Low-dose-rate definitive brachytherapy for high-grade vaginal intraepithelial neoplasia

BACKGROUND

Treatment of high-grade vaginal intraepithelial neoplasia (VAIN) is controversial and could include surgical excision, topical medication, brachytherapy, or other treatments. We report the results of low-dose-rate (LDR) vaginal brachytherapy for grade 3 VAIN (VAIN-3) over a 25-year period at Gustave Roussy Institute.

PATIENTS AND METHODS

We retrospectively reviewed the files of all patients treated at Gustave Roussy Institute for VAIN-3 since 1985. The treatment consisted of LDR brachytherapy using a personalized vaginal mold and delivered 60 Gy to 5 mm below the vaginal mucosa. All patients had at least an annual gynecological examination, including a vaginal smear.

RESULTS

Twenty-eight patients were eligible. The median follow-up was 41 months. Seven patients had a follow-up <2 years, and the median follow-up for the remaining 21 patients was 79 months. The median age at brachytherapy was 63 years (range, 38-80 years). Twenty-six patients had a history of VAIN recurring after cervical intraepithelial neoplasia and 24 had a previous hysterectomy. The median brachytherapy duration was 4.5 days. Median doses to the International Commission of Radiation Units and Measurements rectum and bladder points were 68 Gy and 45 Gy, respectively. The median prescription volume (60 Gy) was 74 cm(3). Only one "in field" recurrence occurred, corresponding to a 5- and 10-year local control rate of 93% (95% confidence interval, 70%-99%). The treatment was well tolerated, with no grade 3 or 4 late toxicity and only one grade 2 digestive toxicity. No second cancers were reported.

CONCLUSION

LDR brachytherapy is an effective and safe treatment for vaginal intraepithelial neoplasia.

[Melanoma in HIV patients: 14 cases]

BACKGROUND

a clinical study of 14 patients presenting both malignant melanoma and HIV infection, and analysis of the literature to determine the frequency and specific features of this association.

PATIENTS AND METHODS

ten men and four women of median age 43 years were included. In 50% of cases, the primary melanoma consisted of spreading superficial melanoma with a mean Breslow thickness of 2.83 mm. In two cases, regional lymph node metastasis was discovered but with no primary melanoma being identified. HIV infection was already documented on diagnosis of melanoma in 11 cases, and it was discovered in three cases at the time of surgery for melanoma (treatment of the primary melanoma in two cases, and in one case, regional lymph node dissection two years after the initial diagnosis). Eight patients died within a mean period of 39 months, with melanoma being the cause of death in six cases. Following relapse of melanoma, the course of the disease was severe, with mean stage IV survival of 3.6 months. No response to chemotherapy was observed where such treatment was feasible.

DISCUSSION

the presence of HIV appears to be an aggravating factor for the outcome of metastatic melanoma.

CONCLUSION

our study suggests the importance of clinical examination of pigmented lesions in HIV patients in order to ensure early identification of melanoma.

[Para-aortic lymphadenectomy in advanced-stage cervical cancer: standard procedure in 2010?]

With tumour size, node involvement is the most important prognosis factor in advanced stage cervical cancer. Para-aortic (PA) disease is observed in 15 to 30% of these patients. CT scan and magnetic resonance imaging (MRI) are not efficient enough to detect these lesions and PET CT have false negatives. Surgical staging is useful to detect carcinosis associated and to adapt therapy (radiotherapy fields are extended if PA nodes are involved). Laparoscopy was crucial to develop this staging because its morbidity associated to chemoradiotherapy is limited. If prognosis impact of PA lymphadenectomy is well established, therapeutic impact is still discussed. The systematic extension of this staging to pelvic nodes that are included in the basic radiotherapy fields is debated because it does not modify therapeutic management and is morbid. Radiotherapy progress, especially with boost and combination to MRI (MRIT), will impact on future therapeutic management.

Prognostic factors in women treated for ovarian yolk sac tumour: a retrospective analysis of 84 cases

BACKGROUND

Ovarian yolk sac tumour (OYST) is a very rare malignancy arising in young women. Our study aimed to evaluate long-term outcomes and to identify prognostic parameters likely to help make appropriate risk-based decisions about therapy in this disease.

METHODS

This retrospective study is based on prospectively recorded OYST cases at the Institut Gustave-Roussy. A univariate analysis using the logrank test evaluated possible associations between survival and patient or disease covariates. The multivariate analysis was performed using the Cox proportional hazard regression method.

RESULTS

Between 1976 and 2006, 84 patients were registered. Since 1991, most of the patients have undergone fertility-sparing surgery. With a median follow-up of 71 months, the overall 5-year and event-free survival rates are 84% and 79%, respectively. In the multivariate model only the absence of ascites and a favourable serum AFP decline rate were significantly associated with better overall survival.

CONCLUSIONS

Patients with a poor prognosis factor such as an unfavourable serum AFP decline may be considered for aggressive treatment whereas those with good prognostic factors could be given less courses of chemotherapy.

Prognostic factors of a large retrospective series of mucinous borderline tumors of the ovary (excluding peritoneal pseudomyxoma)

BACKGROUND

To determine the prognosis and prognostic factors in a large series of mucinous borderline tumors of the ovary (MBOT).

MATERIALS AND METHODS

A retrospective review of patients with MBOT treated or referred to our institution. Three inclusion criteria were defined: (1) centralized histological review by our expert pathologist, (2) exclusion of peritoneal pseudomyxoma and any synchronous malignant tumor in the abdominal cavity, and (3) available data on the management and outcomes of patients.

RESULTS

From 1997 to 2004, 97 patients fulfilled inclusion criteria (95 stage I and 2 stage II disease). Of these, 9 patients had endocervical-like subtypes, 8 patients had stromal microinvasion, and 24 had intraepithelial carcinoma. Radical and conservative surgeries were performed, respectively, in 28 and 69 patients. After a median follow-up of 48 months, 13 patients had developed 14 recurrences: 7 were borderline and 7 were invasive lesions. The probability of recurrence in the form of carcinoma 5 and 10 years after the diagnosis was, respectively, 9 and 13%. The only prognostic factor for recurrence attaining statistical significance was the use of a cystectomy (compared with other surgeries relative risk [RR] = 5.6; P = 0.003; compared with salpingo-oophorectomy RR = 5.5; P = 0.012).

CONCLUSIONS

In the present series of 97 MBOT, mainly early-stage disease and excluding peritoneal pseudomyxoma, the cumulative risk of recurrence in the form of invasive carcinoma at 10 years was 13%. MBOT do not appear to be such a "safe" disease. The only prognostic factor for recurrence was the use of a cystectomy, suggesting that a salpingo-oophorectomy should be preferred in cases of conservative treatment.

How to follow up advanced-stage borderline tumours? Mode of diagnosis of recurrence in a large series stage II-III serous borderline tumours of the ovary

BACKGROUND

The aim of this study was to describe how recurrences were diagnosed in the largest series of patients treated for an advanced-stage serous borderline ovarian tumour.

PATIENTS AND METHODS

From 1973 to 2006, 45 patients with a serous borderline tumour and peritoneal implants relapsed among 162 patients with a follow-up exceeding 1 year. Data concerning recurrences and the mode of diagnosis were reviewed.

RESULTS

The median follow-up interval was 8.2 years (range 19-286 months). The mode of diagnosis of recurrences was imaging (n = 19), clinical symptoms (n = 8), cancer antigen (CA) 125 elevation (n = 7), secondary surgery (n = 5) and unknown (n = 6). The median time to recurrence was 31 months (range 4-242 month). The type of recurrence was invasive low-grade serous carcinoma in 14 patients. Five patients died of recurrent tumour. Among the 39 patients with a known mode of diagnosis of recurrence, the most frequent diagnostic method for invasive recurrences was blood CA 125 elevation (6 of 13) and the majority of noninvasive recurrences were diagnosed by imaging (16 of 23).

CONCLUSIONS

This study demonstrates that ultrasound is the most relevant follow-up procedure in this context. Nevertheless, the blood CA 125 test is of particular interest for detecting invasive recurrent disease, which is the most crucial event.

Correlation Between Macroscopic and Microscopic Diseases on Splenectomies Performed in the Surgical Management of Ovarian Cancer

Background:

Surgical management of primary or recurrent ovarian cancer with extensive upper abdominal disease may require splenectomy to achieve complete cytoreduction. The aims of this series were to correlate the macroscopic exploration with the microscopic analysis of the spleen and to evaluate the morbidity of patients submitted to this procedure for primary and recurrent disease.

Methods:

Data concerning patients who underwent splenectomy at the time of management of the primary (initial group) or recurrent disease were reviewed. The characteristics and survival of patients were analyzed. The correlation between macroscopic suspected lesion and histological results and morbidity according to the Dindo classification was studied.

Results:

From 1995 to 2008, 58 patients (42 in the initial group and 16 in the recurrence group) underwent a splenectomy in our institution. Except for 3 cases requiring splenectomy for hemostatic reasons, the macroscopically suspected splenic lesion was confirmed by histology in 32 (80%) of 40 cases in the initial group and in 14 (93%) of 15 cases in the recurrence group. Eighteen patients (26.5%) had a morbidity grade strictly superior to 2, and in all the factors we tested, only pelvic posterior exenteration was a risk factor for high morbidity (P = 0.02).

Conclusions:

When splenic lesions are macroscopically suspected during cytoreductive surgery for an ovarian cancer, most of the time the disease is confirmed by histology. When required to accomplish complete cytoreduction, splenectomy seemed to be justified.

Surgical procedures and morbidities of diaphragmatic surgery in patients undergoing initial or interval debulking surgery for advanced-stage ovarian cancer

BACKGROUND

Surgical management of advanced-stage ovarian cancer (ASOC) can require diaphragmatic surgery (DS) to achieve complete cytoreduction. The aim of this study was to evaluate modalities and morbidities of DS at the time of initial surgery (INS) and interval debulking surgery (IDS; performed after neoadjuvant chemotherapy).

STUDY DESIGN

Retrospective review of patients undergoing (unilateral or bilateral) DS at the time of INS or IDS for ASOC.

RESULTS

Between 2005 and 2008, 63 patients were studied. Treatment of the diaphragm was unilateral in 31 patients and bilateral in 32 patients. DS was performed respectively at the time of INS in 22 patients (35%) and IDS in 41 (65%) patients. Complete cytoreductive surgery was achieved in 95% (21 of 22 in the INS group and 39 of 41 in the IDS group). Surgical procedures used during DS were (in the INS and IDS groups, respectively) stripping in 14 (64%) and 16 (39%), coagulation in 2 (9%) and 10 (24%), and both procedures in 6 (27%) and 15 (37%). An intraoperative chest tube was placed in 14% of patients in each group. Postoperative chest complications requiring treatment occurred in 6 cases: pulmonary embolism (3 cases), symptomatic pleural effusion requiring chest drainage (1 case), and pneumothorax necessitating chest drainage (2 cases).

CONCLUSIONS

Rate of overall morbidity related to DS was not statistically different in patients undergoing INS and IDS. Surgical treatment of this upper part of the abdomen is key to achieving complete cytoreductive surgery in ASOC.

Prognostic factors and morbidities after completion surgery in patients undergoing initial chemoradiation therapy for locally advanced cervical cancer

PURPOSE

The aim of this study was to evaluate the prognostic factors and morbidities of patients undergoing completion surgery for locally advanced-stage cervical cancer after initial chemoradiation therapy (CRT).

PATIENTS AND METHODS

Patients fulfilling the following inclusion criteria were studied: stage IB2-IVA cervical carcinoma, tumor initially confined to the pelvic cavity on conventional imaging, pelvic external radiation therapy with delivery of 45 Gy to the pelvic cavity and concomitant chemotherapy (cisplatin, 40 mg/m(2) per week) followed by uterovaginal brachytherapy, and completion surgery after the end of radiation therapy including at least a hysterectomy.

RESULTS

One-hundred fifty patients treated in 1998-2007 fulfilled the inclusion criteria. Prognostic factors for overall survival in the multivariate analysis were the presence and level of nodal spread (positive pelvic nodes alone: hazard ratio [HR], 2.03; positive para-aortic nodes: HR, 5.46; p < .001) and the presence and size of residual disease (RD) in the cervix (p = .02). Thirty-seven (25%) patients had 55 postoperative complications. The risk for complications was higher with a radical hysterectomy (p = .04) and the presence of cervical RD (p = .01).

CONCLUSION

In this series, the presence and size of RD and histologic nodal involvement were the strongest prognostic factors. Such results suggest that the survival of patients treated using CRT for locally advanced cervical cancer could potentially be enhanced by improving the rate of complete response in the irradiated area (cervix or pelvic nodes) and by initially detecting patients with para-aortic spread so that treatment could be adapted in such patients. The morbidity of completion surgery is high in this context.

Impact of adjuvant treatment modalities on the management of patients with stages I-II endometrial stromal sarcoma

PURPOSE

To explore whether adjuvant treatment options may impact on the prognosis in localized endometrial stromal sarcomas (ESSs; stages I and II). The historical options usually discussed in addition to hysterectomy and bilateral salpingoophorectomy (BSO) are active surveillance, pelvic radiotherapy, chemotherapy and hormonal therapy, alone or in combination.

PATIENTS AND METHODS

Among 84 consecutive patients treated for ESS at a single referral center, 54 with localized stage disease were identified. Recurrence-free survival and overall survival were estimated and patterns of recurrences described. Univariate and multivariate analyses were carried out.

RESULTS

With a median follow-up of 58 months, only one patient had died. None of the 23 patients who had received adjuvant therapy relapsed compared with 13 of 31 patients who had not received any adjuvant therapy. Adjuvant treatments were hormonal therapy (n = 10) and brachytherapy with/without pelvic radiotherapy (n = 13). Almost the majority of relapses were local (92%) and extra-pelvic metastasis was observed in nearly half of the patients (46%). In the multivariate analysis, the major determinants of relapse-free survival were adjuvant treatment, myometrial invasion (P = 0.005) and no BSO (P = 0.005).

CONCLUSIONS

In this series, adjuvant treatment of localized ESSs was associated with the absence of recurrence.

Ovarian metastases from breast cancer: report of 29 cases

BACKGROUND

The objective of this study was to describe the characteristics and survival outcomes of patients with breast cancer who had ovarian metastases.

METHODS

Data from 29 women who underwent surgery were reviewed retrospectively (from 1998 to 2007). Patient characteristics, tumor characteristics, and treatment data were collected. Pelvic extent of disease was documented using a system analogous to the International Federation of Gynecology and Obstetrics classification for ovarian cancer. Global survival, disease-free intervals, and the distribution to other metastatic sites over time were studied. Outcomes were compared between the group who underwent macroscopic resection of lesions and the group who did not undergo resection.

RESULTS

The data indicated a predominance of premenopausal and hormone receptor-positive status and a greater prevalence of lobular infiltrating carcinoma, bilateral breast cancer, and predisposing genetic factors compared with the global population with breast cancer. Ovarian disease was diagnosed at a median of 5 years after breast cancer. Seventy-five percent of patients were asymptomatic, and advanced-stage pelvic extent or extra-abdominal metastases were observed in 41.5% of patients. The median survival was 3 years, and the median follow-up was 2 years. Survival improved significantly when optimal debulking surgery was performed.

CONCLUSIONS

Breast cancers may be associated with ovarian metastases. The current results indicated that surgical resection tends to increase survival, which may be long; however, larger series would be needed to confirm other prognostic factors. The high rates of hormone receptor-positive tumors and premenopausal patients led the authors to suggest that the surgical option should consist of at least bilateral oophorectomy, even when the contralateral ovary appears to be normal.

Correlation between [18f]fluorodeoxyglucose positron-emission tomography scan and histology of pelvic nodes in early-stage cervical cancer

BACKGROUND

The histological results of pelvic lymphadenectomy were studied in patients treated for early-stage cervical cancer (<4 cm) who had no nodal uptake on [(18)F]fluorodeoxyglucose positron-emission tomography combined with integrated computed tomography (FDG-PET/CT).

PATIENTS AND METHODS

Patients treated between 2005 and 2008 for stage IB1 cervical cancer cancer <4 cm who underwent a FDG-PET/CT followed by surgical evaluation of pelvic nodes were reviewed.

RESULTS

A total of 16 patients were studied. The median age of patients was 43 (range 29-62) years. Surgery was performed laparoscopically and by laparotomic approach in 13 and 3 cases, respectively. Two patients had histologically proven pelvic involvement. The false-negative rate and negative predictive value of PET-CT imaging for pelvic nodal involvement were 13% and 87%, respectively.

CONCLUSION

The accuracy of PET-CT imaging in predicting the pelvic nodal status is very low in patients with early-stage cervical cancer and is not able to replace lymphadenectomy.

[Effects of radiotherapy (external and/or internal) and chemotherapy on female fertility]

The impact of chemotherapy on a woman's fertility depends on her age and the types and doses of the drugs used. Alkylating agents have the biggest negative impact on ovarian function. A trial is currently examining the use of a GnRH agonist to protect ovarian function. The impact of external radiation therapy and brachytherapy on the ovaries depends on three factors: the patient's age, the dose delivered to the ovaries, and concurrent use of chemotherapy. Ovarian transposition is a simple surgical procedure that can be used in selected cases to reduce the risk of early menopause. Both external and internal radiation has an impact on the uterus, notably by altering its vascularization and by reducing its growth when treatment is delivered during childhood.

Conservative management of low-grade endometrial stromal sarcoma followed by pregnancy and severe recurrence

BACKGROUND

Since low-grade endometrial stromal sarcoma (LGESS) has the most favourable prognosis in comparison to other sarcomas, fertility-sparing surgery in young women has been reported in rare cases. However, such tumours almost always show positive sex steroid receptors and their evolution in the hormonal milieu of pregnancy remains unpredictable.

CASE REPORT

We report the case of a 34-year-old woman treated conservatively for LGESS who conceived rapidly after hysteroscopic resection of the tumour. In the post partum period, pelvic pain motivated a laparoscopic exploration which revealed severe peritoneal recurrence.

CONCLUSION

This case report highlights the possible dramatic evolution of LGESS after pregnancy and suggests that definitive surgery should not be postponed but performed as soon as the diagnosis of ESS has been made.

Outcomes after conservative treatment of advanced-stage serous borderline tumors of the ovary

BACKGROUND

The aim of this study was to assess the outcomes of the largest series of patients treated conservatively for a stage II or III serous borderline ovarian tumor.

MATERIALS AND METHODS

From 1969 to 2006, 41 patients were treated conservatively for an advanced-stage serous borderline ovarian tumor. Patient outcomes were reviewed.

RESULTS

Twenty patients had undergone a unilateral salpingo-oophorectomy, 18 a unilateral cystectomy and two bilateral cystectomy (unknown for one patient). Three patients had invasive implants. The median duration of follow-up was 57 months (range 4-235). The recurrence rate was high (56%), but overall survival remained excellent (100% at 5 years, 92% at 10 years). One death had occurred due to an invasive ovarian recurrence. Eighteen pregnancies (nine spontaneous) were observed in 14 patients.

CONCLUSIONS

This study demonstrates that spontaneous pregnancies can be achieved after conservative treatment of advanced-stage borderline ovarian tumors (with noninvasive implants) but the recurrence rate is high. Nevertheless, this high rate has no impact on survival. Conservative surgery can be proposed to patients with a borderline tumor of the ovary and noninvasive peritoneal implants. Should infertility persist following treatment of the borderline tumor, an in vitro fertilization procedure can be cautiously proposed.