Management and clinical outcomes of pregnant patients with invasive cervical cancer

BACKGROUND

The objective of this study was to evaluate the clinical outcomes and to discuss the management of women presenting with an invasive cervical cancer during pregnancy.

PATIENTS AND METHODS

We retrospectively reviewed patients treated for an invasive cervical cancer diagnosed during pregnancy between 1985 and 2000 in our institution.

RESULTS

Twenty-one pregnant patients among a total of 487 women were treated. Thirteen, five, two and one, respectively, were diagnosed during the first, second and third pregnancy trimester and post-partum. The FIGO stage was IB in 15 cases, IIB in five cases and IVA in one case. Mean follow-up was 64 months (range 2-165). Overall and disease-free survival at 5 years were 82% and 79%, respectively. All five patients diagnosed in the second trimester were alive. Two of the 13 patients and one of the two patients diagnosed during the first trimester and the third trimester, respectively, died of their disease. No difference was observed between the nine patients whose treatment was delayed or not.

CONCLUSIONS

Invasive cervical cancer during pregnancy is rare but is a dilemma for women and their physicians. The present study and review of the literature suggest that pregnancy does not seem to influence the prognosis of cervical cancer. Delayed treatment could be proposed to selected patients diagnosed at the end of the second trimester or at the beginning of the third trimester, with a small tumor (<2 cm) and negative nodes, after a multidisciplinary approach.

[Management of advanced stage ovarian cancer]

The management of advanced stage ovarian cancer was deeply modified during last years. The standard treatment of advanced stage ovarian cancer in 2004 remains the initial surgery (in order to obtain ideally a total resection of all macroscopic disease) followed by adjuvant chemotherapy (6 courses of platinum based chemotherapy). But in patients with massive spread, interval debulking surgery (performed after 3 or 4 courses of neo-adjuvant chemotherapy) is becoming an interesting option (and perhaps will become a standard management). This treatment is actually studied in randomized trials.

Impact of surgical staging in patients with macroscopic “stage I” ovarian borderline tumours: analysis of a continuous series of 101 cases

The aim of this study was to assess the patient's clinical outcome following complete or incomplete surgical staging in cases treated for an early stage low-malignant-potential ovarian tumour (LMPOT). One-hundred and one patients treated between 1965 and 1998 for a early stage I LMPOT were reviewed according to whether the initial surgical staging was complete (Group 1/defined by peritoneal cytology + peritoneal biopsies + infracolic omentectomy) or incomplete (Group 2/omission of at least one of the peritoneal staging procedures described above). Complete and incomplete surgical stagings were carried out in 48 (48%) and 53 (52%) patients, respectively. Four (8%) LMPOT recurrences were observed in Group 2, all following conservative management, but there were no recurrences in Group 1. No relapses with invasive carcinoma or peritoneal disease and no tumour-related deaths were observed. The absence of complete peritoneal staging in patients with an apparent "stage I" LMPOT increased the recurrence rate. However, this surgical restaging (in cases of incomplete initial surgery) does not modify the survival of patients with apparent "stage I" LMPOT misdiagnosed during the initial surgery. This procedure could probably be omitted: (1) if the peritoneum is clearly reported as "normal" during the initial surgery; (2) in the absence of a micropapillary pattern; and (3) if the patient agrees to be carefully followed-up.

Value of routine follow-up procedures for patients with stage I/II cervical cancer treated with combined surgery–radiation therapy

BACKGROUND

The aim of this study was to determine the value of routine follow-up for the detection of recurrence in patients treated for cervical cancer.

PATIENTS AND METHODS

From 1986 to 1998, 583 women with stage I and II cervical carcinoma were treated with combined surgery-radiation therapy. After treatment, follow-up was based on clinical examination, a systematic Pap smear and radiography (chest X-ray and abdomino-pelvic ultrasonography).

RESULTS

Forty-five patients had recurrence observed with a delay > or = 6 months following the end of treatment. Thirty-eight patients had symptoms and seven were asymptomatic at the time of their recurrence. Among asymptomatic patients only two recurrences were diagnosed following routine examinations. Survival is similar in asymptomatic and symptomatic recurrent patients.

CONCLUSIONS

In conclusion, follow-up of patients treated for cervical cancer based on routine Pap smears and systematic radiography does not permit earlier detection of recurrence and does not increase survival.

[Infantile and maternal choriocarcinoma]

Infantile or congenital choriocarcinoma is a very uncommon complication of gestational choriocarcinoma. We report such a case with fatal outcome in a 3-week-old newborn, admitted for a hemorrhagic syndrome. Lungs, liver and brain masses were discovered and suggested an angiomatous process. The diagnosis was made later on gingival biopsy with necropsic confirmation. The mother's B-HCG level was elevated. She had asymptomatic pulmonary nodules and a uterine mass. This case report highlights characteristic but non specific clinical findings leading to the diagnosis. Chemotherapy must be undertaken as soon as possible to be effective. It is also necessary to assay maternal serum B-HCG when infantile choriocarcinoma is disclosed.

[Prognostic factors and treatment for advanced-stage borderline ovarian tumors]

OBJECTIVE

The aim of this review is to study the incidence, the prognostic factors and the treatment of patients with advanced stage borderline ovarian tumor (BOT) associated with extra-ovarian disease (peritoneal implants and/or nodal disorders).

METHODS

Review of literature data.

RESULTS

BOT were associated with peritoneal implants in 15% to 40%. The strongest prognostic factors are the histologic subtype of peritoneal implants and the presence of residual disease. The surgical treatment is the gold standard with resection of all peritoneal disease. This surgery could be conservative in selected cases in order to preserve fertility. Noninvasive peritoneal implants do not seem to be chemosensitive lesions.

CONCLUSION

Histologic subtype of peritoneal implants is the most important prognostic factors in patients with serous BOT and extra-ovarian spread. The prognosis of patients with noninvasive implants is good. Treatment is based on surgery. The (only) indication of adjuvant therapy is BOT associated with invasive implants.

[Cancer and pregnancy: the point of view of the chemotherapy oncologist]

Having to start chemotherapy during pregnancy remains a rare event. The decision to proceed this treatment relies on the drugs used, the time of exposure for the foetus and the gestational age at the time of exposure. As a matter of fact, the mutagenicity potential of the chosen medicine has to be known, and consequently, the risk for the child, without challenging the mother's life, nor her health. This question mainly occurs for breast cancers, leukemias and lymphomas. First trimester of pregnancy is the most critical period for the foetus, that corresponds to organogenesis. Antimetabolites are the main drugs bound to generate malformations. Besides, chemotherapy may induce direct toxicity towards the in utero exposed child. Myelosuppression is the most common toxicity, that can induce infections and/or fetal hemorrhages. Regarding the long term risks of cancer on fertility or child's intellectual development, they are still not well known and must be included into prospective studies, as well as being registered in a specific data file.

Tamoxifen-related uterine carcinosarcomas occur under/after prolonged treatment: report of five cases and review of the literature

The risk of tamoxifen-related endometrial adenocarcinoma is well established with daily dose and treatment duration of adjuvant tamoxifen as risk factors. There have also been in the past years, a few descriptions of uterine nonepithelial malignancies occurring after tamoxifen. We describe five recent cases of uterine carcinosarcomas occurring under/after tamoxifen administered in an adjuvant setting. None of these patients had received prior pelvic radiation therapy. Their median age at the diagnosis of breast cancer was 58 years (41-68), and 69 years (50-84) at the diagnosis of uterine carcinosarcoma. The median length of exposure to tamoxifen was 9 years (5-20), and the median time from the initiation of tamoxifen to the diagnosis of the uterine malignancy (latency period) 9 years (7-20). All patients presented with an advanced stage (IIA-IVA). Our data, together with those of the literature, plead for a causal role of a prolonged exposure to tamoxifen on the subsequent development of uterine carcinosarcoma. The long latency period observed even in patients receiving only 5 years of treatment leads us also to consider a prolonged gynecologic follow-up of the patients.

[Gemicitabine in the treatment of epithelial ovarian cancer]

Despite the improvement in the treatment of the ovarian cancer, the latter remains rarely curable, although being a chemosensitive solid tumor. Most patients will not be in definite remission for their disease. Gemcitabine is a new antimetabolite selected for clinical trials based on its activity in preclinical studies. With response rates ranging from 11% to 22% in monotherapy in resistant or platinum refractory diseases, gemcitabine has quickly been shown to be an active agent in the treatment of patients with refractory recurrent ovarian cancer. The toxicity was modest in phase II trials and allowed associations with other drugs, out of which platinum compounds. The response rates that have been obtained appear to be very encouraging (between 61% and 67%) and fully justify the recent phase III trials conducted in first line.

Malignant effusions and immunogenic tumour-derived exosomes

BACKGROUND

Exosomes derived from tumours are small vesicles released in vitro by tumour cell lines in culture supernatants. To assess the role of these exosomes in vivo, we examined malignant effusions for their presence. We also investigated whether these exosomes could induce production of tumour-specific T cells when pulsed with dendritic cells.

METHODS

We isolated exosomes by ultracentrifugation on sucrose and D(2)O gradients of 11 malignant effusions. We characterised exosomes with Western blot analyses, immunoelectron microscopy, and in-vitro stimulations of autologous T lymphocytes.

FINDINGS

Malignant effusions accumulate high numbers of membrane vesicles that have a mean diameter of 80 nm (SD 30). These vesicles have antigen-presenting molecules (MHC class-I heat-shock proteins), tetraspanins (CD81), and tumour antigens (Her2/Neu, Mart1, TRP, gp100). These criteria, including their morphological characteristics, indicate the similarities between these vesicles and exosomes. Exosomes from patients with melanoma deliver Mart1 tumour antigens to dendritic cells derived from monocytes (MD-DCs) for cross presentation to clones of cytotoxic T lymphocytes specific to Mart1. In seven of nine patients with cancer, lymphocytes specific to the tumour could be efficiently expanded from peripheral blood cells by pulsing autologous MD-DCs with autologous ascitis exosomes. In one patient tested, we successfully expanded a restricted T-cell repertoire, which could not be recovered carcinomatosis nodules.

INTERPRETATION

Exosomes derived from tumours accumulate in ascites from patients with cancer. Ascitis exosomes are a natural and new source of tumour-rejection antigens, opening up new avenues for immunisation against cancers.

[Sentinel lymph nodes in gynecologic cancers]

The detection of the sentinel lymph node is one of the most significant surgical advance in cancer research. This technique allow to decrease the morbidity of a surgical gesture which can be noxious in itself even without bringing a profit in survival. In the gynaecological cancers the detection of the sentinel lymph node is still at the stage of feasibility. An evaluation of the technique and the applicability in these cancers is mandatory in view of the prognostic value of the nodal involvement in these patients.

[Prognosis and fertility after conservative treatment for ovarian tumors of limited malignity: review of 68 cases]

The aim of this retrospective study was to evaluate the rate of recurrence and the reproductive outcome after surgical conservative treatment of low malignant ovarian tumors (LMOT).

MATERIAL AND METHODS

Sixty-eight patients with 50 Stage I LMOT and 18 LMOT with peritoneal implants treated conservatively at institut Gustave-Roussy, between January 1969 and December 2000. Fifty-nine patients had an unilateral adnexectomy (associated twelve times with a contralateral cystectomy), Seven had a bilateral cystectomy and two an unilateral cystectomy. Five patients received adjuvant therapy.

RESULTS

With a median follow-up of 71.5 months, 16 patients recurred and one had evolutive peritoneal disease. The histologic pattern of ovarian recurrences was always of borderline type. The histologic patterns of peritoneal recurrence was similar to those initially diagnosed except in one case. Peritoneal implants, exophytic tumor and serous type tumor were significatively associated with a higher 5-year recurrence rate. Recurrence was more frequent after cystectomy than unilateral adnexectomy (p = 0.13). None of patients treated conservatively recurred under the form of ovarian carcinoma. None patient died of tumor. Nineteen patients experienced 26 pregnancies: 24 were spontaneous in a median delay of 19 months. Seven infertile patients underwent ovarian stimulation. None recurred after infertility treatments. The 2-year and 5-year cumulative pregnancy rate were respectively 41.9% and 59.8%. Four patients experienced a pregnancy after a conservative treatment of their recurrence.

CONCLUSION

Despite a high recurrence rate, especially in stage II and III serous LMOT, conservative treatment of LMOT does not affect survival and should be considered in young patients. Such treatment is not advised in case of invasive peritoneal implants. Spontaneous pregnancy rate is good but the frequent infertility associated with these tumors can afterwards require ovarian stimulation. Limited number of stimulation cycles is acceptable in such patients.

[Peritoneal glioblastoma: recurrence of ovarian immature teratoma (report of a case)]

Immature teratomas of the ovary represent less than 1% of all ovarian teratomas. They contain several tissues that derive from the three embryological layers: ectoderm, mesoderm and endoderm. They are rarely associated with peritoneal implants that are essentially composed of mature glial tissue, and of benign evolution. We report the case of a 37-year- old woman who presented an immature teratoma of the right ovary that recurred seven years later as a malignant neuroepithelial peritoneal tumor resembling a glioblastoma. Glioblastoma was diagnosed at a second recurrence six months later. We discuss the histopathogenesis of peritoneal implants secondary to immature teratomas.

Tamoxifen-related uterine carcinosarcomas occur under/after prolonged treatment: Report of five cases and review of the literature

The risk of tamoxifen-related endometrial adenocarcinoma is well established with daily dose and treatment duration of adjuvant tamoxifen as risk factors. There have also been in the past years, a few descriptions of uterine nonepithelial malignancies occuring after tamoxifen. We describe five recent cases of uterine carcinosarcomas occurring under/after tamoxifen administered in an adjuvant setting. None of these patients had received prior pelvic radiation therapy. Their median age at the diagnosis of breast cancer was 58 years (41–68), and 69 years (50–84) at the diagnosis of uterine carcinosarcoma. The median length of exposure to tamoxifen was 9 years (5–20), and the median time from the initiation of tamoxifen to the diagnosis of the uterine malignancy (latency period) 9 years (7–20). All patients presented with an advanced stage (IIA-IVA). Our data, together with those of the literature, plead for a causal role of a prolonged exposure to tamoxifen on the subsequent development of uterine carcinosarcoma. The long latency period observed even in patients receiving only 5 years of treatment leads us also to consider a prolonged gynecologic follow-up of the patients.

Ovarian metastasis on transposed ovary in patients treated for squamous cell carcinoma of the uterine cervix: report of two cases and surgical implications

BACKGROUND

To discuss risk factors for ovarian metastasis in a transposed ovary in patients treated for cervical cancer.

CASES

Cases were two patients with ovarian metastasis in a transposed ovary in a series of 107 patients. These two patients were treated for a Stage IB squamous cell cervical cancer and presented with a tumor devoid of extrauterine spread (absence of nodal involvement or distant metastases) but with involvement of the uterine corpus. Furthermore, lymphovascular space involvement (LVSI) in the cervix or paracervix was present in both patients.

CONCLUSIONS

Ovarian transposition should be performed in patients < or =40 years of age with a small invasive cervical carcinoma (< 3 cm) treated by primary surgery. This procedure should not be performed in patients with bulky tumor and/or in patients with LVSI.