Laparoscopic prophylactic oophorectomy in women with inherited risk of ovarian cancer

The aim of this study was to specify the surgical procedure most adapted for prophylactic laparoscopic oophorectomy in patients with an inherited risk of ovarian cancer. This prospective study was based on a series of 27 patients who underwent prophylactic bilateral laparoscopic oophorectomy between September 1995 and January 1998. Nine patients underwent an oophorectomy (33%) and 18 patients an adnexectomy (67%). The laparoscopic procedure was converted into a laparotomy in one patient in whom an ovarian adenocarcinoma was detected during the surgical procedure. During final histologic examination of the ovaries, 23 patients were found to have benign atypical histologic alterations, one patient had an ovarian adenocarcinoma and only three patients (11%) had normal ovaries. In women with an inherited risk of ovarian cancer, during the laparoscopic procedure for prophylactic oophorectomy, the abdomino-pelvic cavity should be thoroughly explored with peritoneal cytology and systematic peritoneal biopsies. The laparoscopic procedure could be converted into a laparotomy if an ovarian cancer is discovered.

[Prognostic factors of cancer of the endometrium and therapeutic implications]

Tumor differentiation, myometrial invasion and lymph node metastasis are the most important prognostic factors in endometrial carcinoma. Tumor stage, positive peritoneal cytology, obesity and race seems to be also prognostic factors. The surgical treatment of stage I and II endometrial carcinoma is hysterectomy with bilateral adnexectomy and pelvic lymphadenectomy (obturator group). This procedure can be performed by laparotomy or laparoscopy.

Serum levels of dimeric activin A are not a marker of placental tumors in the course of chemotherapy

The aim of the present study was to evaluate whether serum activin A levels may represent, in addition to intact human chorionic gonadotrophin, a marker of placental tumors in the course of chemotherapy. Serial determinations of serum levels of activin A were performed in women with hydatidiform mole (n = 2) or choriocarcinoma (n = 3). Serum activin A levels were measured by using a new specific two-site enzyme immunoassay (EIA) able to detect the dimeric, bioactive, form of the protein. Serum hCG concentrations in samples taken after evacuation before starting chemotherapy were greater than in healthy non-pregnant women (p < 0.001) and decreased following chemotherapy. Activin A serum levels in women with trophoblastic disease after evacuation were significantly higher than in healthy non-pregnant women, but chemotherapy did not significantly affect circulating levels. No correlation was found between changes of activin A and total hCG serum concentrations. Measurement of activin A by ELISA in presence of persistent molar tumor does not seem to be of clinical interest in the follow-up of disease, resulting activin A concentrations after chemotherapy in the range of values occurring throughout menstrual cycle. These evidences suggest that hCG determination is still the most valid for follow-up, because only intact hCG could detect the persistence of trophoblast tissue.

[Are there any arguments against hormone replacement therapy after treatment of ovarian adenocarcinoma?]

The hormonal status of 95% of the women treated for epithelial ovarian carcinoma is menopausal, either naturally or after treatment. This raises the important question of the hormonal replacement therapy (HRT) among these patients. Several retrospective studies have explored the potential positive or negative influence of HRT on the genesis of ovarian adenocarcinoma. Although somehow contradictory, these studies taken all together fail to show any favouring nor protective role of HRT. In vitro, estrogens have been shown to induce the proliferation of ovarian cancer cell lines. On the opposite, progesterone and antiestrogens have antiproliferative effects. Both types of effects are mediated by intracellular steroid hormone receptors (ER, PgR). Although high dose progesterone derivatives and antiestrogens have been shown to obtain therapeutic responses in patients carrying advanced ovarian carcinoma, response rates were usually less than 20%, and no clinico-biological correlation (with ER, PgR status) could be demonstrated. There is therefore no evidence for a clinical significance of the presence of hormonal receptors in these tumors. A single retrospective study explored the possible influence of HRT on the prognosis of patients treated for ovarian carcinoma, and did not demonstrate any deleterious effect. This review of recent epidemiological, biological and clinical data fails to find any argument against the prescription of HRT in patients treated for ovarian adenocarcinoma, in the absence of other contra-indications.

[Medical treatment of ovarian malignant germ cell tumors in the adult]

Malignant ovarian germ cell tumors are infrequent neoplasms that usually affect young and otherwise healthy females. The outcome of patients has been significantly improved by the introduction of cisplatin-based chemotherapy. After conservative surgery which both establishes the diagnostic and initiates therapy, the postoperative management should be adapted to histological type as well as to tumor stage. In patients with nonseminomatous germ cell tumors, the standard treatment is a combination of bleomycin, etoposide and cisplatin (BEP protocol). The number of cycles to be given is 3 when surgery is optimal, and 4 in patients with residual or metastatic disease. In patients with pure dysgerminomas, 4 cycles of BEP are the optimal treatment for advanced stages. In early stages, the alternative to chemotherapy (3 cycles of BEP) is radiotherapy, typically given to the ipsilateral hemipelvis and para-aortic nodes. Results are satisfactory with a long-term survival rate ranging from 80 to 100%, and a minimal toxicity yielding a reasonable probability of having normal offspring.

[First line chemotherapy of epithelial cancers of the ovary]

Treatment of epithelial ovarian cancer is based mainly on surgery and chemotherapy. Indications of chemotherapy depends on stage of disease and tumor histology. Initial polychemotherapy must be a platinum compound based regimen with respect of dose-intensity. Up to now the initial standard chemotherapy is a cyclophosphamide and platinum combination. Only one randomized study comparing cisplatin-cyclophosphamide and cisplatin-Taxol has been published in patients with macroscopic residual disease (> 1 cm). The improvement of survival with Taxol has led to propose this association as standard treatment in the USA and in some European countries. The place and role of anthracyclines are discussed. New drugs (topotecan, Oxaliplatine) and new modalities of administration (intensification, intraperitoneal route) are currently under evaluation.

[Negative second-look laparatomy in ovarian cancers. Survival analysis and prognostic factors from 64 cases treated at the Gustave Roussy Institute]

This study describes 64 cases of ovarian adenocarcinoma seen in the Gustave-Roussy Institut between 1978 and 1988 and who had a negative second-look laparotomy. The median age was 51 years (30-74). FIGO stages were: I: 7 (11%); II: 3 (5%); III: 39 (61%); IV: 3 (5%); and undetermined: 12 (19%). There were 53% of serous type, 14% of endometrioid type, 13% of undifferencied type, 8% of clear cells type, 3% of mucinous type, and 9% of mixed type tumors. There were 50% of grade 3 tumors. Initial debulking surgery was as complete as possible in 59 patients, with a residual tumor after surgery superior or equal to 2 cm in 25 patients. Post second-look surgery treatment (n = 57) consisted of chemotherapy (CT) alone in 22 patients (34%), radiotherapy (RT) alone in 31 patients (49%), and CT associated with RT in 4 patients (6%). Median follow-up is 100 months. The overall survival rates at 3 and 5 years were respectively 86 and 81%, and disease free survival rates 70 and 61%. Among the 64 patients, 26 relapsed (39%). Median time to relapse was 96 months. There is a statistical difference in the survival between patients who had no or inferior to 2 cm residual tumor and others. Residual tumor was the only factor to be significant in univariate and multivariate analysis of survival.

Extensive cytoreductive surgery in advanced ovarian carcinoma

From June 1985 to June 1993, 152 patients with advanced ovarian cancer were treated with maximum cytoreductive surgery, and six to nine cycles of platinum-based chemotherapy. Six patients had stage IIIA-B disease, 101 stage IIIC, and 45 stage IV. Twenty-two tumors were grade 1. 58, grade 2. and 72, grade 3. Eighty-four patients (55%) presented with bulky tumors (> 10 cm in diameter). Optimal cytoreductive surgery (diameter of largest residual mass < 2 cm) was performed in 138 patients (91%). Fifty patients (33%) developed postoperative complications; 38 patients (25%) required a second laparotomy within a few days. Two postoperative deaths occurred. Overall 2-year and 4-year survival rates were 56% and 28%, respectively. There was a clear relationship between residual tumor and survival: the 2-year survival rate was 80% in the absence of residual tumor vs. 22% when the residuum exceeded 2 cm in diameter. The 2-year survival rate was 49% for tumor nodules < 2 cm in diameter. In a multivariate analysis of various risk factors (grade, stage, lymph node metastases, residual tumor, and age), the one that correlated most with survival was residual tumor. Despite a high morbidity rate, this modality of treatment, with the presence of optimal and aggressive perioperative measures in terms of intensive care unit and post-operative follow-up, offers an encouraging if not promising strategy for increased chances of survival in advanced ovarian cancer.

Adult granulosa-cell tumor of the ovary: a retrospective study of 45 cases

This study describes 45 cases of adult granulosa-cell tumors seen in our institution between 1976 and 1993. The median age was 46.5 years (12-77) and 18 women were postmenopausal. Vaginal bleeding was present in one-third of cases; other complaints were abdominal pain (28%) and the presence of a pelvic mass (47%). The tumor size was variable (<3 cm to 30 cm, median 11.5 cm). FIGO stages were: stage I: 30 (73%) (19 Ia, seven Ic, four I unknown); stage II: seven (17%) (two IIa, five IIC); stage III: three (7%) (one IIIb, two IIIc). Two adenocarcinomas and 13 cases of hyperplasia were found in 25 endometrial samples available. The initial therapy for all the cases was surgery, consisting in 34 patients of hysterectomy, bilateral salpingo-oophorectomy, +/- tumor resection. Sixteen patients received adjuvant therapy as well: chemotherapy (CT) alone for 12, radiotherapy (RT) alone for two, and CT + RT for two patients. Among the 39 patients who achieved a complete response after initial therapy, 15 patients have relapsed (pelvic recurrences) (38.5%) including six stage Ia (three received only conservative surgery). All the recurrent tumors were resected and 14/15 had CT (13/14 with cisplatin). The overall survival rate was 77.2% at 5 years, 66.5% at 10 years, and 41.2% at 20 years. A statistically significant difference was found between the survival of patients with stage Ia disease (75% at 10 and 15 years) and that of other patients (60% at 10 years, and <50% at 15 years). Serum estradiol and serum inhibin were measured in some patients and the results are described.

Carboplatin plus paclitaxel in the first-line treatment of advanced ovarian cancer: preliminary results of a phase I study

This phase I trial was designed to determine the maximum tolerated dose of paclitaxel (Taxol; Bristol-Myers Squibb Company, Princeton, NJ) given as a 3-hour infusion in combination with carboplatin (400 mg/m2) as first-line chemotherapy for stage IIIC/IV ovarian adenocarcinoma. After premedication, paclitaxel was infused over 3 hours, followed by carboplatin infused over 30 minutes on day 1 of a 28-day cycle (group 1, with 28 patients accrued and 150 evaluable cycles) or on day 1 of a 21-day cycle (group 2, with 16 patients accrued and 55 evaluable cycles). Dose-limiting toxicities assessed after the first course included grade 4 neutropenia lasting longer than 7 days, febrile grade 4 neutropenia requiring intravenous antibiotics, grade 4 thrombocytopenia, mucositis greater than grade 2 for more than 7 days, grade > or = 3 nonhematologic toxicity (excluding alopecia, vomiting, and muscular pain), no hematologic recovery on day 42 (for group 1) or on day 35 (for group 2), neurotoxicity above grade 2, and persistence of nonhematologic toxicity (excluding alopecia, nausea/vomiting, and musculoskeletal pain) grade > or = 2 at scheduled re-treatment. If any of the events occurred during the first cycle in three or more of six patients, maximum tolerated dose was considered to have been reached. The hematologic toxicity associated with the two treatment schedules was mainly neutropenia, but it was of short duration. Very few dose reductions or dose delays were necessary. Until now, the six planned courses have been administered without colony-stimulating factors. No toxic death has occurred. Grade 2 or 3 peripheral neuropathy has occurred in 12% of patients, mainly with high doses of paclitaxel. At this time, the maximum tolerated dose has not been reached at paclitaxel 275 mg/m2 every 4 weeks or 225 mg/m2 every 3 weeks, and enrollment continues.

[Is there a place for chemotherapy in the initial treatment of cervical cancer? Review of the literature]

Despite their high efficiency in treating cancer of the uterine cervix, surgery and radiotherapy can not cure (local and/or metastatic disease) a certain number of patients with initially adverse risk factors, mostly local or regionally advanced cervical carcinoma (stage III-IVA) or early stage (IB-II) disease with bulky primary lesion or involved regional nodes. Since the 1980s, many investigators have tried to determine whether or not there is any benefit in introducing chemotherapy earlier in the therapeutic plan for these patients: either initially before surgery or radiotherapy (neoadjuvant), or during radiotherapy (concurrent), or after local treatment (adjuvant). In this review we seek to sum up the published data available and to determine if at present there is a place for chemotherapy in the initial treatment of cervical cancer.

Desmoplastic small round cell tumors: results of a four-drug chemotherapy regimen in five adult patients

BACKGROUND

Desmoplastic small round-cell tumor has been identified as a neoplasm with multidirectional immunohistochemical, and molecular features of this tumor sets it apart as a pathologic entity. The optimal treatment remains to be determined.

METHODS

Five adult patients were treated according to a uniform first-line chemotherapy program including cisplatin, etoposide, cyclophosphamide, and either doxorubicin or epirubicin. Chemotherapy was delivered after initial surgery in the four patients with intra-abdominal presentation, and at relapse in the fifth patient who had a paratesticular primary tumor.

RESULTS

All 4 patients with intra-abdominal disease experienced stability lasting from 4 to 9 months. Only one objective persistent complete response was observed; this was in the patient with a paratesticular primary. No salvage treatment was active in the other four patients who died of progressive disease.

CONCLUSIONS

Our experience to a certain degree of chemosensitivity for desmoplastic small round-cell tumors. Despite aggressive treatments, survival rates remain disappointing. Other therapeutic modalities are needed to improve these results.

Antimüllerian hormone as a serum marker of granulosa cell tumorsof the ovary: comparative study with serum alpha-inhibin and estradiol

OBJECTIVE

Our purpose was to evaluate serum antimüllerian hormone as a marker for granulosa cell tumors.

STUDY DESIGN

Serum antimüllerian hormone concentrations were determined in 16 patients with an adult-type granulosa cell tumor; in female patients with ovarian adenocarcinoma, benign ovarian cysts, or extraovarian cancers; and in normal premenopausal and postmenopausal women. Serum antimüllerian hormone, alpha-inhibin, and estradiol levels were compared in 10 patients with a granulosa cell tumor during 6 to 47 months of follow-up.

RESULTS

Serum antimüllerian hormone was undetectable in normal postmenopausal women and was <5 micrograms/L in premenopausal women. Normal serum levels were found in patients with ovarian cancers or cysts or with extraovarian cancers. Levels were between 6.8 and 117.9 microg/L in eight of nine patients with a progressive granulosa cell tumor. In the remaining case antimüllerian hormone, alpha-inhibin and estradiol concentrations were normal. Serum antimüllerian hormone and alpha-inhibin levels became elevated at least 11 months before the recurrence was clinically detectable. During clinical remission serum antimullerian hormone, beta-inhibin, and estradiol were normal in most cases.

CONCLUSION

Serum antimüllerian hormone is a sensitive, specific, reliable marker of adult-type granulosa cell tumors and is useful to evaluate the efficacy of treatment and to detect recurrences early.

[Value of inhibin as a tumor marker in granulosa cell tumors. Apropos of 6 new cases treated at the Gustave-Roussy Institute]

Lappöhn et al showed that inhibin can be used as a marker of granulosa cell tumors (GCT). Inhibin ia s glycoprotein specifically produced by ovarian granulosa cells. This peptide has been given in six women of 45 patients with a GCT who were referred for treatment or judgment in the Institut Gustave Roussy of Villejuif. Inhibin remained undetectable in four patients without evidence of disease. In one of them, inhibin level decreased progressively after surgical resection (for 10 months). Inhibin was also given in two patients with recurrence: in one case inhibin level was very high, and in one case it was barely detectable. In finding with other publications, inhibin can be used as a maker for reccurent disease, when patients are menopaused even when tumor does not produce steroids.

[Neoadjuvant chemotherapy of stage IIb or III cancers of the uterine cervix. Long-term results of a multicenter randomized trial of 151 patients]

Present chemotherapy, with cisplatin combinations, currently offers the possibility of seeking adjuvant therapy in locally advanced and bulky carcinomas of the cervix, which have an unfavorable prognosis (nodal involvement). This initial adjuvant chemotherapy may improve the results of classical pelvic irradiation. From 1982 to 1987, a randomized phase III trial was performed in order to determine the long term effect of induction chemotherapy before irradiation in stage IIb-N1, III, M0 squamous cell carcinomas of the cervix. Radiotherapy (R) for all patients consisted in 50 Gy in the pelvis with a boost by external irradiation of the brachytherapy (cumulative dose of 68 Gy). The chemotherapy regimen (C + R group) was an association of methotrexate, chlorambucil, vincristine and cisplatin, given every 3 weeks, at least two courses were to be given before assessing efficacy and two more courses were given to patients who responded. After a follow up of 5-10 years, 76 patients were fully evaluable in the R arm and 75 in the C + R arm. The response rate (> 50%) to chemotherapy was 42.5% and after completion of treatment, remission rate was 93% in the R arm and 96% in the C + R arm. The disease-free survival was 40% in the C + R group and 35% in the R group, and the median survival was 42 and 45 months respectively (NS). The survival of patients with a complete response at the end of radiotherapy was significantly better in the C + R group when they are responding to chemotherapy, than in R group (P < 0.05). Radiotherapy was not modified whether patients had an initial chemotherapy or not; tolerance was not significantly different between the two groups. Efficacy of induction chemotherapy is an available test for long term results. This approach has the potential for improving the outlook in patients with high-risk primary cancer: earlier use and higher dose intensity of chemotherapy may be associated with a better cytoreduction, and probably a better survival. Further controlled investigations are warranted to confirm the value of adjuvant chemotherapy in cervical cancer.

Phase II study of pirarubicin (THP) in patients with cervical, endometrial and ovarian cancer: study of the Clinical Screening Group of the European Organization for Research and Treatment of Cancer (EORTC)

From 1986 to 1990, a multicentric phase II study was conducted with pirarubicin, a new semi-synthetic anthracyclin[4'-O-tetrahydropyranyl-adriamycin (THP)]. 87 patients with advanced gynaecological cancers were treated: epidermoid cervical carcinoma (n = 31), adenocarcinoma of the endometrium (n = 28) and ovarian adenocarcinoma (n = 28). THP was administered by short intravenous infusion, for 3 consecutive days, every 3 weeks. The initial dose of THP was 25 mg/m2 day (25% of patients) which was then reduced to 20 mg/m2 day. The average number of courses was 3.7 (range 1-10). The cumulative THP dose was 180 mg/m2 (range 56-594) in cervix and endometrial tumours and 121 mg/m2 (range 58-425) in ovarian tumours. Myelosuppression was the major observed toxicity with grade 3-4 leukopenia and thrombocytopenia in 62 and 19% of the patients, respectively. Severe general complications occurred in 6% of the patients with three fatalities due to infections. Gastro-intestinal side-effects were frequent and usually mild (7% of grade 3 vomiting). 48% of the patients showed alopecia, which was complete in 9 cases (10%). 3 patients experienced cardiac events. No significant antitumoral activity was observed in patients who had failed to respond to previous chemotherapy. Promising antitumoral activity was noticed in untreated cervico-uterine carcinomas with 19% partial responses and 12% complete responses (CR). THP activity was lower in endometrial carcinomas (9.5% CR). Results were found to be negligible in ovarian cancer patients, most of them being refractory to previous chemotherapy containing an anthracyclin compound. On the basis of these results, the definite role of THP in gynaecological cancers deserves to be studied in more favourable programmes (e.g. in combined protocols as first-line chemotherapy).

Free human chorionic gonadotropin beta subunit in gonadal and nongonadal neoplasms

The diagnostic value of elevated human chorionic gonadotropin (hCG) and its free alpha (hCG alpha) and beta (hCG beta) subunit serum levels as specific tumor markers for nongonadal malignancies is controversial. In the present report, different monoclonal based immunoradiometric assays specific for hCG and its free hCG alpha and hCG beta subunits have been used to reevaluate the presence of these molecules in the serum of patients with a wide variety of tumors. Serum samples from patients with newly diagnosed, persistent, or recurrent malignancies of either known (n = 717) or unknown (n = 32) primary site, healthy blood donors (n = 309), and nonmalignant disease controls (n = 86) were studied using four highly specific and sensitive monoclonal based immunoradiometric assays to hCG and its free subunits. Low level hCG elevations (less than 1000 pg/ml) were found to be common in cancer patients, normal subjects, and disease controls. However, serum levels greater than 1000 pg/ml were highly diagnostic of gonadal tumors and specifically identified nonseminomatous testicular tumors. Significant serum elevations of free hCG alpha subunit (as high as 3000 pg/ml) were found in approximately 96% of cancer patients, normal individuals, and disease controls. In contrast, free hCG beta subunit levels (greater than or equal to 100 pg/ml) were detected in 70 and 50% of patients with nonseminomatous and seminomatous testicular cancers, respectively, and in 47% of bladder, 32% of pancreatic, and 30% of cervical carcinomas. All normal subjects and disease controls had free hCG beta levels less than 100 pg/ml. Thus, the detection of the free hCG beta subunit in serum of nonpregnant subjects was highly diagnostic of malignancy in general and specifically defines a subgroup of aggressive nongonadal malignancies.

Ovarian dysgerminoma metastatic to the breast

A 16-year-old girl underwent a right salpingo-oophorectomy for a pure dysgerminoma limited to the right ovary. One month later, she developed a right pelvic mass along with abdominal lymphadenopathies, peritoneal carcinomatosis, left breast mass, and left axillary node. Cytology of the breast mass was suggestive of a pure dysgerminoma. Breast metastases of epithelial ovarian carcinoma are uncommon. In the literature, this is the first case of a breast metastasis of an ovarian dysgerminoma.

[Gestational trophoblastic tumors]

The term gestational trophoblastic tumours covers hydatidiform moles, invasive moles and choriocarcinomas. These are rare diseases remarkable for their high chemosensitivity. The current objective is to cure all patients while preserving their potential for child bearing. Several studies have elicited prognostic factors, so that treatment can be adjusted to each individual patient. Advances in immunochemistry have led to the discovery of a highly reliable marker (HCG and beta-HCG) which has proved valuable to confirm the diagnosis and to follow the patients during and after treatment.

Nucleolar Organizer Regions in Ovarian Tumors

Nonhistone nucleoproteins associated with the nucleolar organizer region (NOR) can be visualized by a silver-staining technique on paraffin-embedded tissues. The number of black dots (Ag NORs) appearing on the nuclei are thought to reflect cell differentiation of certain tumors and can be used as an adjunct in predicting their evolution. We applied this method to determine if Ag NORs counts could be used as a diagnostic aid in borderline tumors of the ovary. Thirty-two cases of adenocarcinomas, 25 cases of borderline tumors, and 14 cases of adenomas were selected from Bouin-fixed archival material after histological examination. Both mean values of Ag NORs counts demonstrated a progressive increase from adenomas to borderline tumors and to carcinomas; the differences were statistically significant. Using discriminant analysis, all cases of benign and malignant tumors except one adenoma and one carcinoma were discriminated as belonging to an individualized group. No difference was found between borderline tumor with peritoneal implants and those without peritoneal implants. The results indicate that the Ag NORs counting procedure may be useful in distinguishing borderline tumors from carcinomas and adenomas. Ag NORs counts cannot, however, predict the clinical behavior of borderline tumors of the ovary.

Percutaneous ethanol injection for the treatment of symptomatic cystic metastases from ovarian carcinoma. Work in progress

Two patients with symptomatic cystic metastases from ovarian epithelial carcinoma underwent ultrasound (US)-guided percutaneous aspiration and temporary injection of 99% ethanol into the cyst. In the first case, the patient initially underwent surgical resection of the mass and received systemic chemotherapy, but the cyst recurred 2 months later. Percutaneous aspiration and ethanol sclerotherapy were performed twice in the second case; fluid reaccumulated 2 months after the initial procedure. No side effects occurred. During the follow-up period (8 months in the first case and 4 months in the second), no clinical recurrence of the initial symptoms was noted. At the end of that period, a recurrent but asymptomatic cystic lesion was revealed at US examination in the first case. In the second case, a minimal asymptomatic residual collection was depicted with computed tomography. The results indicate that this technique should be considered in patients with symptomatic cystic metastases from ovarian carcinoma and may have potential benefit in the palliative treatment of such lesions.