[Adjuvant radiotherapy in patients with endometrial cancers]

The treatment of patients with endometrial cancer has been extensively modified in recent years. Several randomized studies have redefined the indications for adjuvant therapy in tumours staged 1. In the absence of poor prognostic factors, the management tends to be less aggressive than before, often limited to vaginal brachytherapy. Conversely, for more advanced lesions, for which prognosis is poor, combinations of chemoradiation are currently being evaluated. This literature review aims to provide an update on recent developments in the management of adjuvant radiotherapy for endometrial carcinoma.

[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.

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.

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.

Results after conservative treatment of serous borderline tumours of the ovary with stromal microinvasion but without micropapillary pattern

The aim of this study was to assess the outcomes of women treated conservatively for a serous borderline ovarian tumour with stromal microinvasion (SBOT-SMI) but without micropapillary pattern. Ten women treated conservatively for a stage I (n= 8) or stage IIIB (n= 2) tumour were followed up. With a median follow-up duration of 62 months (range 7-117 months), five recurrences developed on the preserved ovary. All lesions were borderline recurrences (with noninvasive peritoneal implants in one). All women are currently disease free. Three women achieved a spontaneous pregnancy and three became pregnant after an in vitro fertilisation procedure. This study suggests that conservative treatment of SBOT-SMI is safe.

Combined topotecan and lapatinib in patients with early recurrent ovarian or peritoneal cancer after first line of platinum-based chemotherapy: A French FEDEGYN-FNCLCC phase II trial

5555

Background: High HER1 expression is associated with poor prognosis. Preliminary data have shown links between HER1 expression and topotecan efficacy. The objective of the trial was to evaluate the efficacy of the association of topotecan and lapatinib in non-HER screened patients who failed first line platinum-based chemotherapy within 12 months. Methods: Chemotherapy consisted of 4-week course of topotecan (d1, d8, d15, 3.2 mg/m2 IV) and lapatinib (1250 mg/d PO). Response was assessed using RECIST or RUSTIN criteria. The primary objective was global response (GR, i.e. CR, PR, and SD). Biomarker profiles were evaluated according treatment response. A two-step phase II trial was designed to include 54 patients assuming a GR rate of 75% for the combination compared to 55% for topotecan alone. Results: From March to September 2008, 39 patients (37 ovarian and 2 peritoneal carcinomas), median age 60 (18 to 80), were included in 16 institutions. Patients presented with FIGO stage I (n = 1), II (n = 2), III (n = 29), and IV (n = 7) disease. Twenty and 19 patients had disease relapse occurring < 6 and 6–12 months after initial chemotherapy respectively. 2 patients were non evaluable. After 1 to 8 cycles (median 2) of topotecan-lapatinib there were 0/2 PR, 7/9 SD, 12/7 progressions in patients who failed <6 or 6–12 months respectively. The GR rate was 46% (35 and 58%; 95% confidence limits, 30–63%) and the trial was prematurely stopped. Three patients developed toxicity leading to treatment discontinuation after 3 cycles. Biological data will be presented at meeting. Conclusions: Combined topotecan and lapatinib is associated with modest GR rate. Biological profiles of responders are pending.

No significant financial relationships to disclose.

Final results of a FNCLCC French Sarcoma Group multicenter randomized phase II study of gemcitabine (G) versus gemcitabine and docetaxel (G+D) in patients with metastatic or relapsed leiomyosarcoma (LMS)

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Background: An objective response rate (RR) of 8% and 17% with G and G+D were respectively reported in metastatic soft tissue sarcomas (Maki, J Clin Oncol. 2007). We previously reported a 5% RR in 41 evaluable patients (pts) with ‘non uterus‘ LMS randomized to each arm of this randomized phase II study (Duffaud, ASCO. 2008). We present here the results of G vs G+D in uterine and all LMS. Methods: Patients had histologically proven metastatic or unresectable LMS, one prior anthracycline- based regimen, age ≥18, measurable disease (RECIST), PS ≤ 2. Treatment was G 1,000 mg/m2(over 100 minutes, d1+d8+d15) q28 days (d) or G 900 mg/m2(over 90 min, d1+d8) and docetaxel 100 mg/m2 (over 60 min, d8) q21 days; in the G+D arm, pts received lenograstim d9–15, 25% dose reductions were employed for prior pelvic radiation. The primary endpoint was the objective RR (CR+PR), evaluated every 2 cycles. Stratification was by primary tumor location (uterus vs. non-uterus). The Simon method was used: for “uterus” study, 20 pts per arm for a 74% probability of selecting the arm with a real RR of 50%, expected baseline RR was 40%; for the “non-uterus” study, 20 pts per arm for a 92% probability of selecting the arm with a real RR of 40%, expected baseline RR was 20%. Results: From 02/06 to 12/08, 44 pts were enrolled in the “non-uterus” study, 40 pts in the “uterus” study. Currently 76/82 pts are evaluable for response (41/44 in the “non uterus” and 35/38 in the “uterus” study) and 80/84 for toxicity. In the uterus group the median age is 57 (range 41–80), 24 pts received prior pelvic radiotherapy, the median number of cycles was 5 (range 0–8) and dose received/dose planned (%) were 69% in G arm, 88% of G and 86% of D in G+D arm. No differences in toxicity were observed between both LMS locations: in the G arm, toxicity was moderate except for one pulmonary gr4; in the G+D arm one toxic death was related to gr5 thrombocytopenia and there were 2 non-haemathologic gr4 toxicities; 11 pts stopped for intolerable toxicity (3 in G and 8 in G+D arm) and 1 pt for hypersensitivity (G+D arm). Conclusions: Final tumor response for uterine LMS and updated toxicity and PFS data for all the LMS will be presented during the meeting.

[Table: see text]

Postoperative morbidity after completion surgery in patients undergoing chemoradiotherapy for locally advanced cervical carcinoma

5595

Background: The aim of this study was to evaluate the morbidity rate in patients undergoing completion surgery after homogeneous chemoradiation therapy (CRT) for locally advanced stage cervical cancer. Methods: Patients fulfilling following inclusion criteria were studied: 1. Stage IB2-IVA cervical carcinoma; 2. Tumor confined radiologically initially to the pelvic cavity; 3. Pelvic external radiation therapy with delivery of 45 Gy in pelvic cavity with concomitant chemotherapy (cisplatin 40 mg/m2/week) followed by utero-vaginal brachytherapy; 4. Completion surgery after the end of radiation therapy including at least a hysterectomy. Modalities of this completion surgery depended on the presence, location and size of residual disease. Results: One-hundred and fifty patients treated between 1998 and 2007 fulfilled inclusion criteria. Modalities of hysterectomy performed were: extrafascial hysterectomy in 106 (71%) patients and radical hysterectomy in 44 (29%). Para-aortic lymphadenectomy was performed in 131 (87%) patients and pelvic lymphadenectomy in 34 (23%) patients. Thirty-four (23%) patients had macroscopic (> 1 cm) residual disease on pathologic examination. Twenty-five (23%) patients had post-operative complications (in whom 17 severe morbidity requiring surgical or radiological treatment). Presence of residual disease was the only factor associated with overall morbidity rate in univariate and multivariate analysis. The use of radical hysterectomy and pelvic lymphadenectomy increased significantly the rate of severe morbidity (particularly bowel and urinary tract morbidity). Conclusions: In the present study involving a large number of patients undergoing completion surgery after homogeneous CRT in locally advanced cervical carcinoma the morbidity rate is important. Radical hysterectomy and pelvic lymphadenectomy increase the rate of severe morbidity. The interest on the survival of this completion surgery should be evaluated in prospective trial.

No significant financial relationships to disclose.

Prognostic factors of patients with advanced stage serous borderline tumors of the ovary

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Background: The aim of this study was to determine prognostic factors in a large series of patients with stage II or III serous low malignant potential ovarian tumor (LMPOT) and peritoneal implants. Methods: A retrospective review of patients with a serous LMPOT and peritoneal implants treated or referred in our institution. The slides of ovarian tumors and peritoneal implants were reviewed by the same pathologist. Prognostic factors were studied. Results: From 1969 to 2006, 168 patients were reviewed, 21 of whom had invasive implants. Tumors exhibited a micropapillary pattern in 56 patients. Adjuvant treatment had been administered to 61 patients. The median duration of follow-up was 57 (range, 1–437) months. Forty-four patients had relapsed and 10 patients had died. 5-year overall survival of patients was 98%. Among patients with noninvasive and invasive implants, 8% and 10%, respectively, relapsed at 5 years in the form of invasive disease (p = 0.08). Prognostic factors for recurrence in the univariate analysis were: a laparoscopic approach, conservative treatment and positive second-look surgery. In the multivariate analysis the use of conservative treatment was the only prognostic factors for recurrence. Conclusions: The prognosis of serous LMPOT with peritoneal implants remains good. The strongest prognostic factor in patients with an advanced-stage borderline tumor is the use of conservative surgery. In this series, a micropapillary pattern and implant subtypes (invasive vs. noninvasive) were not prognostic factors.

No significant financial relationships to disclose.

[Not Available]

S. Gouy, C. Uzan, Y. Zafrani, C. Lhommé, P. Pautier, P. Duvillard, C. Haie-Meder, P. Morice Uterine cancer can metastasize to both the pelvic and para-aortic levels. No one questions the diagnostic and prognostic value of lymphadenectomy, but its therapeutic value is still open to debate. In early cervical cancer (<4 cm.), pelvic lymphadenectomy is a routine part of radical hysterectomy. If pelvic lymph nodes show involvement, one can propose an extension of the lymphadenectomy to the para-aortic level. Studies of sentinel lymph node identification and biopsy at this level are currently under way. The standard treatment of cervical cancer > 4 cm is radiotherapy. A pre-radiation laparoscopy to investigate lymph node involvement at the lumbo-aortic level may help to define the extent of the radiation field. For endometrial cancer, the role and benefit of lymphadenectomy are much less clear since these patients often have major co-morbidities which increase the risk of complications from an extended lymph node dissection.

[Not Available]

S. Gouy, C. Uzan, Y. Zafrani, C. Lhommé, P. Pautier, P. Duvillard, C. Haie-Meder, P. Morice Uterine cancer can metastasize to both the pelvic and para-aortic levels. No one questions the diagnostic and prognostic value of lymphadenectomy, but its therapeutic value is still open to debate. In early cervical cancer (<4 cm.), pelvic lymphadenectomy is a routine part of radical hysterectomy. If pelvic lymph nodes show involvement, one can propose an extension of the lymphadenectomy to the para-aortic level. Studies of sentinel lymph node identification and biopsy at this level are currently under way. The standard treatment of cervical cancer > 4 cm is radiotherapy. A pre-radiation laparoscopy to investigate lymph node involvement at the lumbo-aortic level may help to define the extent of the radiation field. For endometrial cancer, the role and benefit of lymphadenectomy are much less clear since these patients often have major co-morbidities which increase the risk of complications from an extended lymph node dissection.

[Lymphadenectomy for uterine cancer]

Uterine cancer can metastasize to both the pelvic and para-aortic levels. No one questions the diagnostic and prognostic value of lymphadenectomy, but its therapeutic value is still open to debate. In early cervical cancer (<4 cm.), pelvic lymphadenectomy is a routine part of radical hysterectomy. If pelvic lymph nodes show involvement, one can propose an extension of the lymphadenectomy to the para-aortic level. Studies of sentinel lymph node identification and biopsy at this level are currently under way. The standard treatment of cervical cancer>4 cm is radiotherapy. A pre-radiation laparoscopy to investigate lymph node involvement at the lumbo-aortic level may help to define the extent of the radiation field. For endometrial cancer, the role and benefit of lymphadenectomy are much less clear since these patients often have major co-morbidities which increase the risk of complications from an extended lymph node dissection.