis and survival. Flow cytometry was determined from archival samples of the endometrial and ovarian tumors.

RESULTS

The mean age at diagnosis was 52.8 years (range 36-71); mean parity was 1.05. With regard to the endometrial component, 68.2% were grade 1, 63.6% were stage I and, by flow cytometry, 62.5% were aneuploid. With regard to the ovarian lesions, 68.2% were grade 1, 68.2% were stage I, and 71.4% were aneuploid by flow cytometry. Twelve (54.5%) of 22 patients had pathologic evidence of coexisting endometriosis. Overall, three-year survival was 75%. All 11 patients with stage I disease at both sites were alive, without disease, at a mean follow-up of 34.9 months.

CONCLUSION

Patients with synchronous endometrioid tumors of the endometrium and ovary are generally younger than reported for either endometrial adenocarcinomas or ovarian epithelial adenocarcinomas. They tend to be low grade and early stage and are frequently associated with endometriosis. Our data suggest that the survival of patients with synchronous primaries correlates with the stage of the individual tumors and that a second, synchronous primary does not adversely affect prognosis.

Malignant mixed mesodermal tumors of the ovary

OBJECTIVE

To review the experience at Women & Infants Hospital and Hartford Hospital of patients with malignant mixed mesodermal tumors of the ovary, and to review the pertinent literature.

METHODS

Fourteen cases of malignant mixed mesodermal tumors of the ovary at the two hospitals over a 5-year period were identified through their tumor registries. Demographic data, pathology, treatment, and survival rates were reviewed.

RESULTS

The median survival of the patients in our series was 7 months, with 64% dead of disease in 1 year. A review of the pertinent literature indicated median survivals of 6-12 months, with more than 70% of the patients dead of disease at 1 year, despite treatment.

CONCLUSION

Further investigation is needed to determine the proper management for malignant mixed mesodermal tumors of the ovary. Meanwhile, current treatment strategies should recognize the present therapeutic limitations, so as not to diminish any further the quality of life for women with this malignancy.

Pelvic endometriosis mimicking advanced ovarian cancer: presentation with pleural effusion, ascites, and elevated serum CA 125 level

Two patients with clinical complications of endometriosis mimicking stage IV epithelial ovarian cancer are described. One had bilateral pleural effusions, ascites, and a serum CA 125 level of 440 U/ml. The other had a right-sided pleural effusion and a large abdominal mass.

The effects of a course in cadaver dissection on resident knowledge of pelvic anatomy: an experimental study

OBJECTIVE

To determine whether a course in cadaver dissection can significantly increase resident knowledge of pelvic anatomy beyond that of current educational practices.

METHODS

Thirteen first- and second-year residents were randomly assigned to a cadaver dissection course (seven) or a control group (six). The dissection group performed dissections with instruction, using a dissection guide designed specifically for the course. The control group received study references on pelvic anatomy and protected study time. Each participant took a practical and written examination at the beginning and end of the study.

RESULTS

The two groups did not differ statistically in their scores on the pre-test. Both groups improved on the post-test, but the dissection group scored nearly 50% higher on the test than did the controls. The two groups differed significantly on the post-test, adjusted for pre-test performance (P < .01). In their evaluation of the course, participants from the dissection group emphasized its educational value and urged that it be offered to residents as a regular part of their training.

CONCLUSION

Dissection of a human cadaver provides a valuable experience, allowing participants to gain a greater understanding of surgical anatomy and surgical procedures in a no-risk, unhurried setting. Residents who participated in a cadaver dissection course designed specifically for their needs showed a statistically significant increase in knowledge compared with those without this experience. Both objectively and subjectively, a cadaver dissection course is an excellent tool for instructing gynecology residents.

Tumor angiogenesis as a prognostic factor in cervical carcinoma

Angiogenesis, the induction of new capillaries and venules, has been associated with tumor growth. Increased tumor size and new vessel growth may further the opportunity for tumor cells to enter the circulation and potentiate metastatic disease. To investigate if tumor angiogenesis could serve as a prognostic factor in cervical carcinoma, we counted microvessels (capillaries and venules) in 29 patients with squamous cell carcinoma of the cervix. Surgical specimens were stained for endothelial cells specifically with Factor VIII to identify all vessels. The microvessels were counted by light microscopy (per 200 x field) in tumor sections with the highest population of microvessels. This was performed by two investigators without knowledge of patient outcome or extent of disease. Microvessel counts in patients with squamous cell carcinoma were significantly different from those of control subjects: 56 +/- 28.9 and 16.3 +/- 3.3 (P = 0.013). There was no correlation between microvessel count and node status, parametrial involvement, depth of invasion, or gross disease. Microvessel count was significantly correlated with vascular space involvement (P = 0.017). Four patients who developed recurrent disease within 1 year had high microvessel counts and yet were node negative and VSI negative at surgery. As shown by Folkman in breast cancer, angiogenesis may also be an independent predictor for recurrent disease in squamous cell carcinoma of the cervix. Microvessel counts could be of prognostic value in patients who do not have other risk factors for disease recurrence.

Endometriosis with myxoid change. A case simulating pseudomyxoma peritonei

After a diagnosis of endocervical adenocarcinoma was made on examination of a curettage specimen, a 46-year-old woman underwent laparotomy for the purpose of radical hysterectomy. After frozen section of a biopsy specimen obtained from a nodule 2 cm in diameter on the posterior surface of the cervix was interpreted as adenocarcinoma, consistent with pseudomyxoma peritonei, the planned hysterectomy was abandoned; only biopsies of the pelvic and para-aortic lymph nodes and a bilateral salpingo-oophorectomy were performed. Permanent sections of the nodule revealed pools of almost acellular mucin, myxoid fibrous tissue, and typical endometriotic glands and stroma. Similar findings were associated with endometriotic foci in the serosa of a fallopian tube and adjacent to a pelvic lymph node. There was no evidence of adenocarcinoma in any of the specimens. A radical hysterectomy was performed subsequently, and pathological examination of the uterus revealed a superficially invasive adenocarcinoma of the cervix without evidence of extrauterine spread. The diagnosis of endometriosis associated with myxoid change was confirmed in residual cul-de-sac tissue. The patient was alive with no clinical evidence of tumor 6.5 years later. This case illustrates that rare cases of endometriosis can be associated with striking degrees of myxoid change, a finding that should not be confused with mucinous adenocarcinoma on microscopic examination.

Persistence of gestational trophoblastic disease for longer than 1 year following evacuation of hydatidiform mole

BACKGROUND

A spontaneous fall in the radioimmunoassay for the beta subunit of hCG to less than 2 mIU/mL documents regression of hydatidiform mole following evacuation of a molar pregnancy. Continued negative hCG levels for the year after evacuation indicates the absence of risk for persistent gestational trophoblastic disease. This report describes an unusual case of recurrent nonmetastatic gestational trophoblastic disease 16 months after initial evacuation.

CASE

A 29-year-old woman presented at 19 weeks' gestation with severe preeclampsia and vaginal bleeding. Pelvic ultrasonography demonstrated a molar pregnancy. Pathology following uterine evacuation confirmed a hydatidiform mole. Serial hCG levels fell progressively to less than 2 mIU/mL over the following 25 weeks. She remained compliant with oral contraceptive pills despite having no sexual activity. Sixteen months after uterine evacuation, recurrence of gestational trophoblastic disease was documented by a rising beta-hCG, negative pelvic ultrasound, normal liver function tests, and normal computed tomography of the head. Endometrial curettage showed no chorionic villi or molar tissue. She was treated with five courses of actinomycin D and has remained disease-free for the following 5 years.

CONCLUSION

This late recurrence of gestational trophoblastic disease suggests that those with a molar pregnancy may benefit from surveillance beyond 1 year after uterine evacuation.

Lower limb ischemic venous thrombosis in patients with advanced ovarian carcinoma

Three cases of lower limb, deep venous thrombosis that progressed to ischemia in patients with advanced ovarian cancer are reported. One patient developed frank gangrene of the extremity. Venous stasis, secondary to venous compression from metastatic disease, was the predisposing factor in all cases. Heparin therapy was uniformly unsuccessful in halting progression of thrombosis. Ischemic thrombosis originating from extrinsic venous compression is unlikely to respond to conventional therapy alone. Local external radiation to metastatic sites, given early and possibly in conjunction with conventional treatment methods, may achieve a clinical response by causing a reduction in tumor size and thus relief of venous compression.

An ectopic pregnancy in the upper retroperitoneum following in vitro fertilization and embryo transfer

Thirty-seven days after successful embryo transfer, a chorionic vesicle was recovered from the upper abdominal retroperitoneal space in a patient presenting with an acute life-threatening hemorrhage. This is the first case report of a retroperitoneal ectopic pregnancy which, although uncommon, is a potentially fatal complication of in vitro fertilization-embryo transfer.

Leiomyosarcoma of the small intestine presenting as a pelvic mass: four cases

Four patients with leiomyosarcoma of the small intestine who presented with a pelvic mass are reviewed. The tumors had clinical and radiographic features resembling ovarian neoplasms. These patients develop sizable tumors and, yet, have relatively few symptoms which would necessarily direct the physician to the intestine as the site of origin. The clinicopathologic features and management of these tumors are reviewed.

Use of the omental J flap for better delivery of radiotherapy to the pelvis

The surgically created omental J flap (or synthetic equivalents) can facilitate radiation therapy, particularly brachytherapy, in which adhesions of the pelvis would otherwise limit its value. The J flap used in this role has an occasional place in the management of patients with carcinoma and exemplifies how surgical procedures and irradiation can be combined for more effective treatment of carcinomas.

Ultrasound for diagnosing and preventing malplacement of intrauterine tandems

Postoperative B-mode ultrasound was used to evaluate final tandem position in 50 consecutive placements (28 patients). In 34% (17 of 50), the tandem was found to be suboptimally positioned; in 24% (12 of 50), it penetrated the myometrium; and in 10% (five of 50), it frankly perforated the uterus. The uterine fundus was the region most commonly perforated, and the anterior myometrium was the site most frequently penetrated. In all cases in which postoperative ultrasound showed malpositioning, the clinical and radiographic assessment indicated proper intracavitary placement. Ultrasound affected clinical management in 42% (21 of 50) of the placements involving 61% (17 of 28) of the patients. To improve tandem placement, we used intraoperative real-time ultrasound to guide 73 consecutive surgical insertions. Ultrasound clearly visualized the procedure, allowing tandems to be positioned with confidence even in the most difficult cases. The immediate feedback from intraoperative ultrasound eliminated malplacements and thus the need for a second anesthesia to reposition the tandem.

Intraoperative real-time ultrasonography during intrauterine tandem placement

Real-time ultrasound is used in the operating room as an aid in the placement of the intrauterine tandem. This method provides excellent imaging of the ongoing procedure, facilitating final tandem placement in the endometrial cavity even in the most difficult case.

The value of endocervical curettage as part of the standard colposcopic evaluation

Whether to perform endocervical curettage (ECC) as part of a routine colposcopic examination in patients with an abnormal Papanicolaou smear remains controversial. Some studies consider ECC an essential part of a colposcopic examination regardless of the level of the squamocolumnar junction (SCJ); others consider it superfluous in cases where the SCJ can be visualized. Between January 1980 and December 1982, 278 new patients with abnormal Papanicolaou smears underwent colposcopy. Directed biopsies established the degree of cervical intraepithelial neoplasia (CIN) and ruled out invasive disease. ECC was done on every patient. A total of 51 patients (18%) had a positive ECC. Seven patients could not be evaluated because their records were incomplete. Of the 44 evaluable patients, 32 (73%) had satisfactory colposcopy. In the remaining 12 (27%) the upper limit of the transformation zone could not be seen clearly; in that group the degrees of CIN on colposcopic biopsy and ECC were in agreement in two cases; ECC revealed the degree to be less severe in four cases and more severe in six (50%). In the group with satisfactory examinations, 15 had the same degree of CIN on colposcopic biopsy and ECC; ten had less severe and seven (22%), more severe degrees of CIN on ECC. Of greatest clinical importance was that, overall, 11.5% had a positive ECC despite a satisfactory colposcopic examination. This study indicated that ECC provides unique and important information, justifying its inclusion as part of the standard evaluation of every patient undergoing colposcopy for abnormal cervical cytology.