To peritonealise or not to peritonealise? A randomised trial at abdominal hysterectomy in Iran

We conducted a trial to determine whether non-closure of the visceral and parietal peritoneum alters the intraoperative or post-operative course at abdominal hysterectomy. This was a parallel-group double-blind randomised controlled trial was performed on 66 women who underwent abdominal hysterectomy with or without salpingo-oophorectomy. Twenty-seven were allocated to the control 'closed' group and 39 women to the study 'open' group. The main outcome measures were operative time, estimated blood loss, postoperative pain assessed by visual analogue scale and amount of postoperative analgesia. The study was conducted in the Department of Gynecological Oncology in a university teaching hospital. The operative time was shorter (P < 0.05) and the time to ambulation without assistance was significantly shorter in study group. There were no difference in postoperative pain, blood loss, amount of postoperative analgesia and antibiotics in the two groups. Peritoneal closure at abdominal hysterectomy provides no immediate postoperative benefits while unnecessarily lengthening surgical time and anaesthesia exposure. We suggest that the traditional practice of visceral and parietal closure be abolished at abdominal hysterectomy.

Topotecan in squamous cell carcinoma of the cervix: A Phase II study of the Gynecologic Oncology Group

PURPOSE

The activity and toxicity of topotecan were evaluated in a multicenter Phase II study for patients with previously treated squamous cell carcinoma of the uterine cervix.

PATIENTS AND METHODS

Histologic confirmation of the primary diagnosis was required, as well as adequate performance status and vital organ function and the presence of measurable disease. Patients were allowed one prior regimen of systemic therapy, usually platinum-based. A two-stage accrual design was utilized with early stopping criteria and monitoring of toxicity. Topotecan was administered at 1.5 mg/m(2) per day for 5 consecutive days on a 21-day cycle with modifications based on hematologic toxicity.

RESULTS

Forty-five patients were entered. Two patients were ineligible (incorrect tumor type) and 2 were inevaluable (never received therapy). One additional patient was not evaluable for response (nonmeasurable disease). A median of 2 cycles was administered to each patient (range: 1-17 cycles) with grade 4 neutropenia in 68% and grade 4 thrombocytopenia in 39% of patients, but without treatment-related deaths. Nonhematologic toxicity was generally mild and not dose-limiting. The overall (complete and partial) response rate among evaluable patients with measurable disease was 12.5% with stable disease in an additional 37. 5%. Median progression-free survival was 2.1 months.

CONCLUSIONS

As a single agent topotecan shows modest antitumor activity, with manageable hematologic and nonhematologic toxicity, in patients with previously treated squamous cell carcinoma of the cervix. Further evaluation in chemotherapy-naive patients or in combination with cisplatin and/or radiation may be indicated.

Phase II evaluation of 24-h continuous infusion topotecan in recurrent, potentially platinum-sensitive ovarian cancer: A Gynecologic Oncology Group study

OBJECTIVES

The aim of this study was to develop an alternative effective and more convenient administration schedule for intravenous topotecan when used as palliative treatment in ovarian cancer.

METHODS

The Gynecologic Oncology Group conducted a Phase II trial of 24-h infusional topotecan (8.5 mg/m(2)) with treatment repeated every 3 weeks in 29 patients with platinum-sensitive recurrent ovarian cancer (prior response to platinum-based chemotherapy with a minimum treatment-free interval >/=6 months).

RESULTS

The major toxicities of therapy were grade 4 neutropenia and thrombocytopenia which developed in 86 and 14% of patients, respectively. Other severe side effects were uncommon. Only 2 partial responses (7%) were observed in the 28 patients evaluable for response.

CONCLUSIONS

Despite the relatively favorable ovarian cancer patient population treated in this trial (platinum-sensitive recurrent disease), the response rate was disappointingly low. Considering the three- to fivefold higher objective response rates observed in other trials employing topotecan in individuals with platinum-sensitive ovarian cancer utilizing a 5-day treatment program (delivered every 3 weeks), the results of the current study provide strong support for the conclusion that clinically relevant antineoplastic activity of this agent is highly schedule dependent.

Intraperitoneal alpha-interferon alternating with cisplatin in residual ovarian carcinoma: a phase II Gynecologic Oncology Group study

OBJECTIVE

The aim of this study was to study the combination of intraperitoneal alpha-interferon and cisplatin administered second-line in an alternating sequence in small volume residual epithelial ovarian cancer after second-look surgery and the activity of this combination based on prior response to first-line platinum compounds.

METHODS

Sixty-two patients with minimal residual (<0.5 cm) epithelial ovarian cancer at reassessment laparotomy were entered into a multicenter trial of intraperitoneal alpha-interferon alternating with cisplatin given for eight cycles unless disease progression or unacceptable toxicity occurred. The patients were considered favorable if they were platinum-sensitive and/or relapsed 6 months or longer after completing treatment. Another reassessment laparotomy was performed within 12 weeks of completion of treatment in patients who were in clinical remission.

RESULTS

Fifty-four patients were clinically evaluable and 18 were surgically reassessed, 5 of whom had a negative reassessment operation (20% complete response and 8% partial response). Of the 54 patients evaluable for toxicity, the most common adverse effects of more than grade 2 were gastrointestinal in 13 (47%), neutropenia in 9 (17%), and leukopenia in 6 (12%). Grade 4 toxicity was seen in 10 instances: 4 gastrointestinal, 2 neutropenia, 2 thrombocytopenia, 1 wound infection, and 1 allergic reaction.

CONCLUSIONS

alpha-Interferon and cisplatin are active agents in favorable patients with minimal residual epithelial ovarian cancer at second-look. The combination of the two drugs administered in an alternating sequence appears to be associated with more side effects than when either drug is administered alone. The combination produced response rates similar to those seen when either drug is given alone.

Phase II trial of intraperitoneal paclitaxel in carcinoma of the ovary, tube, and peritoneum: a Gynecologic Oncology Group Study

PURPOSE

To determine the response rate of intraperitoneal (i.p.) paclitaxel in patients with small-volume residual carcinomas of the ovary, fallopian tube, or peritoneum.

PATIENTS AND METHODS

Eligibility criteria included patients with one of the cancers noted above, with the largest residual disease 0.5 cm or less in maximum diameter at the end of second-look surgery, and prior treatment with systemic paclitaxel was permitted. The treatment plan was paclitaxel 60 mg/m2 i.p. weekly for 16 weeks, followed by surgical evaluation in patients without evidence of disease progression.

RESULTS

Of 80 patients entered onto the study, 76 were eligible, of whom 86% were considered to be potentially cisplatin-sensitive. Although five patients (7%) did not complete the first course of therapy because of catheter leakage or blockade, 53 patients (70%) received all 16 planned courses. Only 14 patients (18%) received fewer than 11 courses. Treatment was well tolerated, which included only moderate abdominal pain (grade 2, 12 patients; grade 3, one patient) and minimal neutropenia (grade 2, three patients; grade 3, one patient). Of 28 assessable patients with microscopic disease at the start of i.p. therapy, 17 patients (61%) achieved a surgically defined complete response (CR). Only one of 31 patients (3%) with any macroscopic disease achieved a CR. Of the eligible patients, 18 of 76 (24%) achieved a CR.

CONCLUSION

Salvage i.p. paclitaxel is tolerable and active in patients with microscopic residual disease. The impact of this treatment strategy on survival remains to be assessed in a phase III trial.

Adjuvant therapy of ovarian germ cell tumors with cisplatin, etoposide, and bleomycin: a trial of the Gynecologic Oncology Group

PURPOSE

This study was performed to determine the effectiveness of postoperative adjuvant chemotherapy in patients with surgically resected ovarian germ cell tumors.

PATIENTS AND METHODS

After tumor removal and thorough surgical staging, patients were enrolled on this study and treated with three courses of cisplatin, etoposide, and bleomycin (BEP). Reassessment laparotomy was required of consenting, appropriate patients initially, but became an optional procedure in 1989.

RESULTS

Of 93 patients assessable on this trial, 89 are continuously free of germ cell cancer. At second-look laparotomy, two other patients were found to have small foci of immature teratoma; both remain clinically free of recurrence. One received subsequent alternate chemotherapy and one did not. Thus, 91 of 93 patients are currently free of germ cell cancer. Follow-up duration ranges from 4.0 to 90.3 months, with 67 patients monitored for longer than 2 years. Acute toxicity was moderate. One patient developed acute myelomonocytic leukemia 22 months after diagnosis. Another patient was noted to have a malignant lymphoma 69 months after protocol treatment.

CONCLUSION

Three courses of BEP will nearly always prevent recurrence in well-staged patients with completely resected ovarian germ cell tumors and should be given to all such patients. The development of acute leukemia as a complication of treatment is disturbing and mandates careful long-term follow-up, but is unusual and does not alter the risk-to-benefit ratio of treatment.

A phase II trial of tricyclic nucleoside phosphate in patients with advanced squamous cell carcinoma of the cervix. A Gynecologic Oncology Group Study

A Phase II trial of TCN-P was conducted in metastatic or recurrent squamous cell carcinoma of the cervix using a 5-day continuous infusion schedule. The starting dose was 35 mg/m2 x 5 days and courses were repeated every 6 weeks. Among 21 evaluable patients, 2 responses were observed. One patient had a complete response for 19+ months. Another patient had a partial response for 5+ months, but developed symptomatic hypocalcemia, requiring discontinuation of the drug. Using this dose and schedule TCN-P appears to have limited activity in metastatic or recurrent squamous cell cancer of the cervix.

Echinomycin (NSC 526417) in recurrent and metastatic nonsquamous cell carcinoma of the cervix. A phase II trial of the Gynecologic Oncology Group

Eighteen evaluable patients with recurrent or metastatic nonsquamous carcinoma of the uterine cervix were treated with 1,500 micrograms/m2 of echinomycin every 4 weeks. Seven patients had received prior chemotherapy. There was one complete response (5.6%), 95% confidence interval for response of 0-27%. The major toxicity was nausea and vomiting, which was moderate to severe in eight patients. Myelosuppression was minimal. Echinomycin in this dose and schedule displays minimal activity in patients with advanced nonsquamous carcinoma of the cervix.

Peritoneal cytology of uncommon ovarian tumors

Peritoneal cytology has been well established as a diagnostic and staging tool in the management of the common epithelial tumors of ovary. Germ cell, mesenchymal, and sex-cord stromal tumors are much less frequently encountered in peritoneal specimens, often with cytologic features that may pose problems in differential diagnosis. This report presents the cytomorphology of the ascitic fluid in cases of endodermal sinus tumor, dysgerminoma, and Sertoli-Leydig-cell tumor, and peritoneal washings in a case of ovarian malignant mixed mullerian tumor. The cytologic features of Sertoli-Leydig-cell tumors have not been well described. Careful correlation of peritoneal cytologic findings, cell-block preparations, and immunocytochemistry with the cytohistologic features of these tumors is crucial for correct tumor classification.

Telephone counseling improves adherence to colposcopy among lower-income minority women

PURPOSE

A randomized trial was conducted to evaluate the impact of a telephone counseling intervention to improve patient adherence to colposcopic examination for suspected cervical intraepithelial neoplasia (CIN).

METHODS

Subjects were lower-income, minority women who missed a scheduled initial appointment for colposcopy at an urban medical clinic. Patients were randomly assigned to either a control condition (n = 42) or a telephone counseling condition (n = 48). The 15-minute, structured telephone counseling intervention protocol addressed educational, psychosocial, and practical barriers to colposcopy adherence.

RESULTS

The most common patient-reported barriers to colposcopy adherence included a lack of understanding of the purpose of colposcopy (50%), worry about or fear of cancer (25%), and forgetting (23%). Telephone counseling was found to be highly effective in addressing these barriers and improving adherence to diagnostic follow-up and treatment. Of patients in the control condition, 43% complied with a rescheduled colposcopy appointment, compared with 67% in the telephone counseling condition. Logistic regression analysis indicated that the effect of telephone counseling was independent of sociodemographic confounder variables (odds ratio = 2.6; P less than .003). Additionally, 74% of patients who received the initial telephone counseling adhered to recommended treatment, compared with 53% of patients in the control condition.

CONCLUSION

Brief, structured telephone contact may be a cost-effective mechanism for improving adherence to diagnostic follow-up and treatment for a variety of cancer screening tests.

Mesonephric rest hyperplasia. A potential diagnostic pitfall

A case of mesonephric rest hyperplasia, an incidental finding in the hysterectomy specimen of a 48-year-old woman, was initially misdiagnosed as a well-differentiated cervical adenocarcinoma. We highlight the histologic, histochemical, and immunohistochemical features of this potential diagnostic pitfall and review the relevant literature.

Adverse psychologic consequences of positive cytologic cervical screening

Cervical cancer is still widely prevalent in the female population. This study explores the relationship of cervical cancer screening, positive versus negative Papanicolaou's test results, and psychologic status among lower-income minority women. All patients were interviewed 3 months after they had received initial test results. One hundred six women with normal Papanicolaou's test results were compared with 118 women who were referred for colposcopic examination for follow-up of positive test results. Women with positive Papanicolaou's-test results showed statistically significant elevations in worries about cancer and impairments in mood, daily activities, sexual interest, and sleep patterns. More fine-grained analyses revealed that the effects of positive results were most pronounced among those women who did not comply with colposcopy (n = 53). These findings suggest that lack of compliance with follow-up may maintain high levels of uncertainty about disease and may interfere with successful psychologic adaptation. Health education targeted to psychologically vulnerable individuals may reduce psychologic distress and enhance compliance.

A phase II trial of gallium nitrate (NSC #15200) in advanced or recurrent squamous cell carcinoma of the cervix. A Gynecologic Oncology Group study

Twenty-four evaluable patients with advanced, persistent or recurrent squamous cell carcinoma of the cervix were treated with 750 mg/m2 of gallium nitrate (NSC #15200) every three weeks. No patient had prior cytotoxic chemotherapy. Two patients had a partial response (8.3%), ten patients had stable disease (41.7%), and twelve (50%) had increasing disease. The 95% upper confidence bound for response is 24.0%. The major toxicities were nausea, vomiting and anemia. Gallium nitrate has minimal activity in patients with previously untreated squamous cell carcinoma of the cervix.

Phase II trial of vinblastine in advanced ovarian carcinoma. A Gynecologic Oncology Group study

A phase II trial of vinblastine in patients with refractory epithelial ovarian adenocarcinoma of the ovary was conducted by the Gynecologic Oncology Group (GOG) between March 9, 1988 and July 7, 1988. Vinblastine was administered in a dose of 9 mg/m2 intravenously every three weeks until disease progression or toxicity supervened. Twenty patients were entered initially. One was ineligible due to a previous primary cancer. Thus, 19 patients are evaluable for toxicity and response. All patients had cisplatin-combination chemotherapy and four had prior radiotherapy. Median age was 63 years (range 40-75 years). Thirteen patients had disease in the pelvis and six had extrapelvic metastases. Ten patients had grade 3 lesions and seven had grade 2. A median of two courses (range: 1-6) were administered. Toxicity was moderate. Seven patients (36.8%) experienced GOG grade 3 or 4 leukocytopenia and six had grade 3 or 4 granulocytopenia. Median nadir WBC was 2,000 cells/microliters (range 600-3,500) and platelet nadirs for the three patients with thrombocytopenia were 60,000, 116,000, and 147,000. Other toxicity included grade 3 gastrointestinal and renal toxicity in one patient each. Seven patients (36.8%) had stable disease on therapy and 12 had increasing disease. No responses were observed. Vinblastine in this dose and schedule is inactive in patients with resistant epithelial ovarian adenocarcinoma progressing on first-line chemotherapy.

Intraepithelial neoplasia of the lower genital tract

The incidence of CIN, VIN, and VAIN has increased dramatically in recent years due to a true increase in disease incidence as well as improved screening methods. Associated high-risk factors in the development of intraepithelial neoplasia are known, and effective treatment modalities are available. With the use of diagnostic techniques, patient education, and selection and utilization of appropriate therapies, intraepithelial neoplasia of the lower genital tract remains a disease that should not affect long-term morbidity, social status, or mortality of female patients.

A phase II evaluation of cisplatin and 5-fluorouracil in patients with advanced squamous cell carcinoma of the cervix: a Gynecologic Oncology Group Study

Cisplatin is one of the most active single agents in advanced squamous cell carcinoma of the cervix and is synergistic with 5-fluorouracil in the laboratory. The Gynecologic Oncology Group has conducted a phase II trial in which cisplatin at 50 mg/ml2 given intravenously on Day 1 was combined with 5-fluorouracil 1000 mg/m2 daily given as a 24-hr infusion on Days 1-5. Treatment was repeated every 21 days. Fifty-five patients were treated with this regimen, resulting in seven complete remissions (12.7%) and five partial remissions (9.1%). The median survival was 6.4 months. Toxic effects of grade 2 or greater were leukopenia in 10 patients (18.2%), thrombocytopenia in 2 patients (3.6%), gastrointestinal effects in 25 patients (45.5%), and renal effects in 1 patient (1.8%). On the basis of these results, the cisplatin and 5-fluorouracil regimen does not appear to have any advantage over cisplatin alone in advanced cervical cancer.

Hexamethylmelamine as first-line chemotherapy in the treatment of advanced or recurrent carcinoma of the endometrium: a phase II trial of the Gynecologic Oncology Group

Thirty-eight patients with advanced or recurrent carcinoma of the endometrium who had received no prior chemotherapy were placed on study by the Gynecologic Oncology Group. One was deemed histologically ineligible. Three patients had insufficient trials to evaluate response. Of the remaining 34 who received hexamethylmelamine 280 mg/m2 orally daily on Days 1 through 14 of each 4-week course, there were only three objective responses, two complete and one partial. Although toxicity was tolerable, hexamethylmelamine has minimal activity in advanced or recurrent endometrial carcinoma at the dose and schedule tested.

Detection of human ovarian tumor-associated antigens by antibodies isolated from ovarian carcinoma ascitic fluid

Ascitic fluid from patients with ovarian epithelial cancer contains large amounts of soluble immune complexes and is a potential source of antibodies and antigens associated with the tumor. The antibodies against tumor-associated antigens were purified from the ascitic fluids of patients with ovarian serous cystadenocarcinoma. These antibodies showed specificity toward ovarian epithelial cancer when tested against ovarian tumor cell lines and paraffin-embedded tissue sections of ovarian cancer. The antigens in sera of patients were separated from IgG and IgG complexes by affinity chromatography and the free antigens were isolated. With the antibodies purified from ascitic fluid, the levels of tumor-associated antigens in sera of 10 patients with serous cystadenocarcinoma and 12 control patients were detected by an enzyme-linked immunosorbent assay. The antigens in patients with ovarian epithelial cancer were 2 to 10 times higher than those in control patients. These studies demonstrate that the antibodies isolated from ascitic fluid detect the tumor-associated antigens on tumor cells as well as the shed antigens present in serum.

Detection of human ovarian tumor-associated antigens by sandwich enzyme immunoassay

Immunoglobulin G (IgG) complexes were isolated from the ascitic fluids of patients with serous cystadenocarcinoma of the ovaries, and antiserum against the IgG complexes was raised in rabbits. The antibodies reacting with the tumor-associated antigens were purified after the rabbit antihuman IgG was removed by affinity chromatography on IgG coupled to agarose. The purified antibodies recognized antigens on two human ovarian cell lines and several fresh ovarian tumor specimens, but did not react with nongynecologic tumors. The purified antibodies (IgG) were labeled with alkaline phosphatase, and a noncompetitive enzyme immunoassay was developed to detect the tumor-associated antigens in the sera of patients with ovarian cancer. The levels of tumor-associated antigens detected by this assay were found to be two to four times higher in patients with ovarian cancer than in controls. Levels of tumor-associated antigens were higher in patients with high levels of CA 125, although a direct correlation was not observed with the levels of CA 125 in these patients.

Biopsy of the scalene fat pad in carcinoma of the cervix uteri metastatic to the periaortic lymph nodes

Fifty-five patients with squamous cell carcinoma of the cervix uteri metastatic to high common iliac or periaortic lymph nodes underwent biopsy of the left scalene fat pad as part of a prospective clinical trial. Patients without metastasis to the scalene nodes were subsequently treated with extended field radiation therapy and were then eligible for a randomized trial of systemic chemotherapy. Only four patients were found to have micrometastases to the scalene fossa. This figure is appreciably lower than that reported in previous literature. While geographic failure continues to be a problem for this group of patients, routine use of left scalene fat pad biopsy before treatment is not recommended.

Psammoma bodies in neuroendocrine carcinoma of the uterine cervix

A case of neuroendocrine carcinoma of the uterine cervix with focal papillary clusters and psammoma bodies, features not previously seen in this tumor, is documented. Papanicolaou-stained cervicovaginal smears and pelvic washings are correlated with tissue sections of endocervical curettage, hysterectomy and cul-de-sac biopsy specimens. Although there was some variation in the cytologic features, the tumor cells were generally distinguished by nuclear molding, indistinct nucleoli, finely granular chromatin and scant cytoplasm. Argyrophil-positive intracytoplasmic granules were identified in tissue sections of the tumor. These granules were positive for ACTH and neuron-specific enolase using the immunoperoxidase technique. Ultrastructural studies were consistent with these findings. Neuroendocrine carcinoma of the cervix is therefore a cytologically distinctive tumor in which psammoma bodies may occur.

Secretion of a 97 kilodalton glycoprotein by primary cultures of human ovarian epithelial tumor cells

The epithelial cells from both control and neoplastic ovaries were grown as primary cultures. The outgrowth of epithelial cells occurred within 3-5 days and the cells formed essentially a monolayer culture covering more than 80% of the surface of the flask within 5 weeks. The incorporation of [3H]fucose into the glycoproteins secreted into the medium was measured in the cells grown for 4 weeks. The secretion of glycoproteins in the tumor cells was twice that of the control. Analysis of the glycoproteins in the medium showed that the ovarian epithelial tumor cells secreted predominantly a 97 kilodalton glycoprotein. The growth of fibroblasts could be inhibited in these cultures by using Falcon Primaria culture flasks and the growth medium containing D-valine.