Adjuvant chemotherapy vs radiotherapy in high-risk endometrial carcinoma: results of a randomised trial

Patients with high-risk endometrial carcinoma (stage IcG3, IIG3 with myometrial invasion >50%, and III) receive adjuvant therapy after surgery but it is not clear whether radiotherapy (RT) or chemotherapy (CT) is better. We randomly assigned 345 patients with high-risk endometrial carcinoma to adjuvant CT (cisplatin (50 mg m⁻²), doxorubicin (45 mg m⁻²), cyclophosphamide (600 mg m⁻²) every 28 days for five cycles, or external RT (45–50 Gy on a 5 days week⁻¹ schedule). The primary end points were overall and progression-free survival. After a median follow-up of 95.5 months women in the CT group as compared with the RT group, had a no significant hazard ratio (HR) for death of 0.95 (95% confidence interval (CI), 0.66–1.36; P=0.77) and a nonsignificant HR for event of 0.88 (95% CI, 0.63–1.23; P=0.45). The 3, 5 and 7-year overall survivals were 78, 69 and 62% in the RT group and 76, 66 and 62% in the CT group. The 3, 5 and 7-year progression-free survivals were, respectively, 69, 63 and 56 and 68, 63 and 60%. Radiotherapy delayed local relapses and CT delayed metastases but these trends did not achieve statistical significance. Overall, both treatments were well tolerated. This trial failed to show any improvement in survival of patients treated with CT or the standard adjuvant radiation therapy. Randomised trials of pelvic RT combined with adjuvant cytotoxic therapy compared with RT alone are eagerly awaited.

An analysis of different approaches to ovarian cysts in Italy

The management of pelvic masses represent a rising problem due to the need to obtain an early diagnosis and treatment of ovarian cancers.

MATERIALS AND METHODS

In order to evaluate the clinical and surgical approach to ovarian cysts in Italy, we sent a multiple choice questionnaire to 214 members of the Italian Society of Gynecologic Oncology (SIOG) and to 230 members of the Italian Society of Gynecologic Endoscopy (SEGi). Ninety-six resulted evaluable.

RESULTS

Transabdominal and transvaginal ultrasound associated with CA125 determination represent the basis for the diagnosis, even if there is no univocal agreement on the ultrasound aspects that may define an ovarian cyst as doubtful. If an ovarian cyst, classified as suspicious, has been diagnosed in a postmenopausal woman, a wide range of therapeutic options have been reported: laparotomic hysterectomy and bilateral salpingo-oophorectomy represent the treatment of choice for 49% of SIOG members, whereas laparoscopic bilateral (45%) or monolateral (39%) salpingo-oophorectomy represents the standard for SEGi members. Ultrasound criteria to distinguish among benign or probably malignant or doubtful ovarian cysts, the treatment of an ovarian cyst during pregnancy, and the management of an unexpected intraoperative diagnosis of borderline ovarian neoplasia are discussed on the basis of answers received by SIOG and SEGi members.

Factors influencing survival in endometrial cancer relapsing patients: a Cooperation Task Force (CTF) study

The purpose of this study was to identify patterns of relapse and to determine the outcome of salvage treatment and the factors influencing survival of endometrial cancer relapsing patients. One thousand six hundred and six endometrial cancer (stages I to IV) patients treated at five Italian institutions were retrospectively reviewed. Of these, 209 (13%) subjects had recurred; the site of relapse was vagina in 35 cases (16.7%), pelvis in 67 (32.1%), and distant locations in 107 (51.2%). Most of the patients relapsed within 24 months: 45% (94) recurred within 1 year, 20.6% (43) between 1 and 2 years. Adjuvant radiotherapy (RT) seemed to reduce the percentage of pelvic recurrence in high risk early stages (IB-IIA) subjects and a higher proportion of patients failed at a distant site when postoperative external-beam pelvic RT was given. However survival curves were not statistically different in the two groups for stage IB endometrial cancer patients. Five and 10-year survival rates of patients with recurrent disease was 26% and 22%, respectively. Relapse of endometrial cancer is often early and at distant sites. Survival rate was related to site of relapse, disease-free interval, and postoperative treatment as independent prognostic variables. The site of relapse is the most important predictor of survival of patients with recurrent disease.

Factors influencing survival in endometrial cancer relapsing patients: a Cooperation Task Force (CTF) study

The purpose of this study was to identify patterns of relapse and to determine the outcome of salvage treatment and the factors influencing survival of endometrial cancer relapsing patients. One thousand six hundred and six endometrial cancer (stages I to IV) patients treated at five Italian institutions were retrospectively reviewed. Of these, 209 (13%) subjects had recurred; the site of relapse was vagina in 35 cases (16.7%), pelvis in 67 (32.1%), and distant locations in 107 (51.2%). Most of the patients relapsed within 24 months: 45% (94) recurred within 1 year, 20.6% (43) between 1 and 2 years. Adjuvant radiotherapy (RT) seemed to reduce the percentage of pelvic recurrence in high risk early stages (IB-IIA) subjects and a higher proportion of patients failed at a distant site when postoperative external-beam pelvic RT was given. However survival curves were not statistically different in the two groups for stage IB endometrial cancer patients. Five and 10-year survival rates of patients with recurrent disease was 26% and 22%, respectively. Relapse of endometrial cancer is often early and at distant sites. Survival rate was related to site of relapse, disease-free interval, and postoperative treatment as independent prognostic variables. The site of relapse is the most important predictor of survival of patients with recurrent disease.

Doxorubicin versus doxorubicin and cisplatin in endometrial carcinoma: definitive results of a randomised study (55872) by the EORTC Gynaecological Cancer Group

BACKGROUND

Combination chemotherapy yields better response rates which do not always lead to a survival advantage. The aim of this study was to investigate whether the reported differences in the efficacy and toxicity of monotherapy with doxorubicin (DOX) versus combination therapy with cisplatin (CDDP) in endometrial adenocarcinoma lead to significant advantage in favour of the combination.

PATIENTS AND METHODS

Eligible patients had histologically-proven advanced and/or recurrent endometrial adenocarcinoma and were chemo-naïve. Treatment consisted of either DOX 60 mg/m(2) alone or CDDP 50 mg/m2 added to DOX 60 mg/m2, every 4 weeks.

RESULTS

A total of 177 patients were entered and median follow-up is 7.1 years. The combination DOX-CDDP was more toxic than DOX alone. Haematological toxicity consisted mainly of white blood cell toxicity grade 3 and 4 (55% versus 30%). Non-haematological toxicity consisted mainly of grade 3 and 4 alopecia (72% versus 65%) and nausea/vomiting (36 % versus 12%). The combination DOX-CDDP provided a significantly higher response rate than single agent DOX (P <0.001). Thirty-nine patients (43%) responded on DOX-CDDP [13 complete responses (CRs) and 26 partial responses (PRs)], versus 15 patients (17%) on DOX alone (8 CR and 7 PR). The median overall survival (OS) was 9 months in the DOX-CDDP arm versus 7 months in the DOX alone arm (Wilcoxon P = 0.0654). Regression analysis showed that WHO performance status was statistically significant as a prognostic factor for survival, and stratifying for this factor, treatment effect reaches significance (hazard ratio = 1.46, 95% confidence interval 1.05-2.03, P = 0.024).

CONCLUSIONS

In comparison to single agent DOX, the combination of DOX-CDDP results in higher but acceptable toxicity. The response rate produced is significantly higher, and a modest survival benefit is achieved with this combination regimen, especially in patients with a good performance status.

The prognostic relevance of histological type in uterine sarcomas: a Cooperation Task Force (CTF) multivariate analysis of 249 cases

PURPOSE OF INVESTIGATION

The objective of this retrospective multicenter study was to assess the prognostic relevance of histologic type in uterine sarcomas.

METHODS

The hospital reports of 249 patients with uterine sarcomas were reviewed. Surgery was the initial therapy for all patients. Histologic type was leiomyosarcoma in 95 cases, low-grade endometrial stromal sarcoma (ESS) in 19, high-grade ESS in 34, and carcinosarcoma in 101. Postoperative treatment was given without well-defined protocols. Median follow-up of survivors was 97 months.

RESULTS

In the whole series 2-year, 5-year, and 10-year survival rates were 53.5%, 41.6%, and 35.8%, respectively, and median survival was 31 months. At univariate analysis survival was significantly related to stage (p = 0.0001), mitotic count (p = 0.0001), and histologic type (low-grade ESS vs leiomyosarcoma vs carcinosarcoma vs high-grade ESS, median: not reached vs 27 months vs 21 months vs 16.5 months, p = 0.0011), but not to postoperative therapy and patient age. The Cox model revealed that tumor stage, mitotic count and histologic type were independent prognostic variables for survival. In detail, the risk of death was significantly lower for low-grade ESS (risk ratio [RR] = 0.257; 95% confidence interval [CI] = 0.071-0.931) and carcinosarcoma (RR = 0.509; 955 CI = 0.324-0.799) when compared to leiomyosarcoma. Conversely, no significant difference in survival was found between leiomyosarcoma and high-grade ESS.

CONCLUSIONS

Histologic type is an independent prognostic variable for survival in uterine sarcomas. Low-grade ESS has the best clinical outcome, whereas leiomyosarcoma has the poorest one. It is noteworthy that, when adjusting for stage and mitotic count, leiomyosarcoma has a significantly worse prognosis than carcinosarcoma.

The clinical outcome of patients with stage Ia1 and Ia2 squamous cell carcinoma of the uterine cervix: a Cooperation Task Force (CTF) study

PURPOSE OF INVESTIGATION

The objective of this retrospective multicenter study was to assess the clinical outcome of patients with microinvasive squamous cell carcinoma of the uterine cervix.

METHODS

The hospital records of 166 patients with microinvasive squamous cell carcinoma of the uterine cervix were reviewed. All cases were retrospectively staged according the 1994 International Federation of Gynecology and Obstetrics (FIGO) nomenclature. One hundred and forty-three cases were in Stage Ia1 and 23 in Stage Ia2 disease. Surgery consisted of conization alone in 30 (18.1%) patients, total hysterectomy in 82 (49.4%), and radical hysterectomy in 54 (32.5%). All patients in whom conization was the definite treatment had Stage Ia1 disease and had cone margins negative for intraepithelial or invasive lesions.

RESULTS

None of the 67 patients submitted to pelvic lymphadenectomy had histologically proven metastatic lymph nodes. Of the 166 patients, eight (4.8%) had an intraepithelial recurrence and four (2.4%) had an invasive recurrence. With regard to FIGO substage, disease recurred in nine (6.3%) out of 143 patients with Stage Ia1 and three (13.0%) out of 23 with Stage Ia2 cervical cancer. With regard to type of surgery, disease recurred in three (10.0%) out of the patients treated with conization alone, four (4.9%) out those who underwent total hysterectomy, and five (9.3%) out of those who underwent radical hysterectomy. It is worth noting that none of the 30 patients treated with conization alone had recurrent invasive cancer after a median follow-up of 45 months. However three (10%) of these patients developed a cervical intraepithelial neoplasia (CIN) III after 16, 33, and 94 months, respectively, from conization.

CONCLUSIONS

Conization can represent the definite treatment for patients with Stage Ia1 squamous cell cervical cancer, if cone margins and apex are disease-free. For patients with Stage Ia2 cervical cancer extrafascial hysterectomy with pelvic lymphadenectomy might be an adequate standard therapy, although the need for lymph node dissection is questionable.

Different types of hysterectomy in the radio-surgical treatment of early cervical cancer (FIGO Ib-IIa)

PURPOSE OF INVESTIGATION

Surgery and radiotherapy achieved equivalent results for FIGO stages Ib-IIa invasive cervical carcinoma. The integration of radiotherapy and surgery provided the same results for a selected series of patients without increasing the rate of complications. The aim of the study was to verify if, applying a radio-surgical protocol, the reduction of the surgery extension on the parametrium in one of two consecutive series might achieve the same results in terms of survival and recurrence rates with fewer complications.

MATERIAL AND METHODS

We analysed actuarial survival (with >10-year follow-up), local control rates and morbidity of 390 patients who had different the kinds of surgery applied in the radio-surgical treatment protocol: Protocol A: brachytherapy plus type III radical hysterectomy vs Protocol B: brachytherapy plus type II radical hysterectomy. Patients were all included in an analysis of complications according to the French-Italian glossary.

RESULTS

Analyses showed no differences in terms of survival, patterns of recurrences and onset time within the two protocols. Urinary complications were more frequent and severe in protocol A vs protocol B (G2: 26.5% vs. 6.1%; G3: 5.3% vs. 3.6%).

CONCLUSION

Our study pointed out that the reduction of the surgery extension allowed the same overall survival and relapses with fewer complications particularly in terms of grade of severity.

Clinical behavior of 203 stage II endometrial cancer cases: the impact of primary surgical approach and of adjuvant radiation therapy

The aim of this study was to verify the impact of primary surgical approach and adjuvant radiation therapy (RT) on survival, recurrence rate, and pattern of relapse in stage II endometrial cancer patients. Two hundred three subjects were retrospectively reviewed; 135 (66%) underwent simple hysterectomy (SH) and 68 (34%) radical hysterectomy (RH). Sixty-six of 111 (59%) of stage IIA and 67 of 92 (73%) of stage IIB patients underwent adjuvant radiation therapy. Actuarial survival rates for stage IIA and IIB were 86% and 74% at 5 years and 82% and 68% at 10 years, respectively. Survival rates by surgical procedure were 79% in the SH group and 94% in the RH group at 5 years and 74% and 94% at 10 years, respectively (P < 0.05). The overall recurrence rate was 13.8% (28/203); by adjuvant treatment it was 18.6% (13/70) in the observation group and 11.3% (15/133) in the RT group. Most of the relapses were locoregional in the observation group and distant in the RT group. Survival rates by RT were not statistically different. Subjects treated with RH improved their survival compared with the SH group; the difference was significant, but randomized studies should confirm this trend. Although adjuvant RT seemed to reduce the recurrence rate, there was no significant difference in survival, and so the role of RT still needs further verification.

Phase II study of mitomycin-C and cisplatin in disseminated, squamous cell carcinoma of the uterine cervix. A European Organization for Research and Treatment of Cancer (EORTC) Gynecological Cancer Group study

The aim of this study was to investigate the tumour response rate and toxicity of a combination chemotherapy consisting of mitomycin-C and cisplatin in patients with disseminated squamous-cell carcinoma of the uterine cervix. Chemotherapy consisted of mitomycin, 6 mg/m(2) intravenously (i.v.), and cisplatin, 50 mg/m(2) given i.v., both administered on day 1 of each cycle. The regimen was repeated at 4-weekly intervals. Mitomycin-C/cisplatin were used to treat 33 evaluable patients aged 29-67 years (median: 50 years). All patients except 1 had previously been treated with either surgery, radiation or both. At the initiation of chemotherapy, 8 patients had loco-regional and disseminated disease and 25 women had only distant metastases. The overall response rate was 42% (95% confidence interval (CI): 26-61%). Five complete and nine partial responses were observed with a median duration of response of 7.9 months (95% CI: 3.7-23.5 months). 9 patients had stable disease and 10 developed progressive disease during mitomycin-C/cisplatin-treatment. World Health Organization (WHO) grade III/IV side-effects were documented in 15 women, of whom 10 had gastro-intestinal toxicity, 3 had haematological toxicity, 1 had alopecia and 1 developed an allergic reaction to cisplatin. There were neither drug-related deaths nor severe or irreversible renal or hepatic dysfunction or peripheral neuropathy. The median progression-free survival was 5.0 months (95% CI: 3.6-6.2 months) for all patients and 10.5 months (95% CI: 6.2-15.2 months) for the responders. The median overall survival was 11.2 months (95% CI: 6.5-18.4 months).The mitomycin-C/cisplatin combination showed antitumour activity in the treatment of advanced or recurrent squamous-cell carcinoma of the uterine cervix. The regimen was well tolerated and could be administered on an outpatient basis.

Analysis of treatment failures and survival of patients with fallopian tube carcinoma: a cooperation task force (CTF) study

OBJECTIVE

The objective of this retrospective multicenter study was to assess the pattern of failures and survival of patients with primary carcinoma of the fallopian tube.

METHODS

The hospital records of 88 patients with primary carcinoma of the fallopian tube were reviewed. Surgery was the initial therapy for all patients. Tumor stage was I in 21 (23.9%), II in 21 (23.9%), III in 43 (48.8%), and IV in 3 (3.4%) patients. Postoperative treatment was given without well-defined protocols. The median follow-up of survivors was 55 months (range, 7-182).

RESULTS

Of the 21 patients with stage I disease, 10 had no postoperative treatment and 11 had platinum-based chemotherapy. Five (23.8%) patients recurred after a median of 29 months (range, 8-93) from initial surgery. Of the 21 patients with stage II disease, 2 had no postoperative treatment, 2 underwent external pelvic irradiation, 16 received platinum-based chemotherapy, and 1 patient had oral melphalan. Eight (38.1%) patients recurred after a median of 25.5 months (range, 7-57). Of the 46 patients with stage III-IV disease, 1 patient refused chemotherapy and died after 19 months and 45 patients received platinum-based chemotherapy. A clinical complete response was obtained in 29 (64.4%) patients and a partial response in 8 (17.8%). A second-look laparotomy was performed in 14 of the 29 clinically complete responders: 12 patients were found to be in pathological complete response and 2 had persistent disease. Six (50.0%) of the former recurred after a median of 22 months (range, 13-101) from initial surgery. The two patients with persistent disease developed tumor progression after 15 and 11 months, respectively. Fifteen clinically complete responders did not undergo second-look, and 7 (46.7%) of them had a recurrence after a median of 18 months (range, 9-41). For the whole series, 5-year survival was 57%. By log-rank test, survival was related to FIGO stage (III-IV vs I-II, P = 0.0001), tumor grade (G3 vs G1 + G2, P = 0.0038), and patient age (>58.5 years vs <58.5 years, P = 0.0069), but not to histological type. The Cox model showed that FIGO stage (P = 0.0018) and patient age (P = 0.0290) were independent prognostic variables for survival. Among the patients with stage III-IV disease, 5-year survival was 55% for the patients who had residual tumor <1 cm compared with 21% for those who had larger residuum (P = 0.0169).

CONCLUSIONS

Primary carcinoma of the fallopian tube shares several biological and clinical features with ovarian carcinoma. However, when compared with the latter, fallopian tube carcinoma more often tends to recur in retroperitoneal nodes and distant sites. Stage, patient age, and, among patients with advanced disease, residual tumor after initial surgery represent important prognostic variables for survival.

[Assessment of reticulocyte hemoglobin content as a guide for iron supplementation in hemodialyzed patients]

BACKGROUND

In literature the reliability of reticulocyte hemoglobin content (CHr) has been recently emphasized to detect "functional" iron deficiency induced by erythropoietin therapy.

METHODS

In the present work the behavior of CHr in 68 uremic patients hemodialysis has been evaluated.

RESULTS

Its values appeared poorly correlated (R2 = 0.32) to the hypochromic erythrocyte percent values, and furthermore CHr sensitivity seemed poor, with pathologic low values detected in three cases only, all characterized by reduced mean corpuscular volume (MCV).

CONCLUSIONS

In the cases personally observed, MCV and CHr are weakly correlated (R2 = 0.15); reticulocyte hemoglobin absolute value in personal opinion does not appear as a reliable index of iron deficiency, being rather dependent on reticulocyte volume.

Patterns of recurrence in patients with squamous cell carcinoma of the vulva. A multicenter CTF Study

BACKGROUND

Invasive vulvar carcinoma is a rare disease with an incidence rate of 3-5% of all female genital neoplasms. The current study discusses the limited number of articles in the literature regarding the patterns of recurrence as well as the clinical outcome of patients with recurrent disease based on a consistent and consecutive series of cases.

METHODS

A common clinical chart focusing on the study of patterns of recurrence was used in five Italian gynecologic institutions with uniform criteria of surgical nomenclature, pathologic variables, and sites of recurrence. Between 1980-1994, 502 cases of primary invasive squamous carcinoma of the vulva were registered consecutively, treated, and considered for this multicentered study.

RESULTS

Of 502 patients, 187 (37.3%) developed a recurrence. Distribution of the recurrences by site was as follows: perineal, 53.4%; inguinal, 18.7%; pelvic, 5.7%; distant, 7.9%; and multiple, 14.2%. In a multivariate analysis, 3 characteristics appeared to be statistically correlated with the risk of recurrence: International Federation of Gynecology and Obstetrics Stage > II (P = 0.029), positive lymph nodes (P = 0.009), and vascular space invasion (P = 0.004). The 5-year survival rate was 60% for perineal recurrences, 27% for inguinal and pelvic recurrences, 15% for distant recurrences, and 14% for multiple recurrences.

CONCLUSIONS

In the current study the prognostic factors found to have statistical significance as prognostic factors for risk of recurrence were tumor dimension, lymph node involvement, and stromal and vascular space invasion. The presence of inguinal lymph node metastases was predictive of multiple and distant recurrences with a low rate of incidence of isolated perineal recurrence (27%) compared with negative lymph node cases (57.5%). Survival analysis of recurrent disease showed that the surgical resection of local recurrences may provide acceptable results (51% at 5 years). This observation may justify a follow-up program aimed at identifying those patients with early local recurrence suitable for radical resection.

Prospective multicenter study on urologic complications after radical surgery with or without radiotherapy in the treatment of stage IB-IIA cervical cancer

A national collaborative group has conducted a multicenter prospective study on the use of a specific glossary for the complications associated with the treatment of cervical cancer, which were analytically described in 1989. This report analyzes the urologic complications with particular reference to radical surgery in stage IB-IIA cancer cases. In the prospective multicenter clinical study 2024 patients with frankly invasive cervical cancer were enrolled (IB = 1041; IIA = 308; IIB = 384; IIIA-B = 237; IV = 54). This report considers 1349 patients with stage IB-IIA disease. Treatment modalities in this group of patients were: type III radical surgery in 21.9%; type III radical surgery followed by radiotherapy in 20.8%; type III radical surgery preceded by radiotherapy in 7.3%; type II radical surgery in 3.1%; type II radical surgery followed by radiotherapy in 8.4%; type II radical surgery preceded by radiotherapy in 18.8%; surgery plus chemotherapy plus radiotherapy in 3.5%; radiotherapy alone in 16%. In this case series 873 complications were registered, and among these 341 (39.1%) were described in the urinary tract. Among 277 bladder complications 47.3% were grade 1; 47.3% grade 2, and 5.4% grade 3. Among 64 ureter complications 59.4% were grade 1; 17.2% grade 2, and 23.4% grade 3. Distribution of severe urinary complications was different according to site (bladder or ureter) and treatment modalities (radical surgery alone: bladder 1.3%, ureter 1.3%; radical surgery followed by radiotherapy: 1.4% bladder, 2.8% ureter; radical surgery preceded by radiotherapy: 3% bladder, 0% ureter). Different distributions of severe urinary complication were also observed in respect to stage (IB vs IIA); treatment: elective vs nonelective. In 673 patients treated with radical surgery plus or minus radiotherapy 123 relapses were registered (18.2%). Incidence of relapse was not different in patients suffering from mild/severe complications vs patients without complications. Disease-free survival, death from tumor, and death from other causes were not different in the group with complications in comparison to the group without complications.

Evolution of physicians' attitudes towards practice guidelines

OBJECTIVES

To assess changes in physicians' attitudes towards practice guidelines and towards the role of empirical evidence in their development.

METHODS

The findings from two surveys carried out in 1993 and 1997 on the same random sample from two Italian medical specialty societies were compared. In both studies, physicians were mailed a questionnaire asking their views on the goals and role of practice guidelines in influencing clinical decision-making, and the role of empirical evidence versus subjective clinical experience in their development.

RESULTS

One hundred and seventy physicians participated in both surveys. An increasing proportion of physicians accepted that cost containment could be a legitimate goal of practice guidelines (from 26% in 1993 to 40% in 1997; P = 0.010). More clinicians (43% in 1993 and 57% in 1997; P < 0.01) supported the use of empirical evidence, as opposed to subjective clinical experience, as the primary basis for practice guidelines. Although only a tiny minority of physicians (6% in 1993 and 1997) supported the view that practice guidelines should reflect patient preferences, an increased proportion of physicians supported the participation of representatives from outside the medical profession in their development. The level of support increased from 6% in 1993 to 26% in 1997 (P < 0.001) in the case of consumers, from 24% to 38% (P = 0.015) for patient involvement and from 16% to 33% (P = 0.003) in the case of health care administrators.

CONCLUSIONS

The documented changes suggest that more clinicians acknowledge the role of empirical evidence and the need for a dialogue with other professionals and patient groups in the development of practice guidelines than was the case in the recent past.

[How have opinions of medical oncologists changed regarding compared guidelines? Findings from two surveys conducted in 1993-1997]

OBJECTIVES

To assess changes in physicians' attitudes toward practice guidelines and towards the role of empirical evidence in the development of recommendations for clinical practice.

DESIGN

Comparison of findings from two surveys carried out in Italy in 1993 and 1997 on the same random sample of 300 physicians from two specialty societies dealing with cancer care.

RESULTS

As for goals, the only change was the increasing (from 26% in 1993 to 40% in 1997; p = 0.010) number of physicians indicating cost containment. More clinicians (43% in 1993 vs 58% in 1997; p < 0.01) stated that guidelines should be based primarily on empirical evidence, rather than on clinical experience, and that the Ministry of Health should have a role in issuing guidelines (from 21% in 1993 to 46% in 1997; p < 0.001). Physicians supporting the participation of representatives from outside the medical profession in developing guidelines increased from 6% in 1993 to 26% in 1997 (p < 0.001) for consumers, from 24% to 38% (p = 0.015) for patients, and from 16% to 33% (p = 0.003) for health care administrators.

CONCLUSIONS

Overall, these changes indicate that an increasing number of clinicians acknowledge the role of empirical evidence and the need for a confrontation with other professional and societal components as to what should be done in clinical practice.

A proposed glossary of terminology related to the surgical treatment of vulvar carcinoma

BACKGROUND

The authors' objective was to provide a glossary of terminology related to the surgical treatment of invasive vulvar carcinoma. There is currently no consensus in the literature regarding the names of the surgical procedures used to treat this disease.

METHODS

A surgical glossary should be supported by clear definitions and acceptance of notions related to topographic anatomy that are specific to the surgical practice. A critical review of the classic, chiefly used Italian, French, German, and English textbooks of anatomy revealed some discrepancies and lack of uniformity in descriptions of vulvar and inguinal fascial structures and lymph nodes, which represent the principal landmarks of surgical treatment. In the proposed glossary, the descriptions of these anatomic landmarks integrate classic anatomic knowledge, data from recent gynecologic studies of inguinal anatomy, and the clinical experiences of the authors.

RESULTS

The glossary is composed of 16 surgical definitions, which are divided into 3 main sections of terminology describing the surgical treatment of the: 1) vulva, 2) inguinal lymph nodes, and 3) pelvic lymph nodes. The fundamental objective behind the glossary is to describe the area and the depth of the surgical procedure. Three determinants of the area (local, partial, and total) and three determinants of the depth of surgery (superficial, simple, and deep) were used to arrive at the fully articulated definitions in the glossary.

CONCLUSIONS

The authors are aware that the proposed glossary should not be considered a definitive one; however, it could serve as a good basis for further debate. The terms employed in the glossary are accompanied by anatomic and descriptive references to help avoid confusion and promote better understanding among gynecologic oncologists who are involved in the treatment of vulvar carcinoma.

Cisplatin, epirubicin, and lonidamine combination regimen as first-line chemotherapy for metastatic breast cancer: a pilot study

We assessed the activity and tolerability of a cisplatin, epirubicin, and lonidamine combination regimen as first-line chemotherapy in 28 advanced breast cancer patients. The schedule of treatment was as follows: 60 mg/ m2 epirubicin followed by 40 mg/m2 cisplatin given on days 1 and 2 every 21 days, with 450 mg lonidamine being given per os (three tablets) on days of chemotherapy administration and in the period intervening between one cycle and the next. Patients received a median of 5 (range 1-6) cycles. Overall, 22 patients were evaluable for response and 28, for toxicity. Four patients refused to continue the treatment after the first course, one was lost to follow-up, and one died due to toxicity (septic shock). The incidence of grade 3/4 nausea and vomiting was found to be greater than that expected with epirubicin and lonidamine alone. The addition of cisplatin resulted in an increase in platelet and hemoglobin toxicities, whereas the WBC toxicity did not differ from that expected with epirubicin and lonidamine. The hematological toxicity was found to be cumulative, leading to treatment delay in about 50% of patients at the fifth and sixth courses. The activity of this cytotoxic regimen was noteworthy, with the overall response rate being 81.8% (31.8% complete responses and 50.0% partial responses) in evaluable patients. This response rate decreased to 64.2% when all registered patients were included according to an intent-to-treat analysis. In conclusion, the association of cisplatin, epirubicin, and lonidamine given on the schedule described herein, appears to be very active but substantially toxic. We are now testing this combination in a randomized comparison, with the cisplatin dose being reduced to 30 mg/m2 given on days 1 and 2.

An analysis of approaches to the management of endometrial cancer in North America: a CTF study

OBJECTIVE

The aim of this study was to define the clinical-therapeutical approach to endometrial cancer now being followed in some of the most important centers of reference for gynecological cancer in North America by means of a questionnaire.

STUDY DESIGN

The questionnaire focused on four principal areas: (1) surgical staging and therapy; (2) adjuvant treatment; (3) treatment modifications; and (4) management of advanced stages (FIGO III-IV).

RESULTS

There were 48 evaluable responses (77%) received by the end of December 1994 which were considered for this analysis. Lymphadenectomy is utilized routinely in 26/48 centers (54.2%) and in selective clinical-pathological conditions in another 21/48 centers (43.5%). In the majority of centers (31/48; 64.6%) radical surgery is utilized for selected indications such as cervical involvement. Only 3/48 (6.2%) centers consider the vaginal approach totally inappropriate. The great majority (40/48; 83.3%) of the centers considered postsurgical adjuvant therapy to be necessary in FIGO Stage Ic. Brachytherapy is routinely performed in 3 centers (6.2%) in postsurgical management of Stage I endometrial cancer, while the majority of the centers (31/48; 64.6%) perform brachytherapy of the vaginal vault in certain clinical-pathological conditions. A wide variety of treatments are used for advanced stages (FIGO III-IV).

CONCLUSIONS

It emerges that some controversial aspects exist on endometrial cancer treatment, and these conflicting data need a large-scale multicenter randomized clinical trial.

Analysis of failures after negative second-look in patients with advanced ovarian cancer: an Italian multicenter study

This multicenter retrospective study is based on 192 patients with advanced ovarian cancer in pathological complete response at second-look surgery. Ninety-four (48.9%) patients developed recurrent disease after a median time of 18 months (range, 4-89 months) from surgical reassessment. The recurrence involved the pelvis in 45 (47.9%) cases, the abdomen in 42 (44.7%), the retroperitoneal lymph nodes in 13 (13.8%), and distant sites in 20 (21.2%). On the whole series, 5- and 7-year disease-free survival rates after negative second-look were 47.4 and 44.5%, respectively. By log-rank test the disease-free survival rate was related to FIGO stage (P = 0.008), tumor grade (P = 0.0021), size of residual disease after initial surgery (P = 0.0038), and type of second-look (laparoscopy vs laparotomy, P = 0.0061), but not to histological type and first-line chemotherapy. Cox proportional hazard model showed that tumor grade, size of residual disease, and type of second-look were independent prognostic variables for disease-free survival. The risk ratio of relapse was 2.386 (95% CI, 1.140-4.990) for grade 2 and 3.118 (95% CI, 1.515-6.416) for grade 3 compared to grade 1 disease. For patients with residual disease 1-2 cm and > 2 cm the risk ratio was, respectively, 1.877 (95% CI, 1.117-3.156) and 2.156 (95% CI, 1.324-3.511) compared to patients with residual disease < 1 cm. The risk ratio was 1.826 (95% CI, 1.121-2.973) for patients who were submitted to a laparoscopic second-look compared to those who underwent a laparotomic reassessment. Poorly differentiated grade and large residual disease after initial surgery are the strongest prognostic variables for recurrence after a negative second-look.

Carcinosarcoma of the uterus: a clinicopathological multicenter CTF study

The purpose of this paper is to retrospectively analyze the clinical and pathological data of 118 cases of uterine carcinosarcoma. Prognostic factors and management were evaluated. chi 2 and log-rank tests were performed. Surgical stage at time of surgery was the most important prognostic factor (P < 0.0001); in stage I-II disease depth of myometrial invasion and lymphatic/vascular space involvement were significantly related to outcome, whereas other factors were not useful. In stage I-II patients postoperative radiation did not improve 5-year disease-free survival. Survival curves in patients with advanced disease treated with cisplatin-containing regimens or with doxorubicin (without cisplatin)-containing regimens were overlapping.

Prognostic factors in metastatic breast cancer patients obtaining objective response or disease stabilization after first-line chemotherapy with epirubicin. Evidence for a positive effect of maintenance hormonal therapy on overall survival

Randomized trials suggest that the outcome of metastatic breast cancer (BC) patients is not affected by the currently available therapies. Although response rates per se may be associated with survival prolongation, patients experiencing objective response may be those patients fated to have the longest natural disease history. The separation of responders from progressing patients after first-line chemotherapy could allow the selection of a more homogeneous subgroup in which further treatment strategies might achieve a better control of the disease. This study investigated the influence of some patient characteristics, disease characteristics, and previous treatments on the outcome of non progressing patients after first-line chemotherapy with epirubicin administration. We also evaluated the effect of the maintenance endocrine therapy in improving response rate and overall survival (OS). From May 91 to May 93, 207 patients were enrolled in a randomized trial aiming to compare the activity of epirubicin (120 mg/sqm) +/- lonidamine (600 mg/daily). Among the 169 patients attaining complete (CR), partial response (PR) or disease stabilization (SD), 65 were not randomly submitted to maintenance endocrine therapy (MET). Liver involvement, previous adjuvant chemotherapy and previous hormonal therapy (administered in adjuvant setting or for advanced disease) were found to negatively influence OS both in univariate and multivariate analysis. Differences in OS stratifying patients according to DFI, estrogen receptor status and PS did not attain statistical significance. Patients receiving MET survived significantly longer than those submitted to observation and this difference maintained the statistical significance also within patient subsets homogeneous for specific prognostic features. In conclusion, most prognostic factors for advanced BC have been confirmed in our series of patients obtaining CR, PR or SD to full dose epirubicin. The positive prognostic impact of MET is impressive and deserves confirmation in randomized studies.